Dallas Ear Institute
7777 Forest Lane, Suite A-103, Dallas, TX 75230 | Phone: (972) 566-7600 | Fax: (972) 566-6560 | www.dallasear.com

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2nd look procedure for Middle Ear Cholesteatoma

1. A view of the reconstructed eardrum. This patient had an extensive cholesteatoma with significant erosion of the ear canal bone and ossicles that was surgically resected 6 months previously. The patient was taken for middle ear exploration to ensure no residual disease and to reconstruct the eardrum.
The black arrow indicates the previously placed cartilage graft, which is directly underneath the eardrum and recreates the ear canal wall that was eroded by cholesteatoma and drilled for adequate visualization of the disease process during the original ear surgery. The white arrow indicates the first hearing bone which is immediately underneath the eardrum—the malleus. This bone is nearly always maintained in the middle ear during surgery, unless involved with cholesteatoma.
2. View of the middle ear cavity after eardrum has been lifted. The stapes footplate is indicated by the white arrow. This is the thin shell of bone that separates the inner ear cavity from the middle ear cavity. In a normal working ear, there are three bones that reside in the middle ear cavity, and the stapes bone, or stirrup bone, sits on this footplate and vibrates the fluid within the inner ear to allow us to hear. Because this patient had extensive erosion of this bone, along with the 2nd hearing bone, the incus, these are no longer present. The black arrow points to the horizontal portion of the facial nerve, the nerve that allows all facial movement. This nerve lies in a bony tunnel just above the stapes footplate.
3. Small cholesteatoma pearl in middle ear cavity. This tiny pearl, or circumscribed skin ball, was found during the 2nd look procedure. In this photo, the tiny pearl was seen under the ear canal bone and was dissected carefully and removed in whole. Often, if some skin cells are hidden from view and unable to be removed during the primary surgery, they form into a pearl such as this which is easily and completely removed during the 2nd look procedure, with little to no chance of residual disease.
4. A view of the tiny cholesteatoma pearl that was removed from the middle ear cavity. Note the size of the skin pearl. The ruler adjacent to the skin pearl indicates that it’s size is less than 2 mm.
5. Hearing reconstruction. Once any disease has been removed from the middle ear cavity, the hearing mechanism is then rebuilt, first by placing a shoe over the footplate. This titanium shoe accepts the ossicular prostheses and allows re-establishment of the hearing mechanism.
6. Hearing reconstruction. The titanium prosthesis with a hydroxyapatite head is then placed from the footplate shoe to the malleus on the undersurface of the eardrum. The connection between the eardrum and the inner ear is re-established.

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Dallas Ear Institute
7777 Forest Lane, Suite A-103, Dallas, TX 75230 | Phone: (972) 566-7600 | Fax: (972) 566-6560 | www.dallasear.com