A patient with pulsatile tinnitus is found to have a glomus tympanicum tumor of the right ear. Calhoun Cunningham III, MD performs a transcanal resection of the mass using the KTP laser.
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1. Patient Preparation
2. Tympanomeatal Flap
- Injection of Anesthetic
- Flap Elevation
3. Middel Ear Anatomy
4. Laser Excision
The patient is a 61 year old female, who presented with pulsatile tinnitus involving her right ear. There was no prior history of ear issues or problems. On examination, she was found to have a vascular appearing mass behind the eardrum on the promontory. This is consistent with a small glomus tympanicum. And we discussed continued observation as well as surgical removal, and she has elected to undergo surgical removal of her tumor. We're going to do this using a transcanal approach, and a laser to remove the tumor.
First irrigating the ear well. We have used Betadine prep in the ear canal, and we’ll now go to the microscope. Can I have a number 6 speculum? And now a number 5 speculum, and a 5 suction. Lorna, can you squirt a little more irrigation down in here? Can I get a large round knife for a moment? Oh wow. Guys, she’s moving a little bit. Can y’all - well is there another option? Okay, should have taped her head. Okay.
So this is gonna - she’ll feel this a little bit. This is 1% Lidocaine with 1 to 40,000 epinephrine. We're going to do a four-quadrant canal block right inside the meatus. And we are just going to march around the meatal skin, allowing it to fill up. And then Lorna, I’m going to need a 4 speculum in just a minute. Four? Yeah. And one more. Hold that - 4 speculum. And we’re going to use a little bit smaller speculum to dilate the ear canal. Large round. Clean some of this loose epithelium out. Wipe.
And actually now we can see quite clearly, if we look down in there, it's a very small glomus tympanicum on the promontory just behind the eardrum, and that sits very nicely. Now the injection one more time. Now that we have injected the outer ear canal, we're going to inject the vascular strip. This injection is placed just at the level of the bony cartilaginous junction. And that’s perfect there. And just keep - you’ll have to just keep reminding me. So this injection is placed just at the level of the bony cartilaginous junction. We’ll go in until we hit bone, and then very slowly inject. And we are now infiltrating the vascular strip region, which is - the boundaries of which are the tympanosquamous suture line and the tympanomastoid suture line. As we inject, we get nice blanching of the vessels of the vascular strip onto the short process of the malleus. Okay, suction. We're going to go to a 5 suction now, Lorna - I mean a 3 suction please.
Next we're going to make a tympanomeatal flap incision. And at the 6 o’clock portion of the eardrum the annulus can be seen as this white band here. And we'll start our incision just lateral to the annulus and come all the way out into the canal, putting this knife right down on bone, one, two, three times. Now a large round knife. Some of this - yeah that right here. Wipe that please - wipe. How’s your view here Scott? Up a little bit. And then, with a round knife, we're going to make our canal cuts, connecting our inferior - inferior incision, connecting this inferior incision superiorly on a round, making a nice generous tympanomeatal flap about 8 mm in length. Suction.
Once we've made our incision, we're now going to elevate our flap. This round knife is placed right down on bone - suction in my left hand. So with my suction now, sucking on the backside of the instrument, so that we're not sucking on our flap, we're going to continue elevating this all the way down to the level of our annulus. And superiorly, we want to get our flap up here. This is the tympanomastoid suture line, which oftentimes - okay -are we back on? Okay, this is the tympanomastoid suture line. Oftentimes, there are little adhesions in this area that you have to cut through to free that up. And then we're going to continue elevating this flap up and around, and then finally - can have a pair of Bellucci scissors? We’ll use Bellucci scissors to relax this upper curve to the left - to relax this upper part of the flap. Good, suction. Now, round knife.
We're going to continue now elevating the flap and get underneath the annulus. I'm starting to see the annular ligament here - this little white band, which can be seen nicely right medially. We have a little bit of mucosal tissue underneath the annulus. And inferiorly, we're going to elevate this flap all the way to our anterior extent of our incision at about the six o’clock location. Come up just a little if you can. Can I have a 59-10 please?
Now I'm going to inside this mucosal layer underneath the annulus. Can you see that Scott? Yeah. Okay. We’ll incise this little mucosal layer. Large round knife. And now we can get under the annulus further and elevate our flap on a round out of the annular groove. Good, now can I have a small cotton ball with epinephrine - a BB. And I'm going to place a very - do you have about half that size? So we’re seeing - these are air cells, that’s the promontory, and the round window niche. And if we elevate this flap a little bit more, we will see this - there's a part of this small glomus tumor, but you can see the back part of the tumor here.
Cotton ball. This is a cotton ball with a little bit of epinephrine that will kind of tamponade some of the oozing that often comes from this inferior aspect of the flap elevation, and it helps hold our - our drum up a bit. Crabtree elevator please. That’s a foot plate - or a this is a - this is a long incus foot. This is tethering us up superiorly, so we want to free up this aspect of the eardrum and our flap a little bit more. Too bad we don’t have an endoscope. Gimmick.
So right now we are looking directly at the promontory. Do we have the laser ready to go, guys? Y’all can go ahead and get them. So we are now under the drum. Here's the tip of the incus, and when we gently touch, we have a nice movement of the round window membrane. So a nice round window reflex can be seen as we palpate. This is the undersurface of the malleus. And what we want to see - table away now please. Rotate away, keep going - okay, that's good. And inferiorly, if we elevate we see this small glomus tympanicum - very small - right on the promontory here. You all see the tumor? It's really tiny. What’s that? Yeah, so Wisti, we’re a - we’ve elevated the eardrum at this point, and that little berry looking thing right there is just a very small glomus tympanicum. And that's what we're here to get rid of.
Okay, can I get a little bit - one size smaller? Do you have a 20 suction Lorna?
Laser. Guys do we have the laser? I have not yet. If you - if you get me a tongue blade, I’ll test it. Yeah, go up to - go up to like 2,000 on the - on the - on the power. I mean sometimes we do - keep going. And I want to go up, increase the pulse duration. Okay. Like 2 - nah, needs to go up more than that. What’s the highest it goes to? I think 1. That’s good. Yeah, it’s fine. Let’s just test the laser. Where’s the pedal? Okay. Hurry guys. Yeah, it works.
Laser. Laser on. It’s on. And we're going to cut - just go around this small little berry. She’s kinda moving isn’t she? I want to at least have something to send to specimen. Let me have cup forceps. Cups - do you have cups to the left Lorna? This thing is really small. And here is our tumor specimen. It’s tiny. Yeah. Alright guys, can we keep her still for just a few more seconds? Wipe. Yeah.
Is it on? It is ready. Now we're just kind of lasering around the base of the tumor, making sure there's no cells remaining. Just hang in there. Okay, can I now have just a piece of amerigel? Standby. Just a little flux - I just need like one little square to put over this denuded part of the promontory. If you have a little bit, that would be great. Then you can just - you could just use a little saline. That would be okay. LR is fine. And we're pretty much done guys. Once we get this - yep, I’ve - I’ve got it. Let's have that amerigel. I just need like a little square Lorna. Let me see how big it is. That's okay. Just put it under here - just hold it right under the - yup - perfect. If it comes off… And we’ll put a little bit of amerigel to cover this spot. Do you have one more little piece Lorna? One more. Okay, now, tighten 3 suction. Now Lorna, I might give you your cotton ball back.
Wipe. Is that it? That’s it. And now we’re just going to bring our flap back. Little hair there. Yeah, it’s very small guys, so we’d love to have some pathology. Can I have a gimmick now? What’s that? Yeah. Just making sure you don’t have any rolled edges, right? Yeah, I’m just smoothing out this flap, getting it right back to where it was. Laterally, at our incision, just pulling it, making sure no skin edges get rolled under.
Okay, ointment now. Do you want a Band-Aid? Yeah, just a cotton ball and a Band-Aid. This flap literally will heal back down within a week or two. And now ointment - this is Bacitracin ointment, and we are going to just fill the ear canal and cover the surface of the eardrum with Bacitracin. Ointment will hold this flap down. And we are done.