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Secrets to Success in   Tympanomastoid surgeries.              Skip Introduction   Dr. Prahlada N B,    MBBS, MS (PGIMER, ...
Dedicated to,                2
3
I am no Guru! First of all let me make it clear,           I  am no Guru! Everyone is capable of lot of things You are ...
First Do No Harm   Making of a  Neurosurgeon      Story of Dr. Kenyon Rainer                     5
Problem in India 7% of Indians have Ear Problems 90% of these are Middle ear infection 35% have bilateral problems 11 ...
Hard work is the shortcut to        success!                               7
SuccessWhat makes a person successfulHow   do we recognize success T some people success means “   o  –W  ealth, Recogn...
“ Success is the progressive realizationof a worthy goal.”           Success is the Progressive Realization of a Worthy Go...
“ Progressive” Success is a journey,   not a destinationWe   never arrive After we reach one goal, we go on to the  nex...
Goals Goals are a must Goals give you direction for your life Life without goals is like a boat without a  sailor When...
S.M.A.R.T GOALS                   SPECIFIC                   MEASURABL                    E                   ACHEIVABL...
MBO Cost effective Time saving Maximum results Least number of complications TQM – TOTAL QUALITY MANAGEMENT          ...
SWOT Analysis                14
SWOT Analysis                15
TQM - Six Sigma                  16
11 Steps to success Important Interdependent Complemnentary to each other                                 17
Learn The Kaizen Way                       18
Practice makes man perfect                             19
20
Ask If you don’t know, Ask ! If you are unsatisfied, Ask ! If you want to accomplish a goal, Ask ! If you are confused...
Step 1 :        Selection of Cases      Know when not to operate :   “Many times, to realize on whichpatients one should n...
Step 2 :                Good Anesthesia Use GA/LA judiciously.   Don’t be  dogmatic. Infiltrate LA even when you operate...
Bevel of the needle should be               towards the bone.   Video   Click video button below.   And click play butt...
25
Step 3 :            Approach/Technique   “Every intra-op surgical decision needs to be    custom-made to the individual p...
Step 3 :        Approach/Technique Multiple choices may have to be considered before each patient is offered a particular...
Step 3 :        Approach/Technique Transcanal Endomeatal End-aural Post-aural                             28
How I do it Trans-canal approach  – Post-traumatic perforation - < 3 months                                              29
How I do it Endomeatal approach – Wide canal  –   Post-traumatic perforation - > 3 months  –   Central perforation – othe...
How I do it End-aural approach – Narrow Canal  –   Posterior Central perforation  –   When Cortical mastoidectomy is not ...
How I do it End-aural incsions for Koerner’s flap/Post- aural approach  –   Anterior perforation/Anterior bony overhang  ...
Step 4 :          Incision Techniques End-aural incisions Video Watch “approach” video with Quick Time Movie Player.   ...
Making End-aural incisions. The Modified Lemperts end-aural incision consists of 3 parts.  –   Part 1 : Posterior canal w...
Making End-aural incisions. Part I : Posterior canal wall incision.                                            35
Making End-aural incisions. Part 2 : Superior Canal Wall incision.                                           36
Making End-aural incisions. Part 3 : Inferior Canal Wall or floor  incision.                                          37
Making End-aural incisions.                              38
Making End-aural incisions.                              39
PrecisionAll that we need is a winning            edge                                40
Step 6 :              Canalplasty To remove bony overhang Post-op examination easy Helps graft uptake Improves hearing...
Canalplasty   Position of bony overhang :                  Post ero-                  Superior    Ot her                 ...
Canalplasty One should be able to see complete annulus at one microscope position.                                       43
Step 7 :      Cortical Mastoidectomy Understand the controversy Listen to the arguments Do what your heart says        ...
Guiding principle   X-Ray Mastoid.            Pneum at iz               ed              17%                          Scle...
Technique of Cortical        Mastoidectomy Canalplasty first Mark cortical mastoidectomy land mark  initially Antrum li...
Consider alternative Limited atticotomy and attic  reconstruction. Video                                  47
Step 8 :            Ossiculoplasty Check for mobility/round window reflex. Gentle is the word. Excise tympanoslerotic p...
Step 8 :             Grafting technique Underlay Interlay Excise the remnants of TM and Fibours  annulus completely  – ...
Step 8 :               Grafting technique Medial / Lateral to malleus ? Medial to malleus :  – Foreshortened malleus  – ...
Step 8 :           Grafting technique Technique of Medializing the graft medial to the malleus.                          ...
Malleus : Foreshortened/         Adherent to promontory Never cut tip of the malleus. Epithelium is never adherent to ma...
Step 9 :      Stabilizing the graft and flaps Prevent anterior blunting. Pack Middle ear and External auditory  canal pr...
Step 10 :               Post-op Care Record the mistakes Analyze your results Improve on them Failures – Do free revis...
Every success story is also a story of great failure       “Failure is the Highway to                  Success”           ...
