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OTITIS MEDIA: SURGICAL PRINCIPLES

BASED ON PATHOGENESIS 0030-6665/99 $8.00 + .OO

THIERSCH SKIN GRAFTING

AND POSTOPERATIVE CARE
OF OTOLOGIC PATIENTS
Hamed Sajjadi, MD, FACS

Successful surgical outcomes depend on a well-coordinated effort by the sur-

gical team and the patient in the following three categories of patient-physician
contact: (1) preoperative planning, (2) intraoperative surgical technique, and
(3) postoperative care and follow-up.

PREOPERATIVE PLANNING

Most uncomplicated, and even some complicated, surgical procedures can be

taught to just about anyone with average intelligence who has commitment and
perseverance. Tedious years of medical school and surgical training are not nec-
essary just to master a few surgical steps. Yet we all know that good or average,
dangerous, and excellent surgeons exist. What defines an excellent or above-av-
erage surgeon? What makes surgeons different is not necessarily how they per-
form a certain ritual in the operating room, but how they analyze the entire picture
before taking the patient to the operating room, how they perform the technique,
and how they deliver postoperative care. Surgeons routinely make hundreds of
difficult decisions before, during, and after each operation. Knowing on which
patients to operate, when to perform the surgery, and what technique to use is the
most difficult task that surgeons strive to master. Many times, to realize on which
patients one should not operate is what makes a surgeons final results shine above
those of others.

lntraoperative Surgical Techniques

Surgeons continuously strive to master the art and science of surgery over
many years of arduous training and hard work, both in their years of residency
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From the Minnesota Ear, Head, and Neck Clinic, Minneapolis, Minnesota
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OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

VOLUME 32 * NLTMBER 3 * JUN!i 1999 597

598 SAJJADI

and years of fellowship, and more importantly in their years of private practice.
As such, this endeavor is a never-ending challenge that keeps us all motivated to
carry on and to tolerate all of the various difficulties associated with being a sur-
geon, no matter how minor or major the case may be. In the operating room, one
needs to master more than one way to achieve the same surgical result. This is the
principle of "flexibility" that most successful surgeons routinely adhere to and
execute smoothly. One of the signs of a less versatile and possibly less successful
surgeon is one who does essentially the same surgical technique for most patients
with a similar diagnosis.
Every intraoperative surgical decision needs to be custom-made to the indi-
vidual patient's needs and the surgeon's capabilities and facilities. Surgeons must
avoid fitting their patients to their surgical techniques. On the contrary, we must
adjust our surgical choices to fit each patient's situational needs. Multiple choices
may have to be considered before each patient is offered a particular type of sur-
gery, and surgeons need to be prepared to change their techniques accordingly
and competently. One of the best ways to avoid postoperative complications is
proper preoperative planning and flawless surgical technique, but without proper
postoperative care, many successful procedures may end with undesirable results.

POSTOPERATIVE CARE AND FOLLOW-UP

Proper delivery of postoperative care is paramount to successful outcomes in

most surgical procedures. In some surgeries, detailed follow-up care may be as
important as, if not more important than, the surgery itself. As a result, inadequate
or inappropriate follow-up care may lead to outright surgical failures or to less
than desirable results, both of which may lead to personal disappointment if not
lawsuits for malpractice. Otologic surgery is one of the oldest microscopic pro-
cedures and one that demands exceIlent execution of au three stages-preopera-
tive, intraoperative, and postoperative delivery of care- to achieve acceptable re-
sults let alone outstanding outcomes. Meticulous attention to postoperative care
is thus the focus of this article.

POSTOPERATIVE OTOLOGIC CARE (SURGERY

FOR CHRONIC PROBLEMS OF THE EAR)
Most otologic procedures are performed on an outpatient basis. Patients are
discharged home with oral and written instructions on how to care for their op-
erated ears. This care is divided into four categories: immediate, intermediate,
short-term, and long-term.

Immediate Care (First 2 Weeks)

During the first 2 weeks after surgery, patients make their initial postoperative
visit for removal of packing and sutures.Mastoid pressure dressings are used only
for mastoidectomies. Most tympanoplasties require only an oval eyepad applied
to the external ear. Proper intraoperative hemostasis is essential to the avoidance
of postoperative hematoma at the wound.
In the recovery room, all otologic patients should have function in their facial
nerve tested and should be checked for any unusual nystagmus that would in-
 THIERSCH SKIN GRAFTING AND POSTOPERATIVE CARE OF OTOLOGIC PATIENTS 599

dicate labyrinthine irritation or injury. Intraoperative use of antiemetic medica-

tions, such as ondansetron, and preoperative use of oral meclizine have been
shown to be highly effective in controlling postoperative nausea and vomiting
associated with most otologic cases, especially in cases in which ossicular manip-
ulation has been carried out. In the recovery room, the routine use of intravenous
ondansetron, 2 to 4 mg every 1 to 2 hours as needed, and the use of transdermal
scopolamine patches, is highly effective in controlling nausea and vomiting, thus
allowing patients to leave the hospital as scheduled. Furthermore, excessive post-
operative straining and vomiting can lead to displacement of grafts on the tym-
panic membrane or to ossicular disruption in cases in which ossiculoplasty has
been carried out. In such cases, patients should be discharged home on antiemetic
medication and with dietary instructions to avoid constipation and straining from
coughing or sneezing.

First PostoperativeVisit

In about 7 to 10 days, one should remove any sutures and external meatal
packs but leave the deeper gelatin sponge packing undisturbed. Avoid suctioning
any deeper than the meatal opening. Check for excessive formation of granulation
tissue or bleeding. If there is such, consider repacking with a less occlusivesponge
for another week. Keep patients on prophylactic oral antibiotics as long as they
have a pack in place. If the ear has been repacked, see the patient the following
week and consider Thiersch skin grafting, if indicated.

Intermediate PostoperativeCare (2 to 8 Weeks)

On the second visit, 3 weeks after surgery, most patients are feeling much
better and external wounds have healed well, but sites of internal incisions in the
canal may show excessive granulation tissue. If this is seen, consider local use of
silver nitrate or phenol cauterization and repacking if the granulation is limited
to a small area. Use the office microscope and carefully check for any remnants of
foreign bodies, such as surgical packing or gauze, that could be causing a foreign
body reaction. If larger areas of granulation tissue and raw surfaces are involved,
or if an open mastoid cavity procedure was performed, schedule the patient for
Thiersch skin grafting with the patient under local anesthesia, using light intra-
venous sedation in the suite for minor surgery in a week or two. If no significant
granulation tissue is detected, have patients leave the ear canal uncovered and
use sulfa and hydrocortisone ophthalmic drops in the ear canal to dissolve the
deeper gelatin sponge packing. Have patients start the drops a month postoper-
atively, twice a day for 10 days, and then schedule their third visit 5 to 6 weeks
postoperatively.

Third PostoperativeVisit (5 to 6 Weeks)

At this time, carefully suction the remaining gelatin sponge packing from the
deeper canal and tympanic area, and check for signs of stenosis of the canal, la-
teralization or blunting of the graft, effusions in the middle ear, and location and
function of ossicular prostheses. Obtain an audiogram if the tympanic area seems
clear and intact.
600 SAJJADI

Short-Term PostoperativeCare (6 to 12 Months)

By this time, most ears have healed well. Care of the mastoid cavity becomes
an important issue if a canal wall-down mastoidectomy has been performed. The
ultimate goal in care of the mastoid cavity is to achieve a self-cleaning and dry
ear that needs minimal professional cleaning of the mastoid cavity once every 10
to 12 months. Selected patients are instructed to irrigate the mastoid cavity gently
with alcohol and vinegar two or three times a day for 6 months. The irrigation
seems particularly helpful if the mastoid cavity has deep pockets that collect mu-
cous and debris. In-office cleaning of the mastoid cavity is performed under a
microscope, and occasionally rigid otic endoscopes for office use may be needed
to evaluate and fully clean all hidden areas in the mastoid bowel.
Consideration of and preparations for a second-look procedure in ears that
had cholesteatoma should be made during this visit. Endoscopic exploration has
been extremely valuable in evaluating such patients. Particularly in cases in which
excellent hearing results have been obtained from the primary procedure, it is best
to avoid disrupting the ossicular chain or the grafted tympanic membrane if at all
possible.

Long-Term Postoperative Care (1 to 5 Years)

Annual audiograms should be obtained after adequate microscopic cleaning

is performed. Watch for trends in hearing thresholds. Consider revisional ossicu-
loplasty or hearing aids, if needed. Inspect all ears with a microscope, checking
for retractions in the attic, posterior inferior atelectasis, or blunting of the anterior
drumhead. One of the most common causes of delayed extrusion into the middle
ear of an ossicular prosthesis is persistent dysfunction of the eustachian tube (ET).
In such instances, placement of ventilation tubes may reverse the extrusingprocess
if implemented early. Cavities still need long-term care with irrigation with alcohol
and vinegar, and an instillation of boric acid powder may be needed, depending
on conditions in individual patients. Superficial fungal infections in mastoid cav-
ities can be treated by frequent rinses with alcohol and vinegar, followed by an
instillation of topical triamcinalone and nystatin ointment. Consider revisional
meatoplasty if the size of the meatus is inadequate and one is unable to visualize
deep mastoid pockets where debris can collect and cause repeated infections.

POSTOPERATIVE INTERVENTION

During the entire period of postoperative follow-up, the following issues need
to be considered to ensure an excellent surgical outcome: rejection of prostheses
in the middle ear, placement of ventilation tubes, second-look endoscopic proce-
dures, meatoplasty, and Thiersch skin grafting.

Rejection of Prostheses in the Middle Ear

Ask patients about their patterns of hearing postoperatively. If a history of

good hearing initially is followed by a sudden decrease in hearing, consider re-
jection of the prosthesis if a prosthesis was used. Check for signs of rejection, which
include an inflamed tympanic membrane and fullness in the ear, but no otalgia,
 THIERSCH SKIN GRARING AND POSTOPERATIVE CARE OF OTOLOGIC PATIENTS 601

no discharge from the ear, and usually an intact graft or tympanic membrane.
Infection near the prosthesis presents differently, with acute pain followed by a
ruptured eardrum or failure of the graft, and otorrhea, possibly with a low-grade
fever before the ear drains.
With clinical suspicion of rejection of the prosthesis, treatment is with oral
prednisone, 1 mg/kg/d for 5 days and then slowly tapered over 10 days. An
intramuscular injectionof Depo-Medrol (methylprednisoloneacetate),40 to 80 mg,
may be substituted for the oral dosing. Follow up the patient closely and repeat
the test with a 512-Hz tuning fork or obtain an audiogram. Patients may need to
continue prednisone therapy for a longer period of time if the hearing fluctuates.

Placement of Ventilation Tubes

Concomitant use of ventilation tubes during most surgical procedures on a

chronically problematic ear leads to a much lower incidence of postoperative at-
electasis of the eardrum, extrusion of the prosthesis, or effusions in the middle ear.
The small downside to having a tube postoperatively remains that one must insist
on precautions to keep a dry ear, and the ever-presentprobability of contamination
with water, leading to otorrhea. Once the intraoperatively inserted ventilation tube
has extruded, careful follow-up should be rendered to check for evidence of dys-
function of the ET that might threaten a previously successful procedure. If evi-
dence of chronic and persistent dysfunction of the ET is present, placement of
long-term ventilation tubes may be needed to avoid various related complications.
This can be achieved in various ways. One way is repeatedly to insert a small
Paparella type 1 tube (Smith and Nephews Richards, Memphis, Tennessee) with
the patient under local anesthesia in the office. Alternatively, longer-acting Papa-
rella type 2 tubes can be used relatively safely. These soft tubes have a relatively
low incidence of postextrusion perforation (10%) and typically last about 2 years
before spontaneous extrusion. Generally, the much larger T-tubes should be
avoided as much as possible because of their high incidence of associated for-
mation of debris (50%);perforations of the tympanic membrane (30%);and, in rare
cases, acquired cholesteatoma.

Second-Look Endoscopic Procedures

Counsel patients about the technique and its limitations, especially the fact
that an open procedure may be needed if significant disease is encountered. Usu-
ally, these are done with the patient under monitored anesthetic control (MAC),
that is, local anesthesia with light intravenous sedation. If there is a need to open
up the ear, then general anesthesia can be induced at the same time. A small
inferior tympanomeatal flap is elevated, a l.5-mm, rigid, 30" otologic endoscope
is carefully inserted, and the middle ear is inspected. Alternatively, a flexible 1.0-
mm endoscope can be inserted through a large myringotomy incision, but it is
best to avoid incising grafted eardrums.
If no significant disease is found, attention is given to the mastoid cavity and
the attic area. If a previous intact canal wall mastoidectomy was performed, one
should search for an air-containing mastoid cavity using a 5-mL syringe and a 21-
gauge needle in the postauricular area. Once air pockets are located, make a stab
incision and insert a small, 1.5-mm rigid otologic endoscope and evaluate the
mastoid, and especially the attic, for recurrent or residual cholesteatoma. If no
cholesteatoma is seen, the tympanomeatal flap can be put back down, and light
602 SAJJADI

gelatin sponge packing in the ear canal is all that is needed. The entire exploration
is done in less than an hour in most cases.

Meatoplasty

An adequately sized and shaped meatus to the ear canal is of paramount

importance to long-term success after all otologic surgeries. This is especially cru-
cial in all canal wall-down mastoidectomies. Furthermore, in some cases with a
small and unusually shaped meatus, the fitting of a hearing aid becomes a chal-
lenge, if not impossible. Occasionally, impressions made for a hearing aid get
trapped in large mastoid cavities hidden behind a small meatus, which can at
times necessitate general anesthesia to remove the hardened and trapped material
for the impression.
Local anesthesia with light intravenous sedation or MAC is usually more than
enough for most compliant adult patients. Inject the entire ear for a total nerve
block. Put some topical 4% cocaine on cottonoid sponges in the cavity. Elevate a
posteriorly based conchomeatal skin flap, exposing the entire meatal and conchal
cartilage. Preserve as much of the meatal skin as possible.
Resect nearly all the conchal and meatal cartilage, elevate the mucosa or a
layer of skin of the posterior mastoid cavity, and reposition the conchomeatal skin
flap onto the exposed mastoid cavity. Pack the external ear canal and meatus with
occlusive, nonadherent, sterile otologic sponges soaked with sulfa and hydrocor-
tisone ophthalmic drops. Continue the same drops postoperatively three times a
day until the packs are removed in 7 to 10 days. Be aggressive in resetion of
cartilage and overcompensatemeatal size. Preserve cartilage of the helical rim and
avoid removing any skin.

Thiersch Skin Grafting

This is probably the most important, and yet a very simple, technique in the
otologicsurgeon's list of things to do after ear surgeries,but it is mainly a forgotten
skill, not taught at most otolaryngologic residency programs worldwide. Thiersch,
in Germany, first described the technique early in this century. It was popularized
in the United States by Schuknecht, who taught it to hundreds of residents and
fellows, including Paparella, who has continued to teach it to numerous residents
in otolaryngology and fellows in otology to this day. Unfortunately, the vast ma-
jority of residents in modem otolaryngology have not even heard of this highly
effective technique.
Poorly healing ear canals after canalplasty or even routine tympanoplasties
should be Thiersch grafted. Extensive raw surfaces in the mastoid cavity after
canal wall procedures should be grafted. Minor defects in a tympanic graft after
an otherwise uneventful tympanoplasty should be grafted.
Obtain an extremely thin split layer skin graft from the ipsilateral inner arm.
One must Thiersch-graft all raw surfaces in the ear canal and mastoid to ensure
proper healing and avoid stenosis and persistent discharge of the mastoid.

Timing of the Surgery

Delay grafting to 2 to 5 weeks after the major surgery on the ear. By delaying,
the wound can contract, and less skin may be needed. Furthermore, the granulat-
ing bed allows for higher take rates for the graft. This delay allows for a "tune-
 THIERSCH SKIN GRAFTING AND POSTOPERATIVE CARE OF OTOLOGIC PATIENTS 603

up of the previous surgery on the ear to correct minor irregularities that may
have gone unnoticed or may have developed since. Not all patients need to receive
grafts, and by delaying, many patients heal just fine on their own. When a Thiersch
graft is obviously needed, such as after primary open-cavity tympanomastoidec-
tomy or after repair of congenital atresia, a proven method the author has used
routinely is to remove the packing and stitches 10 days after surgery and apply
Thiersch grafts at the same time with the patient under general anesthesia (chil-
dren) or local anesthesia (adults).

Instruments and Supplies

Required are a sterile otic microscope and sterile surgical field, with the entire
ipsilateral ear and arm prepped. Put the arm on a regular armboard and drape it.
You will use a myringotomy tray plus an endaural speculum, medium ear-cup
forceps, a straight double-ended curette, a loop curette, a Petri dish, heavy Carmalt
clamps, razor blades, silk gauze, an oval eyepad, a transparent skin dressing,
wrap-around gauze, and cotton twirl tape. Medications required include 2% li-
docaine with 1:100,000 epinephrine in a three-ring syringe with a 27-gauge needle,
topical 4% cocaine (2-4 mL), topical 1:lOOO adrenaline (3 mL), gentamicin oint-
ment, and mineral oil.

Surgical Steps
Most cases can easily be done with the patient under local anesthesia with
light sedation (MAC). Minimal surgical instruments and supplies are needed.
Three steps need to be followed systematically.
Step One: Prepare the Ear. This is done under the microscope using ear cu-
rettes, after the achievement of topical anesthesia (1-2 mL of topical 4% cocaine
put on a cotton twirl tape in the ear). Remove any surgical packing or suturing
material at this time. Check for proper placement and patency of ventilation tubes
and correct any problems if found. Inspect the size of the meatus and perform
conchomeatoplasty as needed before obtaining material for the Thiersch graft.
Using the curette, clean off superficial granulation tissue and identlfy squamous
epitheliallayers to avoid burying any such layers and causing delayed cholesterol
pearls. When the ear is ready, pack the ear with cotton twirl tape impregnated
with topical 1:lOOO epinephrine, and proceed to step two.
Step Two: Harvest the Grafting Material. First inject the inner aspect of the
ipsilateral upper arm with 2% lidocaine with 1:100,000 epinephrine in the sub-
dermal layer, and mark the anesthetized area. Use a regular razor blade of the
type found in grocery stores, mounted on a heavy Carmalt clamp to remove the
extremely thin graft. The skin should be SufficientIy thin to be able to read the typed
lettering on the razor blade through the skin. If you are using a dermatome, set it
to 0.009-inch (0.23-mm) thickness, but use of the razor blade is the preferred
method in the authors clinic.
Grafts of various thickness can be harvested, depending on the patients
needs. Larger areas deep in the mastoid cavity may do better with slightly thicker
grafts, whereas areas in the ear canal and near the tympanic membrane must have
extremely thin grafts to avoid circumferential stenosis and blunting. Estimate the
size of the graft needed, and apply a temporary dressing over the donor site. Put
the grafts over silk gauze on a Petri dish impregnated with gentamicin ointment.
Cut each graft in small, rectangular strips ready to be applied onto the ear. The
weight of the ointment-laden silk gauze is what keeps these extremely flimsy and
thin grafts in place.
604 SAJJADI

Step Three: Apply the Thiersch Graft and Arm Dressing. Remove the epi-
nephrine packing from the ear. Avoid any further curetting because this may cause
minor bleeding and decreased success of the graft. Cover all raw surfaces with
the Thiersch strips. A slight 0.5-mm overlap is desirable to avoid burying squa-
mous epithelium with the grafting strips. No packing is necessary in most cases.
If it is needed, use small, nonadhering sponges in selected areas. Note on the chart
the number of strips that were used.
Apply an oval eyepad to the outer ear. No cotton balls in the meatus are
needed. Apply a large, transparent, sterile dressing to the donor site on the arm,
wrap it with gauze, and leave it wrapped for 24 hours. Leave the transparent
dressing on the arm for 14 days. Inspect the ear with a microscope in 10 to 14
days, and then remove the silk gauze, making sure the count is correct and all
strips are removed!

