← The ENT LibrarySurgical Perspective · Approach guides

How we do it

17 operations described the way they are planned and performed at Santosh Advance ENT Healthcare, Hisar: indication, choice of approach, operative steps in sequence, the landmarks that keep the operation safe, and the recovery that follows. Each guide links to the operative video, the referenced case report where one exists, and the relevant book chapter.

For professional education. Steps are summarised and vary with the patient, the disease and the surgeon; they do not replace supervised training or local protocols. Operative videos are shown with patient consent and without identifying the patient.

Tympanoplasty (type I) with ossicular assessment Mastoidectomy for cholesteatoma: canal wall up and canal wall down Endoscopic stapedotomy Cochlear implantation Lateral skull base approach for glomus jugulotympanicum with facial nerve grafting Endoscopic septoplasty Functