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https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1420519102832-0LEUILMAKZZLE6O3K1SW/51sXsLRdLTL.jpg Years 3 & 4 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1420519164720-AMZCKCBWG91DETYX1U4V/619D1KIdw5L.jpg Years 3 & 4 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1420519207016-ZXOTGKRRX3TTPEBWSDY3/61krfUYgPWL.jpg Years 3 & 4 https://www.headmirror.com/jama-otolaryngology daily 0.75 2018-03-03 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1426370335047-R1802PAG2Z6WDG9MDWQ6/il_570xN.169827430.jpg JAMA Otolaryngol Head Neck Surg https://www.headmirror.com/am-j-otolaryngol daily 0.75 2020-02-17 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1426369998553-CLG37G9M31I158KRD8OS/il_570xN.169827430.jpg Am J Otolaryngol https://www.headmirror.com/otolaryngol-clin-n-am daily 0.75 2018-03-03 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0.75 2023-06-25 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Facial Plastic Surgery https://www.headmirror.com/pediatric-otolaryngology daily 0.75 2022-06-22 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Pediatric Otolaryngology https://www.headmirror.com/sleep-surgery daily 0.75 2022-04-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Sleep Surgery https://www.headmirror.com/headneck daily 0.75 2023-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Head & Neck https://www.headmirror.com/neurotology daily 0.75 2023-10-04 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Otology & Neurotology https://www.headmirror.com/rhinology-sinus-surgery daily 0.75 2023-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Rhinology & Sinus Surgery https://www.headmirror.com/about daily 0.75 2025-04-10 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421026412638-1Q4YUSWKB2RCOPYINUTE/sarland_p01.jpg About https://www.headmirror.com/investigative daily 0.75 2020-02-17 https://www.headmirror.com/ent-quiz-archive daily 0.75 2020-02-18 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1581990330215-SMYE8RSR1JJ6ADEAA1CB/Quiz.jpg Quiz Archive https://www.headmirror.com/video-toc daily 0.75 2023-10-04 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Table of Contents https://www.headmirror.com/facial-plastic-surgery-podcast daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Facial Plastic Surgery https://www.headmirror.com/pediatric-otolaryngology-1 daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Rhinology & Sinus Surgery https://www.headmirror.com/sleep-surgery-podcast daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Sleep Surgery https://www.headmirror.com/otology-neurotology-podcast daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Otology & Neurotology https://www.headmirror.com/laryngology-podcast daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Laryngology https://www.headmirror.com/pediatric-otolaryngology-podcast daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Pediatric Otolaryngology https://www.headmirror.com/head-neck-surgery-podcast daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Head & Neck https://www.headmirror.com/toc-podcast daily 0.75 2023-01-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Table of Contents https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586722261055-NRF7BBLBHCH8F0TIFMTR/rssfeed.png Table of Contents https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586721731704-XLKJ7DI52W1UTBYMIPXC/image-asset.jpeg Table of Contents https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586721625918-SGVJQSH27U1TLA79Q7F0/podbean.png Table of Contents https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586721794074-BGY8RPQOGG8PCGK8NKSB/logo%402x.png Table of Contents https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586721437087-6U1OLFD0HFFEETF83KWD/stitcher-logo.png Table of Contents https://www.headmirror.com/otomatch-link-test daily 0.75 2020-04-01 https://www.headmirror.com/otolaryngology-mlange daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Otolaryngology Mélange https://www.headmirror.com/covid19 daily 0.75 2020-05-20 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588997714986-E6S1195YANAOAECS941I/COVID19.jpg COVID-19 https://www.headmirror.com/tbone-atlas-icw daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152959509-3HMS44SB6KCF9GBGHAAS/Tbone.jpg Intact Canal Wall Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973489625-73XFS9QOQ1NFBOPH2TXP/5-1+Postauricular+Approach+-+Cortical+mastoidectomy+with+antrotomy+-+Annotated.jpg Intact Canal Wall Mastoidectomy - 5.1 Cortical Mastoidectomy with Antrotomy – Removal of the mastoid cortex reveals the air cell system in a well pneumatized temporal bone – The degree to which the cortex is removed varies depending upon the indication for mastoidectomy (e.g., cochlear implantation requires limited mastoidectomy, while translabyrinthine craniotomy requires very wide exposure) – Working in a corridor between the bony EAC and tegmen deep to MacEwen’s triangle will lead to antrum in most temporal bones – Drilling anteriorly into the root of the zygoma exposes the antrum for removal of cholesteatoma https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973489709-E36BGTM7LHDOF0EY38NS/5-1+Postauricular+Approach+-+Cortical+mastoidectomy+with+antrotomy+-+No+annotations.jpg Intact Canal Wall Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973498045-6B46LIPAXTFC5PDTU83U/5-1+Postauricular+Approach+-+Cortical+mastoidectomy+with+antrotomy.jpg Intact Canal Wall Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973491681-W9WCVXCHSUNRLXZIMMWH/5-2+Postauricular+Approach+-+Cortical+mastoidectomy+-+Pitfall+too+posterior+-+Annotated.jpg Intact Canal Wall Mastoidectomy - 5.2 Pitfall: Inadequate thinning of bony EAC – Inadequate thinning of bony EAC: risk of injury to labyrinth, facial nerve – Can always identify skin of the EAC and gauge thickness of canal wall directly – Avoid lowering of level of EAC in a lateral to medial direction: vascular strip inversion and cholesteatoma, mastoid cutaneous fistula https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973493631-6V2PO8MFHMZXI9ZHEGYU/5-2+Postauricular+Approach+-+Cortical+mastoidectomy+-+Pitfall+too+posterior+-+No+annotations.jpg Intact Canal Wall Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973504554-1ALPNVP0937ILG2NDB3U/5-2+Postauricular+Approach+-+Cortical+mastoidectomy+-+Pitfall+too+posterior.jpg Intact Canal Wall Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973499984-Y8DRUEQBJ26ZT5SOCL2T/5-3+Postauricular+Approach+-+Cortical+mastoidectomy+-+Inadequate+root+of+zygoma+-+Annotated.jpg Intact Canal Wall Mastoidectomy - 5.3 Pitfall: Inadequate drilling of root of zygoma – Failure to drill into root of zygoma (Fig 5.3): inability to access epitympanum and access ossicles – Critical step for cholesteatoma removal, lateral temporal bone resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973501651-GE869ECYD94ATC4Y1XDG/5-3+Postauricular+Approach+-+Cortical+mastoidectomy+-+Inadequate+root+of+zygoma+-+No+annotations.jpg Intact Canal Wall Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973511966-AMS9PQ842515U2F8ZWBB/5-3+Postauricular+Approach+-+Cortical+mastoidectomy+-+Inadequate+root+of+zygoma.jpg Intact Canal Wall Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973506265-ERJJ39MT3WKYRO9UPJBW/5-4+Complete+mastoid+-+Annotated.jpg Intact Canal Wall Mastoidectomy - 5.4 Complete mastoidectomy – A complete mastoidectomy is defined by most as mastoidectomy with antrotomy and removal of air cells along the tegmen, sigmoid sinus, sinodural angle, and posterior external auditory canal – Extensions may involve exenteration of air cells in the mastoid tip, retrofacial air cell tract, or around the labyrinth https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973507734-YNQBES6SBMHVRPXASBHQ/5-4+Complete+mastoid+-+No+annotations.jpg Intact Canal Wall Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588973515573-C0BR5556PQB41DZ2F5M0/5-4+Complete+mastoid.jpg Intact Canal Wall Mastoidectomy https://www.headmirror.com/tbone-atlas-lateral-tbone daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589153617172-RU5GXOCCFS0WRB4YQLYE/Tbone.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055684800-UMKHXGBTQM4RXGKE2S08/7-1+LTBR+-+Root+of+zygoma+-+Annotated+copy.jpg Lateral Temporal Bone Resection - 7.1 Drilling the root of zygoma – Lateral temporal bone resection involves en-block removal of the bony external auditory canal, skin, tympanic membrane, and malleus – The superior trough extends to the capsule of the TMJ from the lateral cortex to the epitympanum – Often this can be approached as a simple lateral to medial “osteotomy” if there is adequate space between the dura (superiorly) and ear canal (inferiorly) https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055684859-PFSL4RBTQ998UOFQ8DAL/7-1+LTBR+-+Root+of+zygoma+-+No+annotations.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055712690-TA7OJGR88MVLCPQC5I9J/7-1+LTBR+-+Root+of+zygoma+copy.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055687655-TCTR6DS6BT8ONZ14M5KD/7-2+LTBR+-+Extended+facial+recess+%28start%29+-+Annotated+copy.jpg Lateral Temporal Bone Resection - 9.2 Extended facial recess: Part I – To remove the bony EAC, the incudostapedial joint must be divided and the chorda tympani nerve sacrificed – In this photo, the mastoid segment of the facial nerve is decompressed to outline relevant anatomy; however, a thin layer of bone is typically left over the nerve during surgery – The incudostapedial joint is divided through the facial recess https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055689920-DIO6PYXTA7NPV6TO2SZT/7-2+LTBR+-+Extended+facial+recess+%28start%29+-+No+annotations.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055706953-K1NO9XWD84B1PS5XV6FF/7-2+LTBR+-+Extended+facial+recess+%28start%29+copy.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055709154-VWYWCG3FV3QQIFC4WP1J/7-3+LTBR+-+Extended+facial+recess+%28end%29+-+Annotated+copy.jpg Lateral Temporal Bone Resection - 9.3 Extended facial recess: Part II – The facial recess is extended interiorly and then anteriorly between the annulus and facial nerve until soft tissue is encountered, thereby completing an inferior trough https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055711055-FT9JI6QSHO2L4RQYRZMN/7-3+LTBR+-+Extended+facial+recess+%28end%29+-+No+annotations.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055721276-SDK76XCCFJUO79A1MLRW/7-3+LTBR+-+Extended+facial+recess+%28end%29+copy.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055715612-T7X2O3IE85YC7OI0MB1F/7-4+LTBR+-+Fracture+-+Annotated+copy.jpg Lateral Temporal Bone Resection - 9.4 External auditory canal fracture – Once drilling is complete the only bony attachments remaining should be to the bone around the Eustachian tube orifice and carotid canal – With manual pressure the ear canal is firmly rocked in an anterior direction to fracture the attachment – The tensor tympani tendon can be cut to detach the malleus and the specimen can then be removed en bloc https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055718053-61ZDPZBWHYWU8WIJ1BEK/7-4+LTBR+-+Fracture+-+No+annotations.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055732376-Y70P97GH8XO515M00IDR/7-4+LTBR+-+Fracture+copy.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055723568-LV7560RZRSGH34W6QFIF/7-5+LTBR+-+Complete+-+Annotated+copy.jpg Lateral Temporal Bone Resection - 9.5 Completed lateral temporal bone resection – After complete, the middle ear should be clearly visualized and the stapes in place – The Eustachian tube is then occluded with muscle or fascia https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055725895-O1PNVFC1LZDJWWK9PH2B/7-5+LTBR+-+Complete+-+No+annotations.jpg Lateral Temporal Bone Resection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055737897-OIQN7UGABF91CSG7PE9D/7-5+LTBR+-+Complete+copy.jpg Lateral Temporal Bone Resection https://www.headmirror.com/tbone-atlas-intro daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589121513765-5EC4KB8Q739LIV4MX39C/Tbone.jpg Introduction to Temporal Bone Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589203574991-DKI68D5AB1OAPSPESAOL/1-1+Setup.jpg Introduction to Temporal Bone Surgery - 1.1 Microscope and Basic Instrumentation – Required instrumentation for bony temporal bone dissection includes an operating microscope, drill, suction, specimen holder, and instruments to deglove the temporal bone of soft tissue – Either on-drill irrigation with a separate suction or a combined suction-irrigator may be used – Optional but recommended instrumentation includes middle ear instruments and self-retaining retractors (e.g., Weitlaner) if soft tissue is preserved https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589203575028-1EPDLVB1VTEFS4V3FQ72/1-2+Drill+burs.jpg Introduction to Temporal Bone Surgery - 1.2 Drill burs – Recommended selection of drill burs includes larger cutting burs (e.g. 5 mm, 6 mm, and/or 7.5 mm cutting), a variety of diamond burs (1 mm to 6 mm) – Cutting burs are available in multiple varieties, including two fluted and multi fluted – Diamond burs are available in fine, regular, and coarse varieties with standard and extended lengths https://www.headmirror.com/tbone-atlas-endolymphatic daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152857361-VVOJO32SFMZYXVMPU2QY/Tbone.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056496630-QIGIA9X77NN4HILI2OD2/11-1+Mastoidectomy+with+skeletonization+of+tegmen+and+sigmoid+-+Annotated+copy.jpg Endolymphatic Sac Decompression - 7.1 Mastoidectomy – Skeletonization of Tegmen and Sigmoid Sinus – ELS decompression itself is employed in the nonablative treatment of Meniere’s disease, a condition though to stem from hydrops of the endolymphatic space – Identification, skeletonization, and decompression of the ELS (with or without ligation of the endolymphatic duct) is a component of transpetrosal skull base approaches – Identification begins with a complete mastoidectomy with wide removal of cortex, identification of the mastoid tegmen and sigmoid sinus, and exenteration of air cells in the sinodural angle https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056496531-EXVWSDIGKYLT5E1I9CY7/11-1+Mastoidectomy+with+skeletonization+of+tegmen+and+sigmoid+-+No+annotations.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056506288-H4WYB723W4TRJF19WASF/11-1+Mastoidectomy+with+skeletonization+of+tegmen+and+sigmoid+copy.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056498493-LAC7GA6W20AV20GOPVYQ/11-2+Skeletonizing+labyrinth+PF+dura+and+ELS+-+Annotated+copy.jpg Endolymphatic Sac Decompression - 7.2 Identification of Posterior Semicircular Canal – The posterior canal should be skeletonized to approximate the location of the ELS – Donaldson’s line is an imaginary line parallel to the HSCC that bisects the PSCC and approximates the location of the ELS along the PF dura – The sigmoid and PF dura should be skeletonized for later bony decompression – In a well pneumatized temporal bone (such as this one), the ELS and proximal endolymphatic duct may be visualized; in others, there may be limited pneumatization between the bone over the PF dura and PSCC https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056500176-PM69CF4WTRUIFXBNJV0U/11-2+Skeletonizing+labyrinth+PF+dura+and+ELS+-+No+annotations.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056509922-1OTPVHZS06OG9V9O8172/11-2+Skeletonizing+labyrinth+PF+dura+and+ELS+copy.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056508297-YVC3LIAXE4W4XBDKGUQG/11-3+Decompressing+sigmoid+PF+dura+and+ELS+-+Annotated+copy.jpg Endolymphatic Sac Decompression - 7.3 Bony Decompression of Sigmoid Sinus, Posterior Fossa Dura, and Endolymphatic Sac: Part 1 – The bone overlying the sigmoid sinus and posterior fossa dura is then carefully “eggshelled” in addition to bone over the ELS itself – It is helpful to identify the FN in its mastoid segment to facilitate safe bone removal in the retrofacial area https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056509496-NL0ZRVNR4VTTYKURM5L9/11-3+Decompressing+sigmoid+PF+dura+and+ELS+-+No+annotations.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056517815-Z8P15G9LAXU6YS6KAD4F/11-3+Decompressing+sigmoid+PF+dura+and+ELS+copy.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056511902-8R2Y9DBUMJ0OS73VHXJX/11-4+Bone+removed+from+ELS+-+Annotated+copy.jpg Endolymphatic Sac Decompression - 7.4 Bony Decompression of Sigmoid Sinus, Posterior Fossa Dura, and Endolymphatic Sac: Part 2 – The bone overlying the sigmoid sinus, PF dura, and ELS is then carefully removed – Once the bone is removed in a 180-270 degree fashion around the ELS, some surgeons elect to open the sac with or without placement of a shunt – If a CSF leak occurs, typically fat can be used in a “bath plug” technique https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056513971-C1T3XNLTMU1FD31SDE8P/11-4+Bone+removed+from+ELS+-+No+annotations.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056524121-EPRGLPA0BV8ATJF1GGLZ/11-4+Bone+removed+from+ELS+copy.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056520185-G162QD35IK840AQ2JWFG/11-5+Intracranial+view+of+ELS+and+porus+-+Annotated+copy.jpg Endolymphatic Sac Decompression - 7.5 Posterior Fossa View of Endolymphatic Sac and Associated Structures – While not a surgical view, it is important to recognize the position of the ELS when viewed from inside the posterior cranial fossa – Often its position is subtle but can be seen as a thickening of dura near the sigmoid sinus/jugular bulb junction – The ELS is sometimes used as a landmark for petrous bone removal during retrosigmoid approaches to the IAC https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056522369-X8N1NZF87JN3LBSJS5XD/11-5+Intracranial+view+of+ELS+and+porus+-+No+annotations.jpg Endolymphatic Sac Decompression https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056530289-N7WL9RIZGGK44C1F8HL1/11-5+Intracranial+view+of+ELS+and+porus+copy.jpg Endolymphatic Sac Decompression https://www.headmirror.com/tbone-atlas-anatomy daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589153080406-O3JY498RZXR6B9CXZI1T/Tbone.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957377623-R2GD9VNW4NA0K6LYPSO8/2-1+Lateral+view+and+EAC+-+Annotated.jpg Overview of Anatomy - 2.1 Temporal Bone – Lateral View and External Auditory Canal – The external lateral view of the temporal bone and external auditory canal demonstrates its relationships to the temporomandibular joint and zygoma https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957377695-9AW6VWZI9DGUCPZOWMBK/2-1+Lateral+view+and+EAC+-+No+annotations.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957389354-JS04PBE778M4GB13GISR/2-1+Lateral+view+and+EAC.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957379341-9WZZ6ZBSQEUF7VQ67K52/2-2+Temporal+bone+%28occipital+relationship%29+-+Annotated.jpg Overview of Anatomy - 2.2 Temporal Bone – Suture Landmarks and Relationships to Other Cranial Bones – This oblique lateral view demonstrates the relationship of the temporal bone with adjacent parietal, sphenoid, and occipital bones – Asterion: junction of lambdoid, parietomastoid, and occipitomastoid sutures – Pterion: junction of sphenoparietal, sphenosquamosal, and sphenofrontal sutures https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957380637-OY5RXAZ8LRTYEC9UU9GK/2-2+Temporal+bone+%28occipital+relationship%29+-+No+annotations.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957391051-5C57REBG1N0LUOGN3C3T/2-2+Temporal+bone+%28occipital+relationship%29.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957391318-577HRBH9OMZ4GK6660X3/2-3+Skull+base+-+Annotated.jpg Overview of Anatomy - 2.3 Cranial Base and Foramina – Skull base foramina within the middle and posterior fossae transmit vital neurovascular structures and may be encountered during skull base approaches – F. lacerum: transmits internal carotid artery to carotid canal – F. ovale: transmits mandibular division of trigeminal nerve (V3) – F. spinosum: transmits middle meningeal artery – Jugular foramen: transmits lower cranial nerves through medial pars nervosa and jugular vein through pars vascularis – F. magnum: transmits brainstem and spinal cord https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957392506-LRT4SLLEZNC00FUEKXJY/2-3+Skull+base+-+No+annotations.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957402090-FWO5ZGRIBT7YYDV79XJP/2-3+Skull+base.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957394091-MKOX1QJC089A014OBIB5/2-4+Medial+view+of+petrous+bone+-+Annotated.jpg Overview of Anatomy - 2.4 Temporal Bone – Petrous Part and Relationships to Posterior and Middle Cranial Fossae – The petrous “pyramid” has two main surfaces: a superior one that represens the floor of the lateral aspect of the middle cranial fossa and a posterior one that serves articulates with the clivus and basiocciput to house the posterior cranial fossa – Careful study of the subtle landmarks along both surfaces is vital for approaches to the middle and posterior fossae – Meatal plane: middle fossa floor overlying the IAC – Arcuate eminence: ridge directly over or adjacent to the SSCC https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957395606-8Z3YQVYOD5H1UJELGA8T/2-4+Medial+view+of+petrous+bone+-+No+annotations.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957404233-FZWSD0JU1BAW5PBB1XIS/2-4+Medial+view+of+petrous+bone.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957404069-T5BOM3ANRT6YIFX4OYL1/2-5+IAC+-+Annotated.jpg Overview of Anatomy - 2.5 Temporal Bone – Internal Auditory Canal – The IAC opens to the posterior fossa at the porus acusticus and is collinear with the EAC – The upper compartment containing the FN and SVN is separated from the inferior compartment containing the IVN and CN by the transverse crest – Bill’s bar separates the FN from SVN https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957406104-64HASRJN3GK0N8P1RK1A/2-5+IAC+-+No+annotations.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957413930-YR9MRH1ZRIOZTY6UVSG4/2-5+IAC.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957407820-6YBYDK7EVJL6GS0ZD1BS/2-6+Surface+Anatomy+-+Annotated.jpg Overview of Anatomy - 2.6 Lateral Surface of Temporal Bone (surgical position) – Exposure of the mastoid cortex can be wide, as in the case of planned translabyrinthine craniotomy, or narrow, if only cortical mastoidectomy with antrotomy is required. – Spine of Henle: suprameatal spine, located at the posterosuperior aspect of the bony EAC – Temporal line: superior border of zygomatic process of temporal bone, usually approximates tegmen mastoideum – MacEwen’s Triangle: suprameatal triangle, immediately posterior to spine of Henle, usually approximates mastoid antrum (largest air cell in mastoid) https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957409651-0521JUNXBAGUYBT6UWCT/2-6+Surface+Anatomy+-+No+annotations.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957425084-UK3XY1EUF2PAD3PL666J/2-6+Surface+Anatomy.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957416332-UTS1OC2P75Q78CQMZKLB/2-7+Subtotal+petrosectomy+-+Annotated.jpg Overview of Anatomy - 2.7 Middle ear and mastoid – Complete mastoidectomy with removal of the posterior EAC provides a comprehensive view of the middle ear and mastoid https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957418355-7W4TUZXDUZXORQOKQCSN/2-7+Subtotal+petrosectomy+-+No+annotations.jpg Overview of Anatomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957429828-B90WG8CVDQXPDFCZ94UJ/2-7+Subtotal+petrosectomy.jpg Overview of Anatomy https://www.headmirror.com/tbone-atlas-endaural daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152995229-8DJZS6L2AT33LLVVJYOJ/Tbone.jpg Endaural Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588965241821-BP0X79VGS4EG7YY1IYDD/4-1+Endaural+Approach+-+Annotated.jpg Endaural Approach - 4.1 Incisions and Exposure – The endaural approach can be used for transcanal or transmastoid procedures – The typical skin incision is made at the intercartilaginous incisura (i.e., between the root of the helix and tragus) and carried in a counter-clockwise direction around the lateral posterior EAC down to the mastoid cortex – Several variations of canal incisions have been described (see reference below) Reference: Morizono T. “Endaural Approaches”. Operative Techniques in Otolaryngology – Head and Neck Surgery, Vol 7, No 1 (Mar), 1996:66-70. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588965246416-0PD64NYNLEOX97KP26M6/4-1+Endaural+approach.jpg Endaural Approach https://www.headmirror.com/tbone-atlas-translab daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152535651-SUE53I7OZ1T628CGBFLY/Tbone.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056808084-73BZI3RAICL5M7J94D1O/13-1+Translab+-+Wide+mastoidectomy+-+Annotated.jpg Translabyrinthine Approach - 13.1 Mastoidectomy I – The translabyrinthine craniotomy approach is used to access the internal auditory canal and cerebellopontine angle – Following exposure of the mastoid and root of zygoma, wide mastoidectomy is performed to identify the superior boundary (middle fossa dura), posterior boundary (sigmoid sinus and retrosigmoid dura), and anterior boundary (EAC) – Wide exposure, to enhance visualization and working room, requires decompression of the middle fossa dura and sigmoid sinus https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056808037-DUYJ94HXSOFARIBP7DOH/13-1+Translab+-+Wide+mastoidectomy+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056823172-JWCUTG18VR3BL8CQKQDL/13-1+Translab+-+Wide+mastoidectomy.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056810434-DBPU9N4MSY025UIPJ5R1/13-2+Translab+-+Exposure+of+bone+over+lateral+temporal+and+retrosigmoid+dura+-+Annotated.jpg Translabyrinthine Approach - 13.2 Mastoidectomy II – Removal of squama temporalis bone and bone over the retrosigmoid dura facilitates bony decompression of the dural surfaces and retraction if necessary https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056812554-4ULNVQLX5L7KF66ED3GI/13-2+Translab+-+Exposure+of+bone+over+lateral+temporal+and+retrosigmoid+dura+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056827945-IRXNN8KHVUOY09B6773A/13-2+Translab+-+Exposure+of+bone+over+lateral+temporal+and+retrosigmoid+dura.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056826050-Y7CXRC8BRC67V0EO03SF/13-3+Translab+-+Decompression+of+lateral+temporal+and+retrosigmoid+dura+-+Annotated.jpg Translabyrinthine Approach - 13.3 Bony decompression of temporal dura, retrosigmoid dura, sigmoid sinus, and presigmoid dura – Once the temporal dura, retrosigmoid dura, and sigmoid sinus are decompressed, a periosteal elevator can be used to dissect these surfaces from overlying bone – This approach facilitates rapid removal of bone (often with a rongeur) medially toward the labyrinth – At this point the descending facial nerve should be identified to 1) avoid inadvertent injury while drilling inferior to the posterior semicircular canal and 2) confirm that neuromonitoring equipment is functioning normally https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056828241-ZG49VNWBTICYSORPGM6W/13-3+Translab+-+Decompression+of+lateral+temporal+and+retrosigmoid+dura+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056845985-G5KY7VG31RB4PQEDZFOZ/13-3+Translab+-+Decompression+of+lateral+temporal+and+retrosigmoid+dura.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056830300-W5AC197UBU3UEYAFWKGK/13-4+Translab+-+Skeletonizing+labyrinth+2+-+Annotated.jpg Translabyrinthine Approach - 13.4 Skeletonizing labyrinth and identifying jugular bulb – Once bone is decompressed to the level of the posterior and superior semicircular canals, the labyrinth may be skeletonized prior to labyrinthectomy – The position of the jugular bulb is variable and can be identified via drilling the often pneumatized retrofacial infralabyrinthine air cell tract – For transpetrosal approaches, the superior and posterior semicircular canals may be “blue-lined” to permit an additional 1-2 mm of bony removal without violation of the endostium https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056832358-KT3WLQN3ODMMJWQ2Z7YY/13-4+Translab+-+Skeletonizing+labyrinth+2+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056846467-XBKFZLR3M7QMLOM8O6B8/13-4+Translab+-+Skeletonizing+labyrinth+2.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056858786-U1J2SAIGDTS3WNW1UGPL/13-5+Translab+-+Canals+opened+-+Annotated.jpg Translabyrinthine Approach - 13.5 Labyrinthectomy – Each semicircular canal should be opened sequentially to permit anatomic dissection medially toward the vestibule, and avoid inadvertent injury to the second genu of the facial nerve – The common crus represents the non-ampullated end of the superior and posterior semicircular canals – The subarcuate artery may be identified passing through the center of the superior canal; bleeding can be controlled with a diamond bur without irrigation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056858733-59UR6HG5VD21G776NMNR/13-5+Translab+-+Canals+opened+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056874293-H6OQWKQA16UBNKGH9RYU/13-5+Translab+-+Canals+opened.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056860911-NUB6CIRH1QAP6KJ8TJUN/13-6+Translab+-+Labyrinthectomy+completed+-+Annotated.jpg Translabyrinthine Approach - 13.6 Identification of vestibule, endolymphatic sac and duct – The vestibule can be encountered directly medial to the horizontal semicircular canal and serves as the medial limit of dissection prior to approaching the internal auditory canal dura – The endolymphatic duct is encountered medial to the posterior semicircular canal – The endolymphatic sac is a double leaflet of posterior fossa dura; the junction between the duct and sac (operculum) can be divided to dissect the posterior fossa dura away from the bone https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056863048-VATVKOHNYPSMRJUS2NUG/13-6+Translab+-+Labyrinthectomy+completed+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056877995-IW9KCI5VLJL2RFO6HYXH/13-6+Translab+-+Labyrinthectomy+completed.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056876674-FSUKQBOMDDOWLN5GYODC/13-7+Translab+-+Start+of+IAC+troughs+and+cochlear+aqueduct+-+Annotated.jpg Translabyrinthine Approach - 13.7 Identification of internal auditory canal – The IAC is most easily identified at the fundus, which is immediately medial to the vestibule – In contrast, the porus acusticus may be 1 cm or more medial to the level of the fundus – The cochlear aqueduct can be found approximately midway between the inferior aspect of the internal auditory canal and the jugular bulb in a craniocaudal direction – Opening the cochlear aqueduct often permits egress of CSF and decompression of the posterior fossa, facilitating medial drilling and dural opening https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056878424-ZTRJU3KUT0V4I8GLZLRX/13-7+Translab+-+Start+of+IAC+troughs+and+cochlear+aqueduct+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056887074-7OKWNOO7YO3VQ215VFQ4/13-7+Translab+-+Start+of+IAC+troughs+and+cochlear+aqueduct.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056880433-FYU7PLF55UTTDK6DH487/13-8+Translab+-Developing+troughs+-+Annotated.jpg Translabyrinthine Approach - 13.8 Superior and inferior troughs – Once the porus acusticus is identified, deep troughs are developed superiorly (between the temporal dura and superior aspect of the IAC) and inferiorly (between the jugular bulb and inferior aspect of the IAC) – Medial drilling permits decompression of over 180 degrees around the IAC, facilitates exposure of the root exit zone of CN 7, and allows for greater rotation of the contents of the IAC (i.e. tumor) – When a low lying temporal dura or high jugular bulb limits dissection, maximal exposure of the opposite side of the IAC is vital to permit adequate visualization and access for instrumentation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056889188-178F4IANMFEFZ22TD6RY/13-8+Translab+-Developing+troughs+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056901555-BRX7DBNKRP1BPL2GU9CM/13-8+Translab+-Developing+troughs.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056891211-EIGV1TWD4DHDD1NX8XI7/13-9+Translab+-IAC+open+-+Annotated.jpg Translabyrinthine Approach - 13.9 Opening IAC and posterior fossa dura – After the dura of the IAC and posterior fossa is widely decompressed, the dura may be opened in a manner appropriate for the pathology – Bill’s bar separates the facial nerve and the superior vestibular nerve, while the transverse crest separates the superior and inferior vestibular nerves at the fundus – Care should be taken to avoid inadvertent injury to cerebellar veins – A loop of the AICA may be encountered within the IAC or adherent to the dura and should be avoided – Lower cranial nerves (CN 9, 10, and 13) can be seen traversing from the brainstem to the pars nervosa of the jugular foramen https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056893162-B88BUSK0N99FJJWG8M0M/13-9+Translab+-IAC+open+-+No+annotations.jpg Translabyrinthine Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056904544-7OTQ5OBTZ37LQF2DJI6V/13-9+Translab+-IAC+open.jpg Translabyrinthine Approach https://www.headmirror.com/tbone-atlas-postauricular daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589153040695-KEIZI985THNGRCXHAYCM/Tbone.jpg Postauricular Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957532449-VISPDYNAZVN0DL6EJAE4/3-1+Postauricular+Approach+-+Incision.jpg Postauricular Approach - 3.1 Incision – The postauricular incision (Fig 3.1) for access to the EAC and mastoid is the most common incision used – For chronic ear disease, it is important to extend the incision anterosuperior to grant sufficient access to the antrum and epitympanum – Pitfall: placement of the incision directly in the postauricular sulcus may result poor cosmesis and accumulation of debris; ideally the incision should be at least 0.5cm posterior to the sulcus https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957532631-DSJ33XHVXZUU5ZB68YE6/3-2+Postauricular+Approach+-+Elevation+in+loose+areolar+plane.jpg Postauricular Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957535116-ZP258BA5VZAKWLSUE5T3/3-2+Postauricular+Approach+-+Fascia+Harvest+%282D%29+-+Annotated.jpg Postauricular Approach - 3.2 Harvesting Fascia Grafts – Through a postauricular incision (Fig 3.2), grafts for tympanic membrane reconstruction can be readily harvested – Layers suitable for reconstruction include the loose areolar (“fool’s fascia, Fig 3.2a) located immediately deep to the temporoparietal fascia, true temporalis fascia, and periosteum deep to the temporalis muscle (helpful on revision cases) https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957535403-KFZAHRGR8YEDYCZASQMJ/3-2+Postauricular+Approach+-+Fascia+Harvest+%282D%29+-+No+annotations.jpg Postauricular Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957537142-THKLDJEJXRCOP63T3U9Z/3-3+Postauricular+Approach+-+Exposure+of+mastoid+cortex+-+Annotated.jpg Postauricular Approach - 3.3 Exposure of Mastoid Cortex – To expose the mastoid cortex and bony EAC, incisions are typically made in a “T” or pennant shape through the musculoperiosteum – The musculoperiosteum is then elevated forward with a periosteal elevator until the ear canal is encountered – Definitive identification of the spine of Henle will help the surgeon to adequately thin the bony EAC and safely access the mastoid antrum – In revision cases where mastoidectomy has been performed, it is helpful to elevate superiorly along the root of zygoma and inferiorly along the mastoid tip to identify the EAC and avoid inadvertent injury to a dehiscent sigmoid or transection of the meatal skin https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957537553-4MSEDTX5OT50GFJ13OQX/3-3+Postauricular+Approach+-+Exposure+of+mastoid+cortex+-+No+annotations.jpg Postauricular Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957550015-EJAP641BDDUGZXHDP4YW/3-3+Postauricular+Approach+-+Exposure+of+mastoid+cortex.jpg Postauricular Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957539314-P3G8L4QXQXLIQT2KSW06/3-4+Postauricular+Approach+-+Canal+incision+-+Annotated.jpg Postauricular Approach - 3.4 Canal Incision – Horizontal canal incisions can either be made transcanal with an otic speculum under direct visualization or postauricular transcanal – If the tympanic membrane will not be reconstructed (e.g., stapedotomy procedure), then preserving an adequate length of the tympanomeatal flap is crucial – If needed for exposure, superior and inferior back-cuts can be made in the ear canal skin near the tympanosquamous and tympanomastoid suture lines, respectively. – The ear canal skin can then be retracted forward using a self-retaining retractor such as a Perkins or Weitlaner. – It is important to lay the ear canal skin unfurled and fully within the bony ear canal at the conclusion of the case in order to avoid developing a mastoid-cutaneous fistula or iatrogenic cholesteatoma https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957541088-K7486ND2DR5SV26ULXRH/3-4+Postauricular+Approach+-+Canal+incision+-+No+annotations.jpg Postauricular Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1588957554088-MDIXR8M22LJMP4RNMSFY/3-4+Postauricular+Approach+-+Canal+incision.jpg Postauricular Approach https://www.headmirror.com/tbone-atlas-dehiscence daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152673480-CZCXML9HKEP2G1VP1S97/Tbone.jpg Trasmastoid Superior Canal Dehiscence Repair https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056184505-PP6AJ01O8U4TTYNTO8M7/10-1+SSCD+-+Labyrinth+-+Annotated+copy.jpg Trasmastoid Superior Canal Dehiscence Repair - 11.1 Approach to SSCC and temporal dura – Transmastoid superior SSCD repair begins with mastoidectomy with antrotomy and skeletonization of the tegmen mastoideum, sinodural angle, and sigmoid sinus – This forms a corridor to access the dehiscent portion of the canal (resurfacing) or the anterior and posterior limbs (plugging) https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056184569-9YNV8BZDRJIHIFKSHJG7/10-1+SSCD+-+Labyrinth+-+No+annotations.jpg Trasmastoid Superior Canal Dehiscence Repair https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056196245-DV4ACDU94XLW276M3R5A/10-1+SSCD+-+Labyrinth+copy.jpg Trasmastoid Superior Canal Dehiscence Repair https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056186259-F2E78LTO184S0BKNN1N5/10-2+SSCD+-+Elevating+dura+for+SSCD+resurfacing+-+Annotated+copy.jpg Trasmastoid Superior Canal Dehiscence Repair - 11.2 Elevating temporal dura (resurfacing) – Decompressing the temporal dura lateral to the SSCC permits careful elevation of the dura overlying the dehiscence – Avoidance of suction is vital to reduce the risk of sensorineural hearing loss – A variety of substances may be used for resurfacing, including the cartilage cap technique (see reference below) Reference: Lundy L et al. Cartilage cap occlusion technique for dehiscent superior semicircular canals. Otol Neurotol. 2011 Oct;32(8):1281-4. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056187921-RORC0IDMDXPPM31P9GPO/10-2+SSCD+-+Elevating+dura+for+SSCD+resurfacing+-+No+annotations.jpg Trasmastoid Superior Canal Dehiscence Repair https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056198707-DRJ4ZTP0S7NRIN1FYSJ5/10-2+SSCD+-+Elevating+dura+for+SSCD+resurfacing+copy.jpg Trasmastoid Superior Canal Dehiscence Repair https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056198125-5P1G2VVC8NHX0X096JFS/10-3+SSCD+-+Blue+line+SSC+for+plugging+-+Annotated+copy.jpg Trasmastoid Superior Canal Dehiscence Repair - 11.3 “Blue-lining” the SSCC (plugging) – “Blue-lining” the SSCC involves removing the bone without violating the endostium – This permits careful soft-tissue plugging of the canal without significant injury to the membranous labyrinth and risk of sensorineural hearing loss https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056199234-UXNLRSL9H4AKWQEUHXLD/10-3+SSCD+-+Blue+line+SSC+for+plugging+-+No+annotations.jpg Trasmastoid Superior Canal Dehiscence Repair https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056205232-ZMR9GM6NUDNECPS188FB/10-3+SSCD+-+Blue+line+SSC+for+plugging+copy.jpg Trasmastoid Superior Canal Dehiscence Repair https://www.headmirror.com/tbone-atlas-facial-nerve daily 0.75 2020-05-10 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152587822-4ZOX6WSAX617BDILTXMU/Tbone.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056676611-YRMESVP2Q195ZL101MAM/12-1+Facial+nerve+-+SMF+-+Annotated.jpg Facial Nerve Decompression & Mobilization - 12.1 Exposure: distal to second genu – The intratemporal FN can be approached via middle fossa, transmastoid, or translabyrinthine approaches – The transmastoid approach allows access to the FN distal to the geniculate ganglion – Combining mastoidectomy with a parotidectomy approach permits access to the entire extratemporal FN as well – Mastoidectomy with antrotomy and thinning of the posterior external auditory canal permits exposure of a limited portion of the mastoid segment of the FN – Wider mastoidectomy as pictured with skeletonization of the labyrinth, sigmoid sinus, jugular bulb and mastoid tip permits access to the FN between the second genu and SMF https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056676812-EWDTKNEEAE974AQNMA17/12-1+Facial+nerve+-+SMF+-+No+annotations.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056691493-HRWXZRARNUWOXJXTR8NY/12-1+Facial+nerve+-+SMF.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056680514-BOQJT33MWAXWY7GX2C80/12-2+Facial+nerve+-+Tip+removed+-+Annotated.jpg Facial Nerve Decompression & Mobilization - 12.2 Exposure: Stylomastoid foramen – Exposure of the SMF involves removal of the mastoid tip – Efficient removal of the mastoid tip involves removing bone from the cortex to digastric groove, across the FN epineurium, and anteriorly to the soft tissue adjacent to the parotid inferior to the tympanic ring – The SMF is not a circular “foramen” but rather a conical space with the narrow portion coalescing around the mastoid segment of the FN and the wide base at the main trunk and parotid – Remaining periosteum and sternocleidomastoid muscle attachments can then be removed quickly to amputate the tip – Fibers from the posterior belly of the digastric muscle invest the SMF and obscure direct visualization of the nerve as it leaves the temporal bone https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056682786-O0WL5QWIV2NJ4O9KPEEP/12-2+Facial+nerve+-+Tip+removed+-+No+annotations.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056696124-41B4Q5DJ8X8QAF2TI5XI/12-2+Facial+nerve+-+Tip+removed.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056694374-5FZNJTALAET29FHN3FM2/12-3+Facial+nerve+-+Main+trunk+and+pes+exposed+-+Annotated.jpg Facial Nerve Decompression & Mobilization - 12.3 Exposure: extratemporal – Once the mastoid tip is removed, the FN main trunk can be identified as it extends anteriorly into the parotid gland and divides into the upper and lower divisions at the pes anserinus https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056696566-VULPJ72MIWJ9JNRW6WON/12-3+Facial+nerve+-+Main+trunk+and+pes+exposed+-+No+annotations.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056711104-H1VU3BWOIHZGE4MXX438/12-3+Facial+nerve+-+Main+trunk+and+pes+exposed.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056700468-3S45L2ORSJOY2TDLG5WI/12-4+Facial+nerve+-+Elevating+mastoid+and+tympanic+segments+-+Annotated.jpg Facial Nerve Decompression & Mobilization - 12.4 Anterior transposition I – To approach the jugular foramen and other pathologies involving hypotympanic exposure, the mastoid segment of the FN can be transposed anteriorly – The bone around the nerve should be “egg-shelled” a minimum of 270-degrees and then gently flaked off – Elevating the nerve should occur without injury to the epineurial sheath to minimize postoperative neuropraxia https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056703019-XIV5V7QRF1E5NWKEII7E/12-4+Facial+nerve+-+Elevating+mastoid+and+tympanic+segments+-+No+annotations.