STAPEDIAL SURGERY

Most stapedectomies and stapedotomies are done with the patient under
MAC (monitored anesthesia control), so most patients are relatively stable in the
recovery room and go home the same day. With the advent of lasers and small-
fenestra stapedotomy procedures, severe postoperative vertigo has become less
common. The best way to avoid postoperative complications following stapedial
procedures is to exercise meticulously careful surgical technique intraoperatively.
Local anesthesia does allow for monitoring of the patients gross threshold for
hearing and for assessing for severe vertigo, which may result promptly if the
prosthesis is too long or if an active perilymphatic fistula is starting. Surgeons
must communicate in advance with the anesthesiologist regarding the need for
light sedation. This is important because most anesthesiologists are trained to
provide deep sedation, and in these otologic cases, the patient must essentially be
awake during the stapedial fenestration and insertion of the prosthesis. Alterna-
tively, some patients who are nervous of fearful, and who might move during,
local anesthesia can be treated successfully under general anesthesia.

Medicationsfor Stapedial Surgery

All patients receive oral meclizine, 50 mg preoperatively, and ondansetron

intravenously in the operating room and in the recovery room. With this regimen,
most patients undergoing stapedial procedures are able to tolerate the vestibular
stimulation and be discharged home 4 to 5 hours postoperatively. All patients
receive prophylactic antibiotics: 1 g cefazolinintravenously at induction followed
by a week of ampicillin postoperatively. Postoperativemedicationsfor vertigo and
nausea are prescribed, and patients are encouraged to take them before they feel
worse. A soft diet with a high intake of fluids is prescribed, together with instruc-
tions to avoid constipation, straining, and nose blowing. Patients are requested to
call the clinic if they develop excessive coughing, sneezing, or nasal congestion,
so that they can receive strong, supportive medical therapy as soon as possible,
lest they develop any complications.

Level of Activity

Activities that may endanger function of the ET (travel by air, scuba diving,
swimming, driving or hiking at high altitudes, and even use of express elevators
 THIERSCH SKIN GRAFTING AND POSTOPERATIVECARE OF OTOLOGIC PATIENTS 605

in high-rise buildings) are prohibited for 1 month postoperatively. Heavy lifting

and straining, including aerobic exercises, are also potentially dangerous for a
month after stapedial operations.

PostoperativeVisits

The first visit is in 7 to 10 days, when packing in the external ear is removed
and a tuning fork (512 Hz) is used to check for gross results in hearing. If the
hearing is grossly intact, no audiogram is done until at least 1 month postopera-
tively, but if a patient reports an initial improvement in hearing followed by sig-
nificantly diminished hearing, one should obtain an audiogram to check for sen-
sorineural hearing loss. Prednisone at a dose of 1.5 mg/kg/d (tapered down
slowly over 14 d) is prescribed if postoperative sensorineural hearing loss without
significant vertigo is documented. An early immunologic foreign body reaction
may be present at the level of the vestibule, which may lead into formation of
granuloma.
These ears are better left unexplored because it may cause a total loss of all
hearing. If persistent or sudden onset of severe vertigo and nerve deafness is
present, the patient is treated with prednisone and is considered for possible ex-
ploration to check for perilymphatic fistulas in the oval window or dislodgement
of the prosthesis deep into the vestibule. The findings should then be addressed
as needed. These cases are associated with a poor prognosis for preservation of
hearing, with or without exploration, but some cases may be salvaged if treated
early enough.
After the initial visit, routine visits are scheduled for 1 month, 3 months, and
6 months, and 1 year postoperatively. An audiogram is obtained during each visit.
The contralateral otoscelerotic ear is not operated on until at least 6 months, and
preferably 1 year, has passed since the initial stapedial operation, and not until
the operated ear is hearing well with no vertigo.

ENDOLYMPHATIC SAC ENHANCEMENT

Endolymphaticsac enhancement remains the procedure most commonly per-

formed for intractable M6ni5res disease in the United States, if not in the world.
The endolymphatic sac enhancements is designed to be a conservative and non-
invasive method to help decrease or eradicate the episodic attacks of vertigo and
to reduce the uncomfortable aural pressure suffered by patients who have MC-
nieres disease. Sac enhancement is performed with the patient under general
anesthesia, and a typical procedure lasts approximately 2 hours. Postoperative
patients are kept overnight for a 23-hour stay. Like all operations that deal with
the inner ear, careful handling of tissue around the sac, preservation of the semi-
circular canals, and efficient surgical technique are the keys to avoiding postop-
erative problems, especially vertigo.

