This document provides secrets and tips for success in tympanomastoid surgeries based on the experiences of Dr. Prahlada N B. The key points discussed include: - Carefully selecting appropriate cases and understanding when not to operate. - Using good anesthesia techniques like local anesthesia along with general anesthesia. - Choosing the right surgical approach and technique for each individual patient. - Mastering incision methods like endaural incisions. - Performing procedures like canalplasty to improve outcomes. - Considering whether cortical mastoidectomy is needed in each case. - Perfecting ossiculoplasty and grafting techniques. - Providing good post-operative

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. Dedicated to,
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3. 3

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. First Do No Harm
Making of a
Neurosurgeon
Story of
Dr. Kenyon Rainer
5

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
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7. Hard work is the shortcut to
success!
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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”
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9. “ Success is the progressive realization
of a worthy goal.”
Success is the Progressive Realization of a Worthy Goal
Earl Nightingale
E Nightingale
arl
9

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. 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
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12. S.M.A.R.T GOALS
 SPECIFIC
 MEASURABL
E
 ACHEIVABLE
REALISTIC
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13. MBO
 Cost effective
 Time saving
 Maximum results
 Least number of complications
 TQM – TOTAL QUALITY
MANAGEMENT
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14. SWOT Analysis
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15. SWOT Analysis
15

16. TQM - Six Sigma
16

17. 11 Steps to success
 Important
 Interdependent
 Complemnentary to each other
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18. Learn The Kaizen Way
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19. Practice makes man perfect
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20. 20

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 !
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22. Step 1 :
Selection of Cases
Know when not to operate :
“Many times, to realize on which
patients 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. 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
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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.
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25. 25

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 patient's situation needs. “
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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. Step 3 :
Approach/Technique
 Transcanal
 Endomeatal
 End-aural
 Post-aural
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29. How I do it
 Trans-canal approach
– Post-traumatic perforation - < 3 months
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30. How I do it
 Endomeatal approach – Wide canal
– Post-traumatic perforation - > 3 months
– Central perforation – other aetiology
– < 3 months.
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31. How I do it
 End-aural approach – Narrow Canal
– Posterior Central perforation
– When Cortical mastoidectomy is not planned
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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
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33. Step 4 :
Incision Techniques
 End-aural incisions
 Video
 Watch “approach” video with Quick Time
Movie Player.
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34. Making End-aural incisions.
 The Modified Lempert's 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.
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35. Making End-aural incisions.
 Part I : Posterior canal wall incision.
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36. Making End-aural incisions.
 Part 2 : Superior Canal Wall incision.
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37. Making End-aural incisions.
 Part 3 : Inferior Canal Wall or floor
incision.
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38. Making End-aural incisions.
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39. Making End-aural incisions.
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40. Precision
All that we need is a winning
edge
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41. Step 6 :
Canalplasty
 To remove bony overhang
 Post-op examination easy
 Helps graft uptake
 Improves hearing
 Reduces post-op infections/otomycosis
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42. Canalplasty
 Position of bony overhang :
Post ero-
Superior Ot her
4% 2%
Ant erior
29%
Post ero-
inferior
65%
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43. Canalplasty
 One should be able to see complete
annulus at one microscope position.
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44. Step 7 :
Cortical Mastoidectomy
 Understand the controversy
 Listen to the arguments
 Do what your heart says
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45. Guiding principle
 X-Ray Mastoid.
Pneum at iz
ed
17%
Sclerot ic
83%
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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 !?
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47. Consider alternative
 Limited atticotomy and attic
reconstruction.
 Video
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48. Step 8 :
Ossiculoplasty
 Check for mobility/round window reflex.
 Gentle is the word.
 Excise tympanoslerotic plaques
 Reconstruction with Autologous
Incus/Conchal cartilage
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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
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50. Step 8 :
Grafting technique
 Medial / Lateral to malleus ?
 Medial to malleus :
– Foreshortened malleus
– Malleus adherent to promontary
 Lateral to malleus :
– All other situations.
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51. Step 8 :
Grafting technique
 Technique of Medializing the graft medial
to the malleus.
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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
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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.
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54. Step 10 :
Post-op Care
 Record the mistakes
 Analyze your results
 Improve on them
 Failures – Do free revisions !
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55. Every success story is also a story of great failure
“Failure is the Highway to
Success”
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56. “If you want to succeed, double your failure rate”
T W
om atson Sr., of IBM
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57. Life is full of Compromises
Lifeis full of happiness & sorrow
Good and B ad
Dark Spots and B right spots
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58. “Perseverance”
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59. Manage you time!
 Father of Scientific Management
 Frederick Taylor (1856-1915)
 Taylorism
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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.
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64. C L A
Caring Learning Achieving
S S
Sharing Social
Responsibility
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65. Thank you
www.kenthospitals.com
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