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056716585-4BE38XV2L4NNIE2RSNI8/12-4+Facial+nerve+-+Elevating+mastoid+and+tympanic+segments.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056714000-XDJWNQW1ERF07QDDYVUC/12-5+Facial+nerve+-+Anterior+transposition+-+Annotated.jpg Facial Nerve Decompression & Mobilization - 12.5 Anterior transposition II – Pedicled between the geniculate ganglion and SMF, anterior transposition of the FN provides wide access to the infralabyrinthine space, including the jugular foramen – Complete anterior transposition will result in temporary and possible partial long-term FN paresis https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056716382-P7Y3OB1KZ9AW6ZJJX8IB/12-5+Facial+nerve+-+Anterior+transposition+-+No+annotations.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056730534-7TURDHIAWEOL7K5JSXB9/12-5+Facial+nerve+-+Anterior+transposition.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056719022-MP5SJ6WHD7LVVQLLFLIG/12-6+Facial+nerve+-+Anterior+transposition+removing+ridge+-+Annotated.jpg Facial Nerve Decompression & Mobilization - 12.6 Anterior Transposition: exposure of the jugular bulb – Removal of the bone medial to the “fallopian bridge” and hypotympanic air cells permits access to the jugular bulb and jugulocarotid spine https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056721172-8P6MF94GO3CC4RRKPI7R/12-6+Facial+nerve+-+Anterior+transposition+removing+ridge+-+No+annotations.jpg Facial Nerve Decompression & Mobilization https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056733697-2B208RGUQ3QVHATRBKV6/12-6+Facial+nerve+-+Anterior+transposition+removing+ridge.jpg Facial Nerve Decompression & Mobilization https://www.headmirror.com/tbone-atlas-cochlear-implantation daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152837562-0U0FTOFFVSHINHVMPFI7/Tbone.jpg Cochlear Implantation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056282968-38MQCBOCRAJK12Q8YBAM/9-1+Facial+recess+-+Annotated+copy.jpg Cochlear Implantation - 8.1 Facial recess – The facial recess (posterior tympanotomy) is the most common approach for cochlear implantation – Facial recess is a teardrop-shaped anatomic pathway to the middle ear from the mastoid bounded by the incus buttress, chorda tympani nerve, and facial nerve – Ideally, the stapedial tendon and pyramidal eminence are visualized to estimate the location of the round window niche (roughly 2 mm inferior to pyramidal eminence) https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056283076-MNLIPBR6R8V81W6KX4FP/9-1+Facial+recess+-+No+annotations.jpg Cochlear Implantation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056294372-E44SB5H5XGKBE7CYNN2S/9-1+Facial+recess+copy.jpg Cochlear Implantation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056284930-RQQV8GETV62WN7HV6XPO/9-2+Round+window+niche+drilled+-+Annotated+copy.jpg Cochlear Implantation - 8.2 Round window – The bony overhang of the round window niche, posterosuperior to the round window, commonly obscures visualization of the round window membrane – Frequently there is a pseudomembrane, comprised of middle ear mucosa, that drapes over the true round window membrane – To facilitate electrode placement, the overhang can be removed with a 1 or 1.5 mm diamond bur until the true round window membrane and annulus are identified – Alternatively, an electrode array can be inserted via a separate cochleostomy, typically anteroinferior to the round window to facilitate placement within the scala tympani https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056286817-1K1ZIDR2BT4NI7FKPDU2/9-2+Round+window+niche+drilled+-+No+annotations.jpg Cochlear Implantation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056297960-UOSGXOQGWNRR2FQAOBV9/9-2+Round+window+niche+drilled+copy.jpg Cochlear Implantation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056296229-9VEK14YHJSYRHGZQQH9L/9-3+Scala+vestibuli+-+Annotated+copy.jpg Cochlear Implantation - 8.3 Scala vestibuli insertion – In cases where the scala tympani is inaccessible (typically, due to ossification or otosclerotic involvement) a scala vestibul insertion can be performed – Drilling a cochleostomy anterior superior to the round window yields the osseous spiral lamina and basilar membrane with the superior compartment representing the scala vestibuli – Drilling further superiorly and medially is not advised as one will encounter the modiolus, resulting in potential cochlear nerve damage and CSF leak https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056297884-DESNLYEJB64UT47JOTHX/9-3+Scala+vestibuli+-+No+annotations.jpg Cochlear Implantation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056348835-KJ04CIZOBZWPZCURDM99/9-3+Scala+vestibuli+copy.jpg Cochlear Implantation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056300144-SDB129U9M82TMR39SY6Z/9-4+Second+turn+-+Annotated+copy.jpg Cochlear Implantation - 8.4 Second turn insertion – In labyrinthitis ossificans cases where the fibrous or ossified portion does not extend beyond the basal turn, a second turn insertion can be performed – The target location for cochleostomy should be just anterior to the oval window niche – The tympanic segment of the FN is in very close proximity and should be carefully protected https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056301871-0DHWHXJTPVNK0WXTX6S0/9-4+Second+turn+-+No+annotations.jpg Cochlear Implantation https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589056435865-EHF7HU85AEJFH6AL0POO/9-4+Second+turn+copy.jpg Cochlear Implantation https://www.headmirror.com/tbone-atlas-cwd daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152887769-M9F6MOY3TRJCKRKQXUWT/Tbone.jpg Canal Wall Down Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055561444-YVMW0LVVCJNG5X887ZA2/6-1+CWD+-+Annotated+copy.jpg Canal Wall Down Mastoidectomy - 6.1 Creating the Mastoid Cavity – Removal of the posterior and superior bony EAC to the level of the facial nerve (without uncovering the nerve) and HSCC – The reconstructed tympanic membrane is draped over the facial ridge and rests on the residual stapes superstructure or ossicular reconstruction after interposing cartilage https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055561668-GWA9TC2E3CNOT18ZTAPX/6-1+CWD+-+No+annotations.jpg Canal Wall Down Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055578680-GXWVDUT3DOYJH5W4ZHLY/6-1+CWD+copy.jpg Canal Wall Down Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055563963-9DI8GFOS25DSHPJ7R05M/6-2+CWD+-+facial+ridge+too+high+-+Annotated+copy.jpg Canal Wall Down Mastoidectomy - 6.2 Pitfall: Excessive bone on facial ridge – Inadequate removal of EAC bone results in a “high facial ridge” – After healing, this creates a dependent, difficult to access area of the mastoid cavity and may result in debris accumulation or infection – The goal of meatoplasty and canal wall down tympanomastoidectomy is to create a uniform “bowl” without overhanging bone that can be completely visualized through the enlarged soft tissue meatus https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055566331-LOLRFPY2EVAA0WSEEXRX/6-2+CWD+-+facial+ridge+too+high+-+No+annotations.jpg Canal Wall Down Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055587017-62NUCLLX00I7G6D0QF29/6-2+CWD+-+facial+ridge+too+high+copy.jpg Canal Wall Down Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055581383-WABR7HMTTGIZWN30P8U9/6-3+CWD+-+tip+canal+mismatch+-+Annotated+copy.jpg Canal Wall Down Mastoidectomy - 6.3 Pitfall: Dependent mastoid tip cavity – Removal of the mastoid tip allows the sternocleidomastoid muscle to collapse into the defect – Alternatively, the mastoid tip can be preserved – Excessive exenteration of bone in the mastoid tip without obliteration results in a mismatch between the position of the inferior bony EAC and inferior most point of the mastoid cavity – This dependent area in the mastoid may accumulate debris that cannot be visualized and cleaned effectively, or infection from water exposure https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055583989-28RBH3HPU6NF32H0NW2W/6-3+CWD+-+tip+canal+mismatch+-+No+annotations.jpg Canal Wall Down Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055608703-TOSDN62HL1ALLYDQUAKZ/6-3+CWD+-+tip+canal+mismatch+copy.jpg Canal Wall Down Mastoidectomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055615451-N5IKXII478Z0Q606HBLB/6-4+CWD+-+Meatoplasty.jpg Canal Wall Down Mastoidectomy - 6.4 Meatoplasty – Meatoplasty permits visualization of the cavity for cleaning and aeration – A variety of incisions including those between the root of the helix and tragus and in the incisura – A “one-cut” meatoplasty is pictured (see reference below) – Removal of the cavum concha permits positioning of the skin flap inferomedially – The skin flap is “pinned” with a subcutaneous suture Reference: Hovis KL et al. “The one-cut meatoplasty: novel surgical technique and outcomes.” Am J Otolaryngol. 2015 Mar-Apr;36(2):130-5. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055604441-JM1CKX27VQM2DPG6YGBJ/6-4+CWD+-+Meatoplasty+-+No+annotations.jpg Canal Wall Down Mastoidectomy https://www.headmirror.com/tbone-atlas-middle-fossa daily 0.75 2020-05-10 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152503682-T8E3GTAIOQKGG1K027PT/Tbone.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057231607-6DOSDNBHQPTXMSYZPHRX/14-1+MF+approach+-+Incision+planning+-+Annotated.jpg Middle Cranial Fossa Approach - 14.1 Skin incision – A variety of skin incisions are described for middle fossa or temporal craniotomy – Ideally the incision is kept behind the hairline to promote cosmesis – The superior extent depends on the anticipated “height” of the craniotomy window; for example, addressing superior semicircular canal dehiscence does not require extensive medial dissection, whereas decompression of the internal auditory canal does https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057231812-3JW84KLOMSHIZGGVD36V/14-1+MF+approach+-+Incision+planning+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057244378-BSWV77XMG1SHK334PYK8/14-1+MF+approach+-+Incision+planning.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057254941-A211AQCSMWHUDH7DTR7Q/14-2+MF+approach+-+Exposure+of+temporalis+-+Annotated.jpg Middle Cranial Fossa Approach - 14.2 Exposure of temporalis muscle – In a loose areolar fascial plane, skin flaps are elevated anteriorly and posteriorly – Fascia grafts may be harvested for later use https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057254961-K8L9ZZXA946G3P3WKLCY/14-2+MF+approach+-+Exposure+of+temporalis+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057275485-OKKZG76NATRU125QWRD7/14-2+MF+approach+-+Exposure+of+temporalis.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057257474-BPD89GIY3LOIEGKLE0M7/14-3+MF+approach+-+Temporalis+incision+planning+-+Annotated.jpg Middle Cranial Fossa Approach - 14.3 Muscle incision – The temporalis muscle can be retracted anteriorly (most common), posteriorly, or divided and retracted in both directions – Commonly, a cuff of muscle is left along the superior temporal line to facilitate suture approximation of the temporalis muscle during wound closure https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057259988-4EEGBI61BEUTNOQSAYR4/14-3+MF+approach+-+Temporalis+incision+planning+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057278437-VL6W75UQUFOGDZL030Z4/14-3+MF+approach+-+Temporalis+incision+planning.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057303367-15N0KRIGO7QHXHCDEIMV/14-5+MF+approach+-+Craniotomy+complete+-+Annotated.jpg Middle Cranial Fossa Approach - 14.4 Planning craniotomy – The temporal craniotomy is typically centered on the external auditory canal and can be adjusted anteriorly or posteriorly depending upon the “target” – For internal auditory canal access, typically the craniotomy is centered two-thirds anterior to the EAC – The craniocaudal height of the craniotomy window has some influence on the degree of medial dissection along the middle fossa floor and temporal lobe retraction – In the figure, a 4 x 4 cm craniotomy is marked https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057303544-OKRXW6ZCUFUFMA04E4SH/14-5+MF+approach+-+Craniotomy+complete+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057319743-7THD2AKEKA41LKTBOAUJ/14-5+MF+approach+-+Craniotomy+complete.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057280483-36XUK7D9AAJ9YIW6US1A/14-4+MF+approach+-+Craniotomy+planning+-+Annotated.jpg Middle Cranial Fossa Approach - 14.5 Craniotomy – The craniotomy can be fashioned with two or three burr holes (typically) and troughs – The zygomatic root approximates the middle cranial fossa floor – A rongeur can be used to remove the inferior edge of the craniotomy window to visualize the middle fossa floor https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057283032-3LO8MP1UFKB4NL0JX8LR/14-4+MF+approach+-+Craniotomy+planning+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057292548-8L3QQPO4ZRP6E447M7QQ/14-4+MF+approach+-+Craniotomy+planning.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057305190-11V6PHH2PBKVO3YUDLM8/14-6+MF+approach+-+MF+floor+-+Annotated.jpg Middle Cranial Fossa Approach - 14.6 Elevation of temporal dura – The temporal dura is elevated to the petrous ridge in almost all cases to permit access to the superior semicircular canal, internal auditory canal, facial nerve, and petrous apex – Care should be taken to remain extradural to avoid injury to the temporal lobe – In SSCC dehiscence cases, suctioning should only be performed anterior or posterior to the expected location of the superior semicircular canal, which may or may not be in the area of the arcuate eminence – The position of a dehiscent SSCC can be estimated by measuring a distance of 1 inch medial to the outer edge of the craniotomy in a coronal plane aligned with the EAC (see reference below) – Anteriorly, the dura should be elevated in a posterior to anterior direction to avoid traction on the GSPN and resultant facial nerve neuropraxia Reference: Patel NS et al. “An Easy and Reliable Method to Locate the Dehiscence During Middle Fossa Superior Canal Dehiscence Surgery: It Is a (C)inch.” Otol Neurotol. 37(8): 1092-5. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057306946-SNRPHP9MD5HWNWR6E8I6/14-6+MF+approach+-+MF+floor+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057319045-PUSII1JCU0ENBIUOK3UR/14-6+MF+approach+-+MF+floor.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057320883-OIEI59C5DS9BUIXMZIMC/14-7+MF+approach+-+Superior+canal+-+Annotated.jpg Middle Cranial Fossa Approach - 14.7 Identifying the internal auditory canal – To identify the IAC, the SSCC is often first “blue-lined” – A dehiscent SSCC can be resurfaced or plugged at this point – A line that bisects the angle formed by the SSCC and GSPN marks the expected location of the IAC, deep to the meatal plane https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057321538-EU7VK3T92EW5LSBYOQWF/14-7+MF+approach+-+Superior+canal+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057331326-46UP4M6O2ISVLIV70UMW/14-7+MF+approach+-+Superior+canal.