PREOPERATIVE DIAGNOSIS: Left congenital cholesteatoma.
PROCEDURE PERFORMED: Left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura, operating microscope, facial nerve monitoring.
SURGEON: John Doe, MD
DRAINS: Penrose.
ANESTHESIA: General endotracheal, local 10 mL, 1% lidocaine with 100,000 epinephrine.
SPECIMEN: Left mastoid contents, frozen section, consistent with cholesteatoma.
ESTIMATED BLOOD LOSS: 50 mL.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic female who was noted to have an incidental left mastoid lesion. Preoperative CT and MRI scanning were most likely consistent with a congenital cholesteatoma.
Due to significant concerns of erosion of posterior fossa dural plate and surrounding bone and compression of the sigmoid sinus, left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura was recommended.
Options of observation versus surgery were discussed with the patient. Extensive preoperative counseling and laboratory testing was performed.
The patient decided to proceed with left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura despite potential risks of need for further surgery/therapy, no guarantee of success, recurrence of ear disease, brain fluid leak, meningitis, stroke, heart attack, death, allergic reactions, anesthetic complications, deafness, dizziness, tinnitus, taste changes, facial nerve paralysis as well as other unforeseen problems and complications.
Despite potential risks and complications, the patient decided to proceed with the left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura.
INTRAOPERATIVE FINDINGS:
1. Cholesteatoma measuring approximately 2.5 cm in greatest dimension extending from approximately the sinodural angle to the retrofacial air cells.
2. Cholesteatoma with significant erosion of surrounding posterior fossa dural plate and thinning of posterior fossa dura.
3. Attenuated sigmoid sinus displaced superiorly due to cholesteatoma.
4. See below for more details.
DESCRIPTION OF PROCEDURE: The patient was taken from the preoperative holding area to the operating room where she was placed supine on the operating table for left subtotal petrosectomy with resection of cholesteatoma on posterior fossa dura. The patient was then intubated.
Once the endotracheal tube was secured, the table was rotated 180 degrees. Pneumatic compression devices were placed on the patient’s legs. A Foley catheter was placed.
Hair was shaved posterior and superior to the left auricle. The proposed incision site was marked with a marking pen. It was one fingerbreadth behind the left postauricular sulcus. Facial nerve monitor needle electrodes were applied.
The proposed incision site was infiltrated with local anesthetic. The patient was given a dose of prophylactic IV antibiotics and steroids. The left lower quadrant of the abdomen was kept out in the surgical field in case abdominal fat graft would be needed.
The patient was prepped and draped in the standard surgical fashion. She was adequately padded, belted, and test rolled to make sure she was in good position on the table. Intraoperative facial nerve monitoring was done by me.
The incision was made through the skin down to the subcutaneous tissue with the 15 blade scalpel. Temporalis fascia was identified. Bovie electrocautery was used.
Weitlaners were used to retract soft tissue. The microscope was brought in to view the surgical field. A Palva flap was created with Bovie electrocautery. Intraoperative photos were taken.
Erosion of the mastoid cortex was noted by the cholesteatoma. Pieces of specimen were then removed and sent off for frozen and permanent section.
Surrounding the area of mastoid cortex erosion, a complete mastoidectomy was performed. Tegmen was identified. Digastric was identified. Lateral semicircular canal was identified.
The facial nerve of the mastoid segment was identified. The cholesteatoma was debulked. The matrix was left on the posterior fossa dura. It was elevated off the posterior fossa dura. There was no evidence of CSF leak after complete removal of the specimen. The specimen was removed in pieces.
After separating this specimen from the dura, Valsalva maneuver was performed to make sure there was no inadvertent CSF leak that was created. None was noted.
The wound was well irrigated. Care was taken to irrigate the middle ear space to avoid any osteoneogenesis and postoperative conductive hearing loss. Areas of bleeding were taken care of with Gelfoam with thrombin as well as with FloSeal.
After complete eradication of tumor, interrupted Vicryl sutures were used to close the Palva flap and subcutaneous tissue. A Prolene stitch was used to close the skin. A Penrose drain was placed due to a mild amount of oozing in the subcutaneous space. A Glasscock pressure dressing was applied.
All sponge, needle, and instrument counts were correct at the end of the case. The patient tolerated the procedure well, was extubated and transported to the recovery room. She was noted to have facial nerve function, grade I/VI, with Weber lateralizing to the left ear.