Medications

All patients receive preoperative oral meclizine, 25 to 50 mg, and cefazolin, 1

g intravenously at induction. During the procedure and in the recovery room,
patients receive ondansetron, 2 to 4 mg intravenously each time; this dose may be
repeated every hour as needed. While they are hospitalized overnight, patients
receive intravenous cefazolin, 1 g every 8 hours, and diazepam, 5 to 10 mg orally
606 SAJJADI

every 6 hours, and antinausea medication and other supportive therapies. Patients
are discharged home on 1week of ampicillin and are encouraged to take meclizine
or diazepam as needed for vertigo, as well as oral antiemetic medications.

Level of Activity

All patients are requested to avoid heavy lifting, straining, and air travel for
2 weeks postoperatively. Most patients return to their preoperative levels of activ-
ity within 2 to 4 weeks. Surgical success or failure is not assessed until at least 6
months postoperatively. The postauricular wound and the ear canal are to be kept
strictly dry at all times, and the incision is dressed with antibiotic ointment twice
a day.

PostoperatlveVisits

The first visit is scheduled at 10 to 14 days postoperatively, when the post-

auricular staples are removed, the wound is examined for signs of infection, the
ventilation tube is checked, and a gross assessment of hearing is made using a
512-Hz tuning fork (if applicable).

Complications

Surgeons, especially those on call, should be fully aware of the severity of

infection of a postauricular wound after sac-enhancement surgery; the incidence
of infection is 2%. Such an infection can quickly spread into the open endolym-
phatic sac, causing purulent labyrinthitis and total sensorineural hearing loss in a
matter of days, if not hours. As a result, patients with the slightest hint of an
infected wound are admitted into the hospital for intravenous broad-spectrum
antibiotics and aggressive wound care.
The next most severe complication is postoperative leakage of cerebrospinal
fluid (CSF); the incidence of leakage is 5%. Leakages of CSF are usually detected
during the procedure and promptly treated by packing the defect in the dura using
fascia and gelatin sponge, mastoid pressure dressings, and avoidance of the area
in placement of ventilation tubes. The patient is then kept on bed rest for the next
4 days, in the hospital, and is discharged on restricted activities for 4 weeks. In
the rare case of delayed leakage of CSF, however, the patient is admitted into the
intensive care unit, the ventilation tube is removed from the eardrum, and the ear
canal is packed with nonabsorbable packing. An indwelling lumbar drain catheter
is inserted, and CSF is drained at a rate of 10 mL/h for the next 5 to 7 days, with
the patient at strict bed rest in a supine position. It is extremely rare to have to
reoperate on a patient for persistent leakage of CSF after a sac-enhancement pro-
cedure.

POSTOPERATIVE PALSY OF THE FACIAL NERVE

This is a lengthy topic, and this short article is not intended to cover all aspects
of this complicated issue. Every well-trained otolaryngologistis fully aware of the
significanceof the facial nerve during and after ear surgery. Meticulous awareness
of the variable anatomy of the facial nerve, competent execution of the surgical
 THIERSCH SKIN GRAFI"G AND POSTOPERATIVE CARE OF OTOLOGIC PATIENTS 607

procedure, and efficient use of real-time electromyographic monitoring of the fa-

cial nerve have led to a significant reduction in postoperative palsies of the facial
nerve. Patients undergoing ear surgery should not be discharged from the recov-
ery room unless either the surgeon or one of his associates has properly assessed
function of the facial nerve. This is important to differentiatebetween immediate
palsies and those of delayed onset.
When postoperative facial palsy is detected, the surgeon should be notified
immediately, and a careful protocol should be followed. The possibility that the
use of local anestheticsduring surgery may have caused a temporary palsy should
be ruled out first. The surgeon must try to remain objective in assessing the events
that could have led to this finding. Probably the most important immediate action
is to notify the patient and his or her family properly and to present a detailed
plan to evaluate and treat the paralysis. The surgeon must remain truthful in his
or her explanation concerning what may have happened and how it can be fixed.
If the surgeon is aware of significant manipulation of the facial nerve during
surgery and is confident that the nerve was left fully intact, then conservative
therapy using high-dose prednisone (1.5 mg/kg/d), and close observation using
an outpatient protocol for electroneuronography of the facial nerve (ENoG) is
adequate. On the other hand, if the surgeon is surprised to see postoperative
paralysis of the facial nerve, it is best to consult another otologic surgeon, to coun-
sel the patient and his or her family extensively, and promptly (within a few hours)
to explore the surgical site in a joint effort to locate the site of injury and render
treatment as needed. Prompt surgical exploration and decompressionof the facial
nerve is also indicated in cases of immediate total paralysis in which the surgeon
remembers manipulating the nerve or the area near the nerve but is not certain
concerning the integrity of the nerve. Delayed paralysis or palsy of the facialnerve
is also treated with the following ENoG protocol.