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057322988-1II9AOALC8DNHLQ2X6DG/14-8+MF+approach+-+IAC+identified+-+Annotated.jpg Middle Cranial Fossa Approach - 14.8 Decompression of IAC – Identifying the IAC dura can be achieved by drilling anteromedially near the petrous ridge, whereby the dura surrounding the porus or just anterior to the porus is often first encountered – In contrast to the translabyrinthine approach, the IAC should be approached from a lateral (porus) to medial (fundus) direction – Some surgeons prefer to identify the labyrinthine segment of the facial nerve and follow it to the fundus to identify the IAC https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057324515-OGNJ25UE7QEF8XR52ZE6/14-8+MF+approach+-+IAC+identified+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057333443-J2TU3JWZEL7V7Z13BVFW/14-8+MF+approach+-+IAC+identified.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057333289-BFKDF6CNQRFWBNVU4J0X/14-9+MF+approach+-+Labyrinthine+-+Annotated.jpg Middle Cranial Fossa Approach - 14.9 Exposure of lateral IAC – Decompression of the lateral IAC is more limited due to the position of the superior semicircular canal and cochlea – The cochlea lies just deep and medial to the geniculate ganglion – Decompressing the labyrinthine segment should be performed with continuous irrigation and a size 2 mm diamond bur or less to avoid inadvertent opening of the labyrinth – Access to the lateral most aspect of the internal auditory canal requires identification of the labyrinthine segment of the facial nerve and Bill’s bar https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057334531-C84A42T6C20OD0TCV0ZN/14-9+MF+approach+-+Labyrinthine+-+No+annotations.jpg Middle Cranial Fossa Approach https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057339539-2LF476HGAH948Y83D5ML/14-9+MF+approach+-+Labyrinthine.jpg Middle Cranial Fossa Approach https://www.headmirror.com/tbone-atlas-abbreviations daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589153138741-836CW74P4VLLM7CNCBH8/Tbone.jpg Abbreviations https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589057459908-CT7QDA7WMEVULPC4O9PN/Abbreviations.png Abbreviations https://www.headmirror.com/tbone-atlas-eac-closure daily 0.75 2020-05-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152708524-GDJCE7BSN420BZQVP8JG/Tbone.jpg Ear Canal Closure https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055805862-P119SXMZ196H6TZA4C51/8-1+Ear+canal+closure+copy.jpg Ear Canal Closure - 10.1 Ear Canal Closure – Closure of the EAC is an adjunct procedure in the surgical management of cholesteatoma, lateral skull base CSF leaks, and temporal bone malignancy, among others. – Cholesteatoma: Patients with poor hearing following multiple tympanomastoidectomy procedures or chronically draining mastoid cavities may elect to undergo subtotal petrosectomy and ear canal overclosure (with or without bone conduction hearing device placement) to eliminate the need for periodic cleanings. – CSF leaks: Spontanous or postoperative CSF otorrhea is often managed with either transcanal removal of the TM, malleus, incus, and all associated epithelium or formal subtotal petrosectomy. – Temporal bone malignancy: While rare, medial external auditory canal or middle ear tumors may result in resection of the TM, malleus, and incus. – Steps 1. Transect the posterior EAC skin at the level of the mastoid cortex. 2. Via transcanal visualization, incise the skin down to the tragal cartilage or perichondrium on the anterior side and complete a circumferential incision to connect the two. 3. Posteriorly, the lateral skin may be visualized and dissected sharply using scissors with the conchal cartilage and tragal remnant as deep boundaries. The most adherent area is typically the inferior corner, care should be taken in this location to avoid perforation of the skin. 4. The skin can then be retracted for sutures to be placed at the superior and inferior corners. This permits eversion of the closure. 5. Sufficient laxity of skin is vital to promote healing and reduce inversion with debris collection or cholesteatoma development from medial skin trapping 6. The skin can be sewn closed with interrupted vertical or horizontal mattress absorbable sutures. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055788720-J7X0CX57KV84YAMX57MG/8-2+Subtotal+petrosectomy+-+Annotated+copy.jpg Ear Canal Closure - 10.2 Removal of posterior canal wall, malleus, incus, and ear canal contents – Subtotal petrosectomy is in effect a canal wall down mastoidectomy procedure with preservation of the stapes, labyrinth, and facial nerve – This procedure facilitates visualization of the ET orifice (e.g. for obliteration with muscle or facial in CSF leak procedures) or cochlea (e.g. for cochlear implantation) – Using a diamond bur to smooth the anterior bony canal is important to eliminate remnant squamous epithelium or portions of the tympanic membrane annulus https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055790773-721AZYE8V27087AHZDJL/8-2+Subtotal+petrosectomy+-+No+annotations.jpg Ear Canal Closure https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589055804404-DZ0C2ODFIR8XPXNO7PGI/8-2+Subtotal+petrosectomy+copy.jpg Ear Canal Closure https://www.headmirror.com/how-to-take-3d-anatomy-photos daily 0.75 2020-07-23 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152503682-T8E3GTAIOQKGG1K027PT/Tbone.jpg Creating 3D Anatomy Images https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589169567054-S6HBOAF52U06K641PA95/Stereo-diagram.png Creating 3D Anatomy Images https://www.headmirror.com/tbone-atlas-about daily 0.75 2021-05-16 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589121208816-J7TCY6Z9WU1LK1VNRH1I/Tbone.jpg About this Section https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589160756298-PXLNTE16WZ8YEJSZULGE/Patel.jpeg About this Section https://www.headmirror.com/trauma daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Trauma https://www.headmirror.com/general-otolaryn daily 0.75 2020-09-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png General Otolaryngology https://www.headmirror.com/cme-survey daily 0.75 2020-05-22 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Survey https://www.headmirror.com/cpg daily 0.75 2020-12-03 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591399235964-2MYIBLZQSV2B9EVTBVDM/Untitled_Page_3.jpg Clinical Practice Guidelines https://www.headmirror.com/651243960299 daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062812220-2BAAKNG2HJHODNSIVJCJ/CPG.jpg Evaluation of the Neck Mass in Adults, 2017 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592144701180-BWL7537XQCQUEGHK1TMJ/image-asset.jpeg Evaluation of the Neck Mass in Adults, 2017 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592144715053-XRL8APJH1JAMLHTQQ3KR/image-asset.jpeg Evaluation of the Neck Mass in Adults, 2017 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/874522830892 daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062847252-RE1ED8Z1T09IY8RAMOLA/CPG.jpg Benign Paroxysmal Positional Vertigo (BPPV), 2017 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592147859562-6YE01A8PMHQAAR68XY5Y/image-asset.jpeg Benign Paroxysmal Positional Vertigo (BPPV), 2017 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592080298143-6MH80X8C2TK0E9VZ5C7B/BPPV+Algo.jpeg Benign Paroxysmal Positional Vertigo (BPPV), 2017 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cpg-rhinoplasty daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062894307-V0TDD4SWO498FZDZF78F/CPG.jpg Improving Nasal Form and Function after Rhinoplasty, 2017 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592142074599-2ACDA900P1NU3QHIWTP2/image-asset.jpeg Improving Nasal Form and Function after Rhinoplasty, 2017 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592142094530-LQJO8H3V61NLBUGAWNE1/image-asset.jpeg Improving Nasal Form and Function after Rhinoplasty, 2017 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/817289426360 daily 0.75 2020-12-03 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062693147-7P72C7KDZQIZ4NLF43KR/CPG.jpg Sudden Hearing Loss, 2019 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591575346941-AQDEVUH30DS9TJ7E1PQA/table+4+-+Summary+of+Guideline+Key+Action+Statements.png Sudden Hearing Loss, 2019 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591575209052-7OYOP2FKJMOTD62SN1GR/SSNHL+Algo.png Sudden Hearing Loss, 2019 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cpg-otitis-externa daily 0.75 2020-12-03 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598063164311-DQVRDH6O879MT904TJUR/CPG.jpg Acute Otitis Externa, 2014 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592084299496-TODOOYV06261D159ELCK/AOE+Key+Statements.jpeg Acute Otitis Externa, 2014 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592084312600-Q4T50X9B399EUPM6R5EE/image-asset.jpeg Acute Otitis Externa, 2014 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/908959891595 daily 0.75 2020-12-03 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062656512-QPF4EG1PD1HT39BU6MLX/CPG.jpg Nosebleed (Epistaxis), 2020 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592145431664-3EQHF5IT9GQPWTOSJI1U/image-asset.jpeg Nosebleed (Epistaxis), 2020 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592145445569-TFKY75VK55AELSQ75839/image-asset.jpeg Nosebleed (Epistaxis), 2020 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/454822715176 daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062752070-0727F7J6HZ7ZCLXXOH3C/CPG.jpg Tonsillectomy in Children, 2019 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592146290646-V2QUQRCP09AKDBNB6JG1/image-asset.jpeg Tonsillectomy in Children, 2019 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592146307818-1SSVBFJPL5K8U48FDAS5/image-asset.jpeg Tonsillectomy in Children, 2019 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cpg-sinusitis daily 0.75 2020-12-03 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598063013269-XYTTIL7CFNJL30NC79RY/CPG.jpg Adult Sinusitis, 2015 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592143628376-LXLN7XRDE6DJ7FV4S3UM/Sinusitis+Key+Statements.jpeg Adult Sinusitis, 2015 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592143644269-XL4FFKYF1JQIC3NG81H2/image-asset.jpeg Adult Sinusitis, 2015 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cpg-voice daily 0.75 2020-12-03 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598063553307-IYPKGJ41IDYO13HS62PF/CPG.jpg Improving Voice Outcomes After Thyroid Surgery, 2013 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592145143881-E2B47RLMY6696BR39W3H/image-asset.jpeg Improving Voice Outcomes After Thyroid Surgery, 2013 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592145131118-44GICRY64O0JUIYRSXB7/image-asset.jpeg Improving Voice Outcomes After Thyroid Surgery, 2013 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/highyield-reviews daily 0.75 2020-06-05 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591400147151-K1SU35U4LRJYOGI79RYL/Skull.jpg High-Yield Reviews https://www.headmirror.com/442380923820 daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062432900-L19R20BXTC26EP9Q1WEK/CPG.jpg Ménière’s Disease, 2020 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591465644434-GT1Y1VWU3UBLZH3PE4O6/Menieres+-+Summary+of+Guideline+Key+Action+Statements.png Ménière’s Disease, 2020 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591466166048-YI9M4AZO4LDPOHU7UF62/Menieres+Algorithm.png Ménière’s Disease, 2020 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cpg-otitis-media daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062974379-JHWIXXQKQVH8L9X77M29/CPG.jpg Otitis Media with Effusion, 2016 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592083523054-SW0J5HLEBQU5LC9UT9T2/image-asset.jpeg Otitis Media with Effusion, 2016 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592083538727-I15OO4ARAH9MSYUI4EL7/OME+Algo.jpeg Otitis Media with Effusion, 2016 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cpg-tinnitus daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598063092582-XFUY83ZJZ9FEZIDDFY88/CPG.jpg Tinnitus, 2014 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592084077738-7OZVMGQGOBOZZ7AR7NJA/image-asset.jpeg Tinnitus, 2014 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592084091917-C26N57CQPFOU0Y3AFN5X/image-asset.jpeg Tinnitus, 2014 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/394468024425 daily 0.75 2020-12-03 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062787617-H6T69G1CVBPN94QSAI8E/CPG.jpg Hoarseness (Dysphonia), 2018 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592145729995-UMSEHG7YYPBV3H27FRVW/image-asset.jpeg Hoarseness (Dysphonia), 2018 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592145739834-OS40826GCDXP44RLG0N6/Dysphonia+Algo.jpeg Hoarseness (Dysphonia), 2018 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/new-page daily 0.75 2020-06-05 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591398614253-NTABTZHRMDS2IG9NXY7H/Untitled_Page_2.jpg Landmark Papers https://www.headmirror.com/cpg-allergic-rhinitis daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598063057700-W41A5T2URE43EUPOG1VJ/CPG.jpg Allergic Rhinitis, 2015 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592144252444-5TTRKC2EZ8JVOD2T0589/image-asset.jpeg Allergic Rhinitis, 2015 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592144264599-ODR0IVO5KS4SHLZAQUZD/image-asset.jpeg Allergic Rhinitis, 2015 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592144281760-URA9EA5672KYFY048YZN/image-asset.jpeg Allergic Rhinitis, 2015 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cpg-bells daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598063129884-50Z0XCG8YQFLUH08M4GB/CPG.jpg Bell's Palsy, 2013 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592141250147-WAB0W654O759A7NMHCFE/Bells+Key+Statements.jpeg Bell's Palsy, 2013 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592141296734-AG2I057IPVMSNK9ELCHD/Bells+Algo.jpeg Bell's Palsy, 2013 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cpg-tympanostomy-tubes daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598063206755-U62PNV6BTJQJBV12LFPL/CPG.jpg Tympanostomy Tubes in Children, 2013 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592141602185-R9JWJ8LNDEI4ITVOU6M5/image-asset.jpeg Tympanostomy Tubes in Children, 2013 