“If you want to succeed, double your failure rate”         T W          om atson Sr., of IBM                              ...
Life is full of CompromisesLifeis full of happiness & sorrowGood and B   adDark Spots and B  right spots               ...
“Perseverance”           58
Manage you time! Father of Scientific Management Frederick Taylor (1856-1915) Taylorism                                ...
Our Vision for the Year                         2007-08   To achieve $ 231 million in revenue.   To be among the top 10%...
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C L ACaring   Learning   Achieving                                 S S                                Sharing      Social ...
Thank youwww.kenthospitals.com                        65
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Secrets of success in Tympanomastoid surgeries

This is a motivational and scientific presentation related to Tympanomastoid Surgeries in Otorhinolaryngology. This presentation is prepared to motivate junior colleagues to take up Otology (Medical Science related to Ear disease), learn and excel in the same for the benefit of the humanity suffering from Ear diseases. This presentation mainly addresses the basic concepts in commonly performed Micro-Ear surgeries like Myringoplasty, Tympanoplasty, Cortical mastoidectomy and Canaloplasty. The author has used management principles like Total Quality Management, Six Sigma and SWOT analysis to improve quality of the care provided to patients.

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Secrets of success in Tympanomastoid surgeries

  1. 1. Secrets to Success in Tympanomastoid surgeries. Skip Introduction Dr. Prahlada N B, MBBS, MS (PGIMER, Chandigarh)Karnataka ENT Hospital & Research Center, Chitradurga, Karnataka, India. 1
  2. 2. Dedicated to, 2
  3. 3. 3
  4. 4. I am no Guru! First of all let me make it clear, I am no Guru! Everyone is capable of lot of things You are a treasure trove of knowledge, skill and ideas You just have to wake up the Genius within you! I am only trying to un-ravel the potential within you! 4
  5. 5. First Do No Harm Making of a Neurosurgeon Story of Dr. Kenyon Rainer 5
  6. 6. Problem in India 7% of Indians have Ear Problems 90% of these are Middle ear infection 35% have bilateral problems 11 Crore ears need tympanoplasty ! 22,000 Cases/ENT Surgeon 6
  7. 7. Hard work is the shortcut to success! 7
  8. 8. SuccessWhat makes a person successfulHow do we recognize success T some people success means “ o –W ealth, Recognition, Good Health, Good family, H appiness, Satisfaction, Peace of Mind. “Success is subjective” 8
  9. 9. “ Success is the progressive realizationof a worthy goal.” Success is the Progressive Realization of a Worthy Goal Earl Nightingale E Nightingale arl 9
  10. 10. “ Progressive” Success is a journey, not a destinationWe never arrive After we reach one goal, we go on to the next and the next and the…….. ……………………………………… 10
  11. 11. Goals Goals are a must Goals give you direction for your life Life without goals is like a boat without a sailor When you make goals, make big goals Write down your goals and read them out aloud everyday 11
  12. 12. S.M.A.R.T GOALS  SPECIFIC  MEASURABL E  ACHEIVABLE REALISTIC 12
  13. 13. MBO Cost effective Time saving Maximum results Least number of complications TQM – TOTAL QUALITY MANAGEMENT 13
  14. 14. SWOT Analysis 14
  15. 15. SWOT Analysis 15
  16. 16. TQM - Six Sigma 16
  17. 17. 11 Steps to success Important Interdependent Complemnentary to each other 17
  18. 18. Learn The Kaizen Way 18
  19. 19. Practice makes man perfect 19
  20. 20. 20
  21. 21. Ask If you don’t know, Ask ! If you are unsatisfied, Ask ! If you want to accomplish a goal, Ask ! If you are confused, for good counsel, Ask ! If you desire to communicate, Ask ! When you expect good things in life, Ask ! 21
  22. 22. Step 1 : Selection of Cases Know when not to operate : “Many times, to realize on whichpatients one should not operate is what makes a surgeon’s final results shine above those of others”. Hamed Sajjadi, MD, FACS. OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Volume 32. Number 3. June 1999. 22
  23. 23. Step 2 : Good Anesthesia Use GA/LA judiciously. Don’t be dogmatic. Infiltrate LA even when you operate under GA. Variation of anesthetists. – Superficial type – Gas man – Freelancer 23
  24. 24. Bevel of the needle should be towards the bone. Video Click video button below. And click play button in Quite time movie player. Open movie file anesthesia with Quick Time Movie Player. 24
  25. 25. 25
  26. 26. Step 3 : Approach/Technique “Every intra-op surgical decision needs to be custom-made to the individual patient’s needs and the surgeon’s capabilities and facilities. Surgeon’s must avoid fitting their patients to their surgical techniques. On the contrary, we must adjust our surgical choices to fit each patients situation needs. “ 26