PROTOCOL FOR ENoG FOR POSTOPERATIVE PARALYSIS

OF THE FACIAL NERVE

This applies only to total paralysis of the facial nerve seen clinically either in
delayed onset or as in the case of "expected palsy seen after extensive manipu-
lation of the nerve with a clinically intact nerve. Obtain a baseline ENoG within
the first 24 hours; this should be normal and should stay that way for the first 3
to 4 days postoperatively.
Start the patient on prednisone, 1.5 mg/kg/d (with a slow tapering off over
14 d). If the paralysis remains unchanged, do serial ENoGs at twice-weekly inter-
vals; if these confirm more than 90% degeneration of the nerve on two consecutive
ENoGs, together with persistent total clinical paralysis, consider surgical decom-
pression of the nerve at the expected site of injury at the earliest possible time. If
the facial nerve shows significant and prompt improvement, either clinically or
on the ENoG, continue to treat with steroids and supportive care. Recovery of the
patient should be normal to near normal, and surgical decompression may not
improve the outcome significantly.Detailed and straightforward counseling of the
patient is crucial for the best final outcome.

SUMMARY

When proper preoperative planning has been carried out and a flawless pro-
cedure has been performed, delivery of postoperative follow-up care ensures SUC-
608 SAJJADI

cessful surgical outcomes. In many instances, postoperative care is as important

as the actual surgical procedure, if not more important. Improper postoperative
care by the patient or the physician, through neglect or ignorance, can lead to
various minor complications that, if not treated promptly, may lead to significant
morbidity and dissatisfaction in a patient and poor results. Assessment of proper
meatal size, location of the eardrum (atelectatic or blunted), poor healing of the
wound in the cavity or the ear canal, and proper hearing thresholds are important
factors in the postoperative period. Failure of prostheses in the middle ear caused
by immunologic rejection of the prosthesis or infection at the prosthesis needs to
be recognized and treated accordingly.
Patients need to be counseled preoperatively on possible needs for a delayed
Thiersch skin grafting, second-look procedures, and long-term follow-ups (life-
long, in case of cholesteatoma).Thiersch skin grafting remains an excellent tech-
nique to ensure proper healing in the mastoid cavity and ear canal. This simple
and effective procedure allows for a detailed postoperative check of the surgical
sites, including a check of the position of the graft on the tympanic membrane,
patency of ventilation tubes, healing in the canal, status of the mastoid cavity, and
a final check for any residual surgical packing or suturing materials that could
cause an indolent foreign body reaction. Delayed meatoplasty may avert long-
term meatal stenosis after both canal wall-up procedures and canal wall-down
procedures; this is a highly effective technique that allows for a much larger me-
atus, making care of the cavity easier for patients, the otolaryngologist, and dis-
pensers of hearing aids.
Meticulous and proper intraoperative handling of the facial nerve goes a long
way toward avoiding postoperative facial palsies that invariably prove to be dif-
ficult to treat. Otologic surgeons must prepare themselves to deal with this tragic
complication and must have a detailed plan ready to be implemented in such
cases. In some cases, it may be highly beneficial to consult another competent
otologic colleague to help with the management of postoperative paralysis of the
facial nerve in a joint operation. Proper and prompt counseling of the patient is
essential to achieve the best overall outcome in all otologic cases, particularlywhen
severe complications, such as palsies of the facial nerve, are encountered.
Address reprint requests to
Hamed Sajjadi, MD, FACS
Minnesota Ear, Head, and Neck Clinic
701 25th Avenue South, Suite 200
Minneapolis, MN 55454