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592141617379-9JI16KB1IJ8V5ES9WAEB/Tubes+Algo.jpeg Tympanostomy Tubes in Children, 2013 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/cochrane-reviews daily 0.75 2023-09-20 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591392353013-PTVAWQCMHL3AM69JA0QP/Cochrane.jpg Cochrane Reviews https://www.headmirror.com/cpg-cerumen daily 0.75 2020-06-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598062934011-8VIQ9TU9A4SPE3TOQVXL/CPG.jpg Earwax (Cerumen Impaction, 2017 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592083273024-05UVIE0O4VLW12NRHR69/image-asset.jpeg Earwax (Cerumen Impaction, 2017 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592083299778-637VM692DBQKPT8TJH2V/Ear+wax+algo.jpeg Earwax (Cerumen Impaction, 2017 Image Credit: American Academy Of Otolaryngology - Head And Neck Surgery https://www.headmirror.com/survival-guide/tonsil-bleed daily 0.75 2020-06-08 https://www.headmirror.com/headmirror-pubs daily 0.75 2021-08-14 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1591582076966-BAFJ94N3HSL1A0VJRUPA/Extra.jpg Headmirror Pubs https://www.headmirror.com/diversity-and-inclusion daily 0.75 2021-07-12 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1592358883139-O5W5KIFOB6W0EB4739BK/DiversityInclusion.png Diversity & Inclusion https://www.headmirror.com/papers-intro daily 0.75 2023-09-20 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1593921140219-ECGCNRDJZZCQ8LB2S0O5/Untitled.jpg Papers Introduction https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1593559240865-T9AGB27LHLR454IVJKPO/Strength+of+the+Recommendations.png Papers Introduction https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1593559371446-A0RJ4UA2WBTD3E8F2K78/Grades+of+Evidence.png Papers Introduction https://www.headmirror.com/otitis-media daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Otitis Media https://www.headmirror.com/tbonetrauma daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Temporal Bone Trauma https://www.headmirror.com/frontal-bone-fractures daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Frontal Bone Fractures https://www.headmirror.com/otitis-externa daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Otitis Externa https://www.headmirror.com/epistaxis daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Epistaxis https://www.headmirror.com/cme-moc2 daily 0.75 2020-07-15 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png CME & MOC 2 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586722261055-NRF7BBLBHCH8F0TIFMTR/rssfeed.png CME & MOC 2 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586721731704-XLKJ7DI52W1UTBYMIPXC/image-asset.jpeg CME & MOC 2 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586721625918-SGVJQSH27U1TLA79Q7F0/podbean.png CME & MOC 2 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586721794074-BGY8RPQOGG8PCGK8NKSB/logo%402x.png CME & MOC 2 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1586721437087-6U1OLFD0HFFEETF83KWD/stitcher-logo.png CME & MOC 2 https://www.headmirror.com/match-2021 daily 0.75 2020-10-20 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1597960547624-KQ6CUXY6OA2EI58ALRVF/Virtual.jpg Match 2020-2021 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1599604207999-1363X74ZW0VIE6GA7E77/signaling+timeline.png Match 2020-2021 https://www.headmirror.com/invasive-fungal-sinusitis daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Invasive Fungal Sinusitis https://www.headmirror.com/dictation-pediatric-otolaryngology daily 0.75 2020-07-28 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421205096888-N7RUM37UUW4VAUJILIT5/latest.jpg Pediatric Otolaryngology https://www.headmirror.com/dictation-otology daily 0.75 2021-09-20 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421205096888-N7RUM37UUW4VAUJILIT5/latest.jpg Otology & Neurotology https://www.headmirror.com/dictation-head-and-neck daily 0.75 2020-07-25 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421205096888-N7RUM37UUW4VAUJILIT5/latest.jpg Head & Neck https://www.headmirror.com/dictation-sleep-surgery daily 0.75 2020-12-01 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421205096888-N7RUM37UUW4VAUJILIT5/latest.jpg Sleep Surgery https://www.headmirror.com/dictation-laryngology daily 0.75 2020-07-25 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421205096888-N7RUM37UUW4VAUJILIT5/latest.jpg Laryngology https://www.headmirror.com/dictation-facial-plastic-surgery daily 0.75 2020-11-10 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421205096888-N7RUM37UUW4VAUJILIT5/latest.jpg Facial Plastic Surgery https://www.headmirror.com/dictation-rhinology-and-sinus-surgery daily 0.75 2020-07-28 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421205096888-N7RUM37UUW4VAUJILIT5/latest.jpg Rhinology & Sinus Surgery https://www.headmirror.com/lacerations daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Lacerations https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1597722568477-56KWI843SCQLR7ZJSFDA/survival+guide_Page_2.jpg Lacerations https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1597722620109-6CI00583K9GZ9UHWK0JO/survival+guide_Page_1+2.jpg Lacerations https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1597722667607-NA078HTPQGLM5F4EKKKD/survival+guide_Page_1.jpg Lacerations https://www.headmirror.com/complicated-acute-sinusitis daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Complicated Acute Sinusitis https://www.headmirror.com/nasal-bone-fractures daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Nasal Bone Fractures https://www.headmirror.com/tonsilitis daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Tonsillitis & Peritonsillar Abscess https://www.headmirror.com/posttonsillectomy-bleed daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Post-tonsillectomy Bleed https://www.headmirror.com/adult-tracheotomy-consult daily 0.75 2020-10-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Adult Tracheotomy Consult https://www.headmirror.com/deep-neck-space-infections daily 0.75 2020-08-29 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Deep Neck Space Infections https://www.headmirror.com/tracheostomy-tube-exchange daily 0.75 2020-10-10 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Tracheostomy Tube Exchange https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1602216835920-0PDVC1PJIYD2PAEUXRP4/Bivona+Tubes.PNG Tracheostomy Tube Exchange https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1602217006446-S72MPT206CK5CM3RA4MK/Shiley+Tubes.PNG Tracheostomy Tube Exchange https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1602217616330-O5QGMP3VGLZ7RCPNRY81/ETT+size.PNG Tracheostomy Tube Exchange https://www.headmirror.com/sudden-sensorineural-hearing-loss daily 0.75 2020-08-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Sudden Sensorineural Hearing Loss https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1598410033988-2LCXDP4U01Q0RGYE7KL6/SSNHL+Table+CC.PNG 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10 (Copy) (Copy) https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1633896262730-70VUZ2EC5E6JKJAUL8Q1/NOISY+BREATHING+IMAGE.png SG placeholder 10 (Copy) (Copy) - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1633896794391-9V3M5NGKQLYK8FLZN3LN/ETT+Size.png SG placeholder 10 (Copy) (Copy) - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.headmirror.com/sg-free-flap daily 0.75 2021-10-11 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Free Flap Checks https://www.headmirror.com/carotid-blowout daily 0.75 2021-05-23 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Sentinel Bleeds and Carotid Blowout 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Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/bc2ff599-2eca-4191-b6e8-104faf89e535/Airway+sizing+chart.PNG Pediatric Otolaryngology - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1633895591725-K8YSBHIR4L1B9POJM732/bronch+size+image.png Pediatric Otolaryngology - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.headmirror.com/trauma-survival-guide daily 0.75 2021-10-18 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1421199765149-APLYIL1GJ6PPE02WJACX/tumblr_m9au78OHdD1qzia08o1_1280.jpg Trauma https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1633915595114-QVOXYAAO4D67LPAXQXY3/anesthetics.png Trauma 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Age Appropriate Bronchoscope/Esophagoscope Sizing (individualized patient sizing must be considered) https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1633913273239-IW04YZ65F55X3O34M4DP/airway+size+pic.png Neck & Airway https://www.headmirror.com/on-call-consult-series daily 0.75 2020-11-19 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png On-Call Consults in <10 Minutes https://www.headmirror.com/no-home-program daily 0.75 2020-11-30 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1606695472917-F5EWNN3C6JJ79DRRTEM1/No+home.png No Home Program https://www.headmirror.com/facial-trauma daily 0.75 2021-07-02 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Facial Trauma https://www.headmirror.com/business-of-medicine-1 daily 0.75 2021-04-02 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Residency Applicant Toolkit https://www.headmirror.com/business-of-medicine-course-curriculum daily 0.75 2021-07-27 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1617674992353-2FPO9PCESL0ZRF15DGHC/BOM.jpg Curriculum https://www.headmirror.com/business-of-medicine-claim-cme-credit daily 0.75 2021-07-27 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1617674992353-2FPO9PCESL0ZRF15DGHC/BOM.jpg Claim CME Credit https://www.headmirror.com/business-of-medicine-intro daily 0.75 2021-04-06 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1617674992353-2FPO9PCESL0ZRF15DGHC/BOM.jpg Introduction https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1617674392336-8QTBG7FD8PG4OGDFCEFU/Nassiri.jpg Introduction https://www.headmirror.com/headneck-atlas-parotidectomy daily 0.75 2022-01-20 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619401589049-4MBRPS35XSG4HTPWIDMX/9Internalmaxillary2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300151147-AHDK543CKI7A51LTG4I5/2incision2D.jpg Parotidectomy & Parapharyngeal Space Dissection - 2.2. The incision should be carried down to the sub-SMAS plane. — Starting at the skin, the layers of soft tissue include skin, subcutaneous fat, superficial muscular aponeurosis (SMAS), additional fat, and parotid fascia. The SMAS is continuous with the platysma muscle and temporoparietal fascia. — The parotid fascia is identified as a thick white fascial layer below the SMAS. Dissection in this plane keeps the branches of the facial nerve safe. — When making the incision, care should be taken to avoid injuring the lobular branch of the greater auricular nerve that supplies sensation to the ear lobe. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300151835-BJCY3SHNHM45BR6G0KKH/2incision3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300156519-A6FALYN0C2B0W935HKQX/3SubSMASLabels.jpg Parotidectomy & Parapharyngeal Space Dissection - The skin flap is elevated over the parotid fascia, in a sub-SMAS plane. — In a traditional superficial parotidectomy, the skin flap is elevated inferiorly over the sternocleidomastoid muscle. In a partial parotidectomy or extracapsular dissection parotidectomy, the extent of skin flap elevation can be adjusted to account for the location of the tumor and extent of exposure necessary for tumor removal. — The greater auricular nerve and external jugular vein should be identified and preserved. — Superiorly, the skin flap should be elevated over the superior extent of the gland. Often times the superficial temporal vessels are visible here. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300152806-AYIQK8GYYSLHA797P3K2/3SubSMAS2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300155294-TO2GEB35EKF6GK44ZAIE/3SubSMAS3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300159050-1NMBJGSXQ47YG5ROYT7Y/4MasseterLabels.jpg Parotidectomy & Parapharyngeal Space Dissection - The skin flap is elevated anteriorly over the edge of the gland, such that the fascia overlying the masseter muscle is visible. — Again, in a limited partial parotidectomy or extracapsular dissection approach, the extent of dissection can be adjusted as necessary. — Bunt dissection should be used over the masseteric fascia, as distal branches of the facial nerve can become more superficial this far anteriorly. The parotid duct is sometimes visible at the anterior extent of dissection. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300157185-ECZ99X7FR7N26CV6YE7I/4Masseter2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300158508-KX5UNF9BPSO224FV0D0G/4Masseter3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300162869-ISB6KSU6SW42UJ7KOPSB/5GreatauricularLabels.jpg Parotidectomy & Parapharyngeal Space Dissection - Branches of the greater auricular nerve. — The tail of the parotid gland should be separated from the sternocleidomastoid muscle. In this process, the greater auricular nerve should be traced over the sternocleidomastoid muscle. — An anterior branch of the greater auricular nerve can typically be identified entering the parotid gland tissue. This branch often must be sacrificed during parotidectomy. The posterior branch of the greater auricular nerve that innervates the ear lobule should be identified and preserved. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300160725-0Y3RTND1BL1AVPAGD7QQ/5Greatauricular2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300161939-PL1BJROBCSSR6CQFMJS6/5Greatauricular3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300166334-ZVMLH43NEV2HNNB62X4N/6Pretragaltunnellabels.jpg Parotidectomy & Parapharyngeal Space Dissection - A pre-tragal tunnel is made and the posterior belly of the digastric muscle is identified. — The fascia overlying the sternocleidomastoid muscle is entered, and the muscle is retracted posteriorly. Dissection in the anterior and medial direction within the deep cervical fat will reveal the posterior belly of the digastric muscle. — The posterior bellow of the digastric serves as a landmark for the facial nerve. In adults, the nerve almost always lies deep to the digastric muscle. — A pre-tragal tunnel is created by sharp dissection in the fascia plane just anterior to the tragal pointer. Dissection should hug the tragal cartilage so as to not inadvertently injure the facial nerve. — The pre-tragal tunnel can now be connected to the plane over the digastric muscle, as dissection at this depth should again protect the facial nerve from injury. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300164088-AAVHRP22DTSUFH2XYJKB/6Pretragaltunnel2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300165723-EOKKCJPX8S4E4O37G1SR/6Pretragaltunnel3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300171699-WZ15VROX3A8S2SOJV084/7SuperficialParotidNerveLabels.jpg Parotidectomy & Parapharyngeal Space Dissection - The facial nerve main trunk is identified. — Landmarks often used to identify the main trunk of the facial nerve include: 1) the posterior belly of the digastric muscle – the digastric enters the medial surface of the mastoid tip at the digastric ridge, and the nerve should be just medial to this muscle attachment; 2) the tragal pointer – the main trunk of the facial nerve is typically 1cm deep and inferior to the distal end of the tragal pointer; 3) the tympanomastoid suture line – the suture line between the tympanic and mastoid segments of the temporal bone is just a few mm lateral to the stylomastoid foramen. Palpation of the suture line with a thumb often yields the main trunk of the facial nerve at the tip of the surgeon’s thumb. If proximal pathology obscures identification of the main trunk of the facial nerve, retrograde dissection from a more distal branch, or proximal dissection within the mastoid can also be utilized. — Careful dissection is performed to identify the facial nerve trunk, by carefully separating the fascia between the mastoid tip and the parotid gland, layer by layer. Dissection can be carried slightly anteriorly within the parotid tissue. The nerve travels deep to superficial as it exits the stylomastoid foramen, so dissection more anteriorly will reveal the nerve in a more lateral plane. — The main trunk of the nerve can be followed anteriorly after it is identified. It separates into the pes anserinus that defines the superior and inferior divisions of the facial nerve. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300168157-L7JT9TAR19A9JFPNZ48T/7SuperficialParotidNerve2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300171223-PFD6TWK6107EJ231BXJS/7SuperficialParotidNerve3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300176511-SR0NWME5B25OE67GUSVQ/8FacialnerveLabels.jpg Parotidectomy & Parapharyngeal Space Dissection - All branches of the facial nerve can be followed, dissected, and identified. — The facial nerve contains 5 branches: 1) The temporal (frontal) branch; 2) The zygomatic branch, 3) the buccal branch, 4) the marginal mandibular branch, and 5) the cervical branch. These branches can be recalled by the mnemonic “To Zanzibar By Motor Car.” — The branches of the facial nerve separate the parotid gland into its superficial and deep lobes. — Note that the most distal portions of the facial nerve branches are intimately associated with the masseter muscle. This emphasizes the importance of careful dissection when raising the skin flap anteriorly over the masseteric fascia. — The retromandibular vein descends posterior to the ramus of the mandible and lies superficial to the external carotid artery. It lies in the deep parotid gland, deep to the facial nerve. The vein can often be identified on CT scans of the parotid gland, and tumors that are intimately associated with the retromandibular vein are often also located deep to the facial nerve in the deep lobe of the parotid gland. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300173539-FC5Y3WK2LW15IRP6HIHU/8Facialnerve2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300175906-CGCPHG5X31HXDC0H8Q4O/8Facialnerve3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300179718-ST9558STQ5YA8UTYSUXU/9Internalmaxillarylabels.jpg Parotidectomy & Parapharyngeal Space Dissection - Deep lobe parotidectomy. — In cases of a total parotidectomy or deep parotidectomy, all branches of the facial nerve should be carefully traced out such that they are free floating, separated from both the superficial and deep lobe of the parotid gland. — In a deep lobe parotidectomy, several large vessels are identified and must be ligated. — The terminal external carotid artery transitions into the internal maxillary artery and the superficial temporal artery – its two terminal branches. The internal maxillary artery runs within the substance of the deep parotid gland, just under the ramus of the mandible. It will be encountered during deep lobe parotidectomy dissection and must be ligated. The superficial temporal artery, if not already ligated at the time of superficial parotidectomy, may be ligated as well. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300177363-HQN9VYLW2EUXTZKKY3WI/9Internalmaxillary2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300179626-JVNPKC0KOPUU6LHGWGBH/9Internalmaxillary3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300183707-OPIPI691PQMAZ7IQQEVP/10ExternalCarotidLABELS.jpg Parotidectomy & Parapharyngeal Space Dissection - The external carotid artery. — Inferiorly, during deep lobe parotidectomy, the external carotid artery can also be encountered as it enters deep to the gland, and should be ligated as well. The external carotid artery contains numerous branches and is generally more lateral than the internal carotid artery. — If the external carotid artery is followed superiorly within the deep parotid lobe, it can be followed to its terminal branching point. — Superiorly, the external carotid artery lies deep to the stylohyoid muscle. Removal of the deep lobe of the parotid gland will reveal the styloid process and its associated musculature. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300181701-PZOO251PQTCECAWUA6V2/10ExternalCarotid2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300183004-DQR5QIMNW4LA13REJM0W/10ExternalCarotid3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300186103-YUYWHUWYYHC70UBB4VKD/11ParapharynxLABELS.jpg Parotidectomy & Parapharyngeal Space Dissection - Entering the parapharyngeal space. — The parapharyngeal space is a 3-dimentional space that resembles an inverted pyramid. The apex of the pyramid is at the hyoid, while the base is at the base of the skull. It is bound medially by the buccopharyngeal fascia, which separates it from the oropharynx. Anteriorly, it is bound by the pterygomandibular raphe, and posteriorly by the prevertebral fascia. Laterally, the boundary of the parapharyngeal space includes the pterygoid musculature, deep lobe of the parotid gland, and the posterior belly of the digastric muscle. — Note that the stylohyoid muscle lies lateral to the styloglossus muscle and is the most lateral of all the styloid muscles. It is just medial to the posterior belly of the digastric. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300184322-Y84CKFTRY2828AUTL19W/11Parapharynx2D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300185782-D2X36VKNV7K4APXOAM81/11Parapharynx3D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300187622-VCJ4PXJ3JRXURISEX2E2/12CN9Labels.jpg Parotidectomy & Parapharyngeal Space Dissection - Understanding the components of the parapharyngeal space. — Commonly, the parapharyngeal space is further subdivided by the styloid process into the pre- and post-styloid compartments.. The pre-styloid compartment contains mostly fat and lymph nodes; the post-styloid compartment contains the important contents of the carotid sheath including the common carotid artery, internal jugular vein, and the vagus nerve. — The styloglossus and stylopharyngeus muscles attach to the medial surface of the styloid process. The styloglossus muscle travels anteriorly to join the extrinsic tongue musculature, while the stylopharyngeus muscle travels inferiorly to join the pharyngeal musculature. — The glossopharyngeal nerve (CN IX) exits the skull base at the jugular foramen between the internal jugular vein and internal carotid artery and passes inferiorly, curving laterally around the stylopharyngeus muscle and supplying it with its only motor efferents. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300188041-RO2NSPH2DA4QCML8K02C/12CN92D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300190044-CTI2INIRIHJR3641Q9RH/12CN93D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300190532-5BM2D5689BYRZ2HH53LI/13CN11CN12Labels.jpg Parotidectomy & Parapharyngeal Space Dissection - Relationship between the parapharyngeal space and the neck. — Vital structures of the post-styloid parapharyngeal space can be seen entering the parapharyngeal from the upper neck. This includes the internal jugular vein, accessory nerve (CN XI), vagus nerve (CN X), internal and external carotid artery, and the hypoglossal nerve. — In a transcervical approach to the parapharyngeal space, the mandible is retracted anteriorly and superiorly, the submandibular gland is retracted anteriorly, and the digastric muscle is retracted posteriorly or divided. The vital structures above are then identified and preserved, and finger dissection superiorly will identify the parapharyngeal space. — The stylomandibular ligament (cut away here) is a thick fascial band that extends from the styloid process to the angle of the mandible, and often must be cut to allow adequate exposure to parapharyngeal space tumors. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300191860-WHFKRPXRQEONPZ7XVZT5/13CN11CN122D.jpg Parotidectomy & Parapharyngeal Space Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619300193046-8SR9Y49N9FPLUBLTGTX9/13CN11CN123D.jpg Parotidectomy & Parapharyngeal Space Dissection https://www.headmirror.com/headneck-atlas-3d-creating daily 0.75 2021-04-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619401589049-4MBRPS35XSG4HTPWIDMX/9Internalmaxillary2D.jpg Creating 3D Head & Neck Anatomy Images https://www.headmirror.com/headneck-atlas-parotidectomy-2-1 daily 0.75 2021-04-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619401589049-4MBRPS35XSG4HTPWIDMX/9Internalmaxillary2D.jpg Introduction https://www.headmirror.com/headneck-atlas-about daily 0.75 2021-05-15 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619401589049-4MBRPS35XSG4HTPWIDMX/9Internalmaxillary2D.jpg About this Section https://www.headmirror.com/how-to-take-3d-anatomy-photos-1 daily 0.75 2021-04-26 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589152503682-T8E3GTAIOQKGG1K027PT/Tbone.jpg MISC Creating 3D Temporal Bone Images https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1589169567054-S6HBOAF52U06K641PA95/Stereo-diagram.png MISC Creating 3D Temporal Bone Images https://www.headmirror.com/3d-atlas-toc daily 0.75 2021-05-15 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1520045995322-46H6R0S4NR657N572JV0/Surgical+Instruction.jpg Table of Contents https://www.headmirror.com/osteopathic-applicants daily 0.75 2021-06-19 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1623464299524-WP6DS2L4F5UIRVA30TT9/0022osteopathic.jpg Osteopathic Applicants https://www.headmirror.com/noig-register-interest-group daily 0.75 2025-03-07 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1626118382534-AM4ID06Y1OYHDQ0ERVC4/US+Map+City+Lights.jpg NOIG Register Interest Group https://www.headmirror.com/noig-seeking-otolaryngology-mentor daily 0.75 2025-03-07 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1627139513042-M4335EJU5F9ADH2TH5NR/US+Map+City+Lights.jpg NOIG Seeking Otolaryngology Mentor https://www.headmirror.com/noig-seeking-research-opportunity daily 0.75 2025-03-07 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1626118382534-AM4ID06Y1OYHDQ0ERVC4/US+Map+City+Lights.jpg NOIG Seeking Research Opportunity https://www.headmirror.com/noig-register daily 0.75 2025-03-07 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1626118382534-AM4ID06Y1OYHDQ0ERVC4/US+Map+City+Lights.jpg NOIG Register Individual https://www.headmirror.com/noig daily 0.75 2025-07-25 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1626118382534-AM4ID06Y1OYHDQ0ERVC4/US+Map+City+Lights.jpg NOIG https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/8c245f9f-87b9-4302-ac01-8c557ed322c0/2025-2026+NOIG+Leadership+Team.png NOIG - 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Surface landmarks -Palpation of the anterior neck reveals the midline cartilaginous structures of the neck, the sternal notch, and the thyroid notch. Note that the thyroid notch is more prominent in male patients compared to female patients. -The tracheostoma should be designed approximately 2 finger-breadths above the sternal notch. Note that although a circle is drawn on this image to indicate a tracheostoma, typically a 2-3 cm horizontal incision is made centered over the midline of the neck. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213165195-0E2XLDNA3ZA0ZP5O76BL/Trachnecklandmarksorientation.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213217586-253APMPBDKN0LCTQB3VN/Trachnecklandmarks.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213295188-C872CIYC3ES9CSZ9OJ4Q/trachneckincisionLabels.jpg Tracheostomy - Dissection of the subcutaneous tissue -After incision is made, dissection is carried down to reveal the fascia over the anterior strap muscles. Palpation dissection along the midline should reveal the midline raphe of the anterior straps -In the anterior neck, the most superficial paired strap muscle is the sternohyoid. Deep to this are the thyrohyoid and sternothyroid muscles, only the latter of which is encountered during dissection for a tracheostomy. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213284278-J5MOWFATU0BO0VJL4W5T/trachneckincisionplainorientation.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213288141-M75BDKG3HDFAMWEKP5NW/trachincision3D.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213381275-O5RP8WSQH3U4T4DD5W0E/TrachneckstrapsLabels.jpg Tracheostomy - Ligation of the anterior jugular vein -Frequently a prominent anterior jugular vein is encountered between the strap muscles. This is often ligated to provide hemostasis as dissection continues in a bigger plane -As the midline raphe is divided and the sternohyoid and sternothyroid muscles are retracted laterally, palpation will reveal the cricoid cartilage. The isthmus of the thyroid gland typically sites over the cricoid cartilage the first tracheal ring. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213356961-WL2V72FF64YBRYXI0XDS/Trachneckstrapsplainorientation.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213374982-JRL4J77XGDWIM45NIMXD/Trachneckstraps3d.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213009230-5CMBV2RXXUVZIIH5MS99/TrachneckthyroidLabels.jpg Tracheostomy - Division of the thyroid isthmus and planned tracheotomy -The thyroid isthmus can be divided and/or ligated, or it can be left intact and retracted superiorly – depending on the patient’s anatomy. Dissection of the thyroid isthmus off the inferior border of the cricoid cartilage will clearly reveal the first tracheal rings and the cartilaginous landmarks required for tracheotomy. -The ideal tracheotomy should be between the 1st and 2nd tracheal rings or the 2nd and 3rd tracheal rings. Note that the first and second tracheal rings can be fused in some patients with a very narrow space in between, especially in older patients. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212982973-G5D6XF7ICI7WT0D8TUF7/Trachneckthyroidplainorientation.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213044710-I20580CLTCQY7ICZTAXR/Trachneckthyroid3D.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212952614-8KV3C3ESLJ79LNAD2CKI/Trachnecktrachealabels.jpg Tracheostomy - Tracheotomy -The tracheotomy is made by making a horizontal incision in the membranous trachea between the 2nd and 3rd tracheal ring. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212937987-C72MTXK2E40FBX242N6Z/Trachnecktracheaplainorientation.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212942988-6Y4VOHKYM5NXZOC9BCFZ/Trachnecktrachea3d.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213478381-DF28WHJZQ3YPU1OND7F0/TrachNeckbjorklabels.jpg Tracheostomy - Bjork flap -A Bjork flap can be fashioned by making lateral cuts through the inferior cartilage ring and then suturing this cartilage flap to the skin edge. This can minimize false passaging during tracheostomy change, especially in a patient with an abundance of soft tissue between the airway and skin. If a Bjork flap is fashioned, the stitch should be removed prior to decannulation to prevent scarring at the tracheotomy site. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213471222-C4UEBY2N8MYBBMU81DMR/trachneckbjorkplainorientation.jpg Tracheostomy https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642213474525-9NFC6WG4OHWJ36ZK1I4O/trachneckbjork3d.jpg Tracheostomy https://www.headmirror.com/headneck-atlas-neck-dissection daily 0.75 2022-01-20 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1619401589049-4MBRPS35XSG4HTPWIDMX/9Internalmaxillary2D.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211423305-07ZSRM6DJ2G66Y0FK48P/Submandibularlabels.jpg Neck Dissection - A curvilinear incision is made and sub-platysmal flaps are raised superiorly to the level of the mandible, and inferiorly to the level of the clavicle -Here, the anterior triangle of the neck can be seen, bound superiorly by the inferior border of the mandible, laterally by the sternocleidomastoid muscle, and medially by the midline of the neck. -A thick layer of fascia, known as the investing layer or superficial layer of the deep cervical fascia envelops the sternocleidomastoid muscle, submandibular gland, and fatty lymph node packet of the lateral neck. -Levels of the lateral neck and their boundaries include: -Level 1a: Submental lymph nodes, boundaries: anterior belly of the digastric muscle (bilaterally), hyoid bone -Level 1b: Submandibular/perifacial lymph nodes, boundaries: inferior border of the mandible, anterior and posterior bellies of the digastric muscle -Level 2: Upper jugulodigastric lymph nodes, boundaries: skull base (superior), posterior border of the submandibular gland/the stylohyoid muscle (anterior), posterior border of the SCM (posterior), carotid bifurcation (inferior). The accessory nerve divides level 2 into 2a (anterior) and 2b (posterior) -Level 3: Middle jugular lymph nodes, boundaries: midline strap muscles (anterior), posterior border of the SCM (posterior), carotid bifurcation (superior), omohyoid muscle (inferior) -Level 4: Lower jugular lymph nodes, boundaries: midline strap muscles (anterior, posterior border of the SCM (posterior), omohyoid muscle (superior), clavicle (inferior) -Level 5: Posterior triangle lymph nodes, boundaries: posterior border of the SCM (anterior), trapezius muscle (posterior), junction of the two muscles (superior), clavicle (inferior). Level 5a (above the level of the omohyoid) is also known as the spinal accessory nodes, and 5b (below the level of the omohyoid) is otherwise known as the supraclavicular nodes. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211409990-7JCRPHOMV7WMYCDZR0PT/SubmandibularPlain.jpg Neck Dissection Test https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211415888-HB7X8K5Z6VWD0Q1U36WO/Submandibular3d.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211755920-XJ64AJ69SU93RZO95NKE/facialarterylabels.jpg Neck Dissection - Dissection of level 1 lymph nodes -The marginal mandibular nerve is identified in the fascia overlying the submandibular gland, and the facial artery and vein are ligated. -The distal facial artery and vein are retracted up to protect the marginal mandibular nerve. - Dissection then carries along the inferior border of the mandible, incorporating the perifacial nodes around the facial artery and vein as well as the submandibular gland. Anteriorly, the anterior belly of the digastric muscle is identified. Level 1a lymph nodes are incorporated in the packet by removing all fatty tissue between the two anterior bellies of the bilateral digastric muscles. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211720021-WVY7VE7BY0BHFCIGJ801/facialarteryplain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211742778-Z6FPU2YBRFD2ZA6FGN71/facialartery3d.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642266722822-XHJD44P5I5DL6CVNH15T/1blabels.jpg Neck Dissection - Dissection of the submandibular triangle -Dissection continues until the mylohyoid muscle is encountered. This muscle is retracted anteriorly to reveal the important structures of the submandibular triangle: the hypoglossal nerve (CNXII), lingual nerve, submandibular ganglion, and submandibular duct. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211540148-U7FPU031N0RL0RJTXL11/1bplain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211557820-71J3KM48BPZAU2KAX28C/1b3D.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211801307-ANR0OEJUVVGGPS0V5B4M/facialartery2labels.jpg Neck Dissection - Completion of a Level 1 neck dissection -Ligation of the submandibular ganglion just inferior to the genu of the lingual nerve and duct allow the submandibular gland and the associated lymph node packet of level 1 to be freed from the submandibular triangle and released posteriorly. - Note that the hypoglossal nerve is carefully preserved along its course deep to the digastric muscle. The proximal facial artery is ligated again as it travels deep to the digastric muscle. This completes a level I neck dissection. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211788799-O9HO5LUMDR0CVRB0Z4CD/facialartery2plain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211794295-2ODDOOUN9859UWOJGK0G/facialartery23D.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211942149-TCC1LWXAXD6Y04O0I5MI/level2blabels.jpg Neck Dissection - Dissection of level 2 lymph nodes -The posterior bellow of the digastric muscle is followed back toward the sternocleidomastoid muscle. This helps open up the corner between the skull base and the posterior border of the SCM and provides the space required for dissection of level 2b. -The hypoglossal nerve is followed posteriorly until it curves medial to the internal jugular vein. The hypoglossal nerve travels on top of the external carotid artery and then medial to the internal jugular vein toward the skull base. The hypoglossal nerve is often pinned down by the occipital artery, a posterior branch off the external carotid artery. This artery often has to be ligated to appropriately release the lymph node packet from the internal jugular vein. -These jugulodigastric lymph nodes are peeled off the superior portion of the internal jugular vein. Lateral to the IJ, the accessory nerve (CN XI) can be identified. The majority (75-90%) of the time, CN XI crosses in front of the IJ as it descends from the skull base. In a minority (10-25%) of patients, CN XI can cross posterior to the IJ as it descends, and the surgeon must be aware of this variant when dissecting along the lateral border of the IJ vein. In very rare circumstances, CN XI may travel through the IJ as it descends. -Dissection of level 2b requires freeing the fatty lymph node packet from the skull base superiorly, the posterior border of the SCM posteriorly, and the muscles of the floor (levator scapulae, splenius capitis). The packet from level 2b is then passed underneath the accessory nerve to connect it to the rest of the packet from level 2a. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211920686-FE47LU1N17A2FI60IXEF/level2bplain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211936812-SN04ARM575QQPO24F48K/level2b3D.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642266716643-V6K5E5KFYPWWC2375W7A/level3labels.jpg Neck Dissection - Dissection of level 3 and 4 lymph nodes -Working superiorly to inferiorly, cervical rootlets are identified, marking the floor of dissection for level 3. The lymph node packet is dissected off the floor in a posterior to anterior direction, until it remains only pedicled on the carotid sheath. -Inferiorly, the omohyoid muscle is dissected off the carotid sheath and retracted inferiorly. Retraction of the omohyoid muscle inferiorly reveals the fatty lymph node packet in level 4. Similarly, the level 4 lymph nodes are freed from the posterior border of the SCM and the scalene muscles along the floor of the neck. -During dissection of level 4, the transverse cervical artery and vein are encountered and should be preserved if possible. The phrenic nerve can be seen coursing along the anterior scalene muscle along the floor. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211990417-5YA0R7GD07C4O1KTCPMI/level3plain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642211999542-UV9V4AGWMY3EX509C8M8/level33d.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212048027-YH25ZHVEBW255HRJFU3O/jugularlabels.jpg Neck Dissection - Dissection off the carotid sheath -With the lymph node packet now only pedicled on the carotid sheath, the deep cervical fascia that envelops the internal jugular vein, carotid artery, and vagus nerve is carefully opened to free the lymph node packet from these critical structures https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212040772-08DWZ8QPVPFORZ5HO62I/jugularplain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212044986-MFA0DUDNGA7P0X5H8XEZ/jugular3d.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212082338-4BPCGYAO3DWN4GC7LQNX/externalcarotidlabels.jpg Neck Dissection - Completion of a level 1-4 neck dissection -Anterior branches from the internal jugular vein can be ligated or preserved. The superior thyroid artery is typically encountered when dissecting the packet off the external carotid artery. This can also be ligated or preserved. The packet is then rolled off anteriorly and delivered from the neck https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212070895-P1MCTR26SCR0QK6WHJ2W/externalcarotidplain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212075087-E0K5S6BPFEV6AFBP8D32/externalcarotid3d.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212124869-74C5PEYBHSX37S3RJGP3/FinalNeckplainlabels.jpg Neck Dissection - Initiating a level 5 neck dissection -The spinal accessory nerve is traced distally through the sternocleidomastoid muscle towards its insertion into the trapezius muscle. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212114840-2PPWRZJFNEIEW27PK36A/FinalNeckplain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212119469-RFDX211G0PZA73V87WP0/FinalNeck3d.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212192439-88SYYYOUMX4N78S6SS43/Level5labels.jpg Neck Dissection - Level 5 neck dissection -Posterior to the SCM, Erb’s point is identified. This point marks the convergence of several sensory nerves including the greater auricular nerve and the transverse cervical nerve. The accessory nerve exits the posterior border of the SCM approximately 1cm above Erb’s point -The accessory nerve is traced to its insertion into the trapezius muscle, and cervical rootlets are also followed posterior to the SCM. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212180401-YZU8MG113AHJ3PGXTV5K/Level5plain.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212188391-RK8I477SN43RVO21IFR7/Level53d.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642266699696-ODKD8JCGNYRWDVX17F9A/level5bcN11labels.jpg Neck Dissection - Completion of a level 5 neck dissection -The fatty lymph node packet is taken off the trapezius muscle, the posterior border of the SCM, and the clavicle. Cervical rootlets that are adherent to any diseased lymph nodes in the packet may need to be sacrificed. https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212251206-Q2N1C4JWYKSEEL8VQ53E/level5bcN11plain1.jpg Neck Dissection https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1642212258312-SI4K960F3PAEUP5WQUYD/level5bcN113d.jpg Neck Dissection https://www.headmirror.com/intern-boot-camp daily 0.75 2022-03-18 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1647613706063-KM41JE1GMKVNFWGEIFC7/bootcamp.jpg Intern Boot Camp https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/ffc2d5b3-b6a8-4e23-96d8-2f50d91188ea/Sample+Curriculum.png Intern Boot Camp - Make it stand out Sample of weekly curriculum https://www.headmirror.com/match-20222023 daily 0.75 2022-09-04 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1597960547624-KQ6CUXY6OA2EI58ALRVF/Virtual.jpg Match 2022-2023 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/5c26c16a-e908-4b71-94ff-007d59238c77/2022-2023.png Match 2022-2023 - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.headmirror.com/global-surgery-podcast daily 0.75 2022-10-16 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1585018778005-YNBOAJXJHUGX7IZRGBW8/ENTNutshellLong.png Global Surgery https://www.headmirror.com/global-surgery-introduction daily 0.75 2022-10-25 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1666655839458-MLJ1JCGJXACGJS79IHG5/Global%2BSurgery.jpg Introduction https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/79321e4f-2e24-4088-a870-0a01fbb02547/Wiedermann.jpg Introduction - Make it stand out Josh Wiedermann, MD https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/9dac03be-45fb-433b-b86d-9b21e07b0903/Chweya.jpg Introduction - Make it stand out Cynthia Chweya, MD https://www.headmirror.com/global-surgery-episode-list daily 0.75 2023-03-05 https://images.squarespace-cdn.com/content/v1/54a9fe4de4b034981b596525/1666655839458-MLJ1JCGJXACGJS79IHG5/Global%2BSurgery.jpg Episode Index https://www.headmirror.com/intro-hayden daily 0.75 2025-05-12 https://images.squarespace-cdn.com/content/v1/5310cef7e4b08602cbfa36bf/1395951531371-UHVVQPY7DU2MY6Z73FW2/hayden-header.jpg Intro https://images.squarespace-cdn.com/content/v1/5310cef7e4b08602cbfa36bf/1412380936909-3NDYSVN9D7FZDQHHCO0P/image-asset.jpeg Intro - RESIDENTIAL Add a description of your services here. 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