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Following the physical examination, biopsies and imaging studies, the patient and family should meet with the skull base team — ear surgeon, head and neck surgeon, neurosurgeon, and in some cases plastic surgeon and eye surgeon. Discussions should include the possibility of facial nerve removal and grafting, if the tumor has invaded the facial nerve. In addition, most patients with extensive tumors will lose the hearing and balance functions of the inner ear. In order to isolate the tumor and remove it completely, portions of the ear canal, mastoid and inner ear will be removed in an “enbloc” operation. This means that the structures of the ear canal, drum, middle ear, and inner ear are removed in one piece. This technique reduces the possible spillage of tumor to adjacent sites, but provides a greater chance of cure.
Teaching mastoid surgery with binocular operating microscope and KTP LASER Before antibiotics, mastoid surgery was commonly done in desperate circumstances for acute infection, a mastoid abscess. Our predecessors had nothing better than a hammer and gouge, and no magnification other than some spectacle loupes. It was counted a success if the patient – usually a young child – survived. No delicate work could be done, and most survivors were deafened. It was only after the introduction of the binocular operating microscope in the 1950’s that modern delicate controlled microsurgery of the ear became possible. Even with all the latest high powered microscopes, lasers and modern anaesthetics, mastoid surgery is very difficult. Surgeons have to train for years to get good at it. Like all ear surgeons trained since the 1960’s I did my basic training (in the 1980’s) on temporal bones from cadavers (dead bodies). Although some might find that macabre, I’d prefer the learning curve to be on my dead granny, rather than on my live child. The margin of error in mastoid surgery is measured in fractions of a millimetre. Anatomy varies considerably, and a surgeon needs to practice on lots of bones before embarking on live patients. Simulators and plastic bones just aren’t up to it. Unfortunately, in the UK, a public attitude has become established against the use of post-mortem tissues, which has led to a severe shortage of temporal bones for the next generation of ear surgeons to train on. I teach trainee surgeons ear surgery on live patients every week, sometimes two or three cases. The operations take anywhere between one to six hours. The average is around three hours.