A sickle knife and McCabe flap knife are used to incise normal tissue around the lesion of suspect, ensuring adequate margins of normal tissue.Additional anesthesia is used through the postauricular sulcus into the mastoid bowl and through the tragus to anesthetize the lateral EAC. 2% lidocaine with 1:20,000 epinephrine is used to anesthetize and vasoconstrict the EAC in a 4-quadrant fashion with the needle inserted at the bony-cartilaginous junction.This is also the method of choice for biopsying small lesions of the EAC. Small tumors arising from the cartilaginous EAC or involving limited bony EAC are amenable to sleeve resection.Nitrous oxide may be used as no tympanic membrane grafting is typically performed.Advise the need for "no paralysis" during the case for facial nerve monitoring.Decadron 12 mg IV at beginning of case if facial nerve manipulation anticipated.Cefazolin (Ancef) 1 g IV 1 hour prior to surgical incision.Double check arms and legs padding to ensure safety.Patient should be tucked and padded to allow +/- 30° table rotations. Varidyne vacuum suction drains: 7 mm or 10 mm.See Skin graft protocol and Sural Nerve Graft Harvest protocol for specific draping if necessary.Split sheet around cranium leaving the entire ipsilateral face visible.Clear plastic drape over ipsilateral face and neck split sheet around cranium leaving entire ipsilateral face visible, and drainage bag placed 1 cm behind intended incision.Towels around head and towels to square off graft site.Head drape (leave ipsilateral face free of tape).Place NIMS (Neurologic Integrity Monitoring System) electrodes into glabella, orbicularis oculi, and orbicularis oris.Ipsilateral face prepped to allow intraoperative visualization.Wide 10% providone iodine prep from head to xiphoid (in case of need for a pectoralis major myocutaneous flap), left lower quadrant of abdomen (for fat harvest), and left leg (for sural nerve graft).Hair shaven 6 cm posterior to postauricular sulcus.Ringer's irrigation solution, 1000 cc bottles, in warmer x 4.Ringer's injection, 1000 cc bag x 6 for irrigation while drilling.1:100,000 epinephrine for preauricular/periparotid infiltration.1% lidocaine with 1:100,000 epinephrine for postauricular incision site.Major Instrument Tray 2, Otolaryngology.Major Instrument Tray 1, Otolaryngology.Nerve stimulator control unit and instrument.NIMS (Neurologic Integrity Monitoring System). Requires "dual setup" for both an otologic procedure and neck procedure with possibility of a craniotomy setup with the neurosurgeons.Osteoradionecrosis of the temporal bone.Stress that hearing will often be significantly worsened or sacrificed to achieve surgical goals.Stress that facial nerve excision and grafting may be required.Your ear canal will be oversewn, and the mastoid bone will be filled with fat from your abdomen or will require an additional piece of tissue from elsewhere in your body to fill the cavity created behind your ear." Removal of your hearing and balance organs, facial nerve, parotid gland, and lymph nodes in your neck may also be necessary. Description: "At minimum, remove your mastoid cells, ear canal, ear drum and hearing bones to encompass the tumor excision.Depending on particular type of carcinoma and presentation, may consider pre-operative interventional radiology evaluation.
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