  27. 27. Step 3 : Approach/Technique Multiple choices may have to be considered before each patient is offered a particular type of surgery, and surgeons need to be prepared to change their techniques accordingly and competently. Hamed Sajjadi, MD, FACS. OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA AMERIC Volume 32. Number 3. June 1999. 27
  28. 28. Step 3 : Approach/Technique Transcanal Endomeatal End-aural Post-aural 28
  29. 29. How I do it Trans-canal approach – Post-traumatic perforation - < 3 months 29
  30. 30. How I do it Endomeatal approach – Wide canal – Post-traumatic perforation - > 3 months – Central perforation – other aetiology – < 3 months. 30
  31. 31. How I do it End-aural approach – Narrow Canal – Posterior Central perforation – When Cortical mastoidectomy is not planned 31
  32. 32. How I do it End-aural incsions for Koerner’s flap/Post- aural approach – Anterior perforation/Anterior bony overhang – Large perforation/Subtotal/total perofrations – When Cortical mastoidectomy is contemplated 32
  33. 33. Step 4 : Incision Techniques End-aural incisions Video Watch “approach” video with Quick Time Movie Player. 33
  34. 34. Making End-aural incisions. The Modified Lemperts end-aural incision consists of 3 parts. – Part 1 : Posterior canal wall incision. – Part 2 : Superior canal wall incision. – Part 3 : Inferior canal wall or floor incision. 34
  35. 35. Making End-aural incisions. Part I : Posterior canal wall incision. 35
  36. 36. Making End-aural incisions. Part 2 : Superior Canal Wall incision. 36
  37. 37. Making End-aural incisions. Part 3 : Inferior Canal Wall or floor incision. 37
  38. 38. Making End-aural incisions. 38
  39. 39. Making End-aural incisions. 39
  40. 40. PrecisionAll that we need is a winning edge 40
  41. 41. Step 6 : Canalplasty To remove bony overhang Post-op examination easy Helps graft uptake Improves hearing Reduces post-op infections/otomycosis 41
  42. 42. Canalplasty Position of bony overhang : Post ero- Superior Ot her 4% 2% Ant erior 29% Post ero- inferior 65% 42
  43. 43. Canalplasty One should be able to see complete annulus at one microscope position. 43
  44. 44. Step 7 : Cortical Mastoidectomy Understand the controversy Listen to the arguments Do what your heart says 44
  45. 45. Guiding principle X-Ray Mastoid. Pneum at iz ed 17% Sclerot ic 83% 45
  46. 46. Technique of Cortical Mastoidectomy Canalplasty first Mark cortical mastoidectomy land mark initially Antrum lies postero-superior to Spine of Henle, not posterior Do Cortical mastoidectomy/Not just antrotomy Don’t burr hole !? 46
  47. 47. Consider alternative Limited atticotomy and attic reconstruction. Video 47
  48. 48. Step 8 : Ossiculoplasty Check for mobility/round window reflex. Gentle is the word. Excise tympanoslerotic plaques Reconstruction with Autologous Incus/Conchal cartilage 48
  49. 49. Step 8 : Grafting technique Underlay Interlay Excise the remnants of TM and Fibours annulus completely – Total/Subtotal perforations – Epithelium has grown inside – Mucosa has grown outside 49
  50. 50. Step 8 : Grafting technique Medial / Lateral to malleus ? Medial to malleus : – Foreshortened malleus – Malleus adherent to promontary Lateral to malleus : – All other situations. 50
  51. 51. Step 8 : Grafting technique Technique of Medializing the graft medial to the malleus. 51
  52. 52. Malleus : Foreshortened/ Adherent to promontory Never cut tip of the malleus. Epithelium is never adherent to malleus /only fibrous layer can. Length of the malleus is important Cut the tensor tympani tendon to increase the middle ear space 52
  53. 53. Step 9 : Stabilizing the graft and flaps Prevent anterior blunting. Pack Middle ear and External auditory canal properly. Prevent haematoma beneath Tympanomeatal/Koerner’s flaps. Prevent narrowing of EAC. 53
  54. 54. Step 10 : Post-op Care Record the mistakes Analyze your results Improve on them Failures – Do free revisions ! 54
  55. 55. Every success story is also a story of great failure “Failure is the Highway to Success” 55
  56. 56. “If you want to succeed, double your failure rate” T W om atson Sr., of IBM 56
  57. 57. Life is full of CompromisesLifeis full of happiness & sorrowGood and B adDark Spots and B right spots 57
  58. 58. “Perseverance” 58
  59. 59. Manage you time! Father of Scientific Management Frederick Taylor (1856-1915) Taylorism 59
  60. 60. Our Vision for the Year 2007-08 To achieve $ 231 million in revenue. To be among the top 10% in our business in terms of profit after tax (PAT) and return on investment (ROI). To be one of the top 20 globally admired companies in our industry. To give a significant portion of our PAT to support primary education. 60
  61. 61. 61
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  64. 64. C L ACaring Learning Achieving S S Sharing Social Responsibility 64
  65. 65. Thank youwww.kenthospitals.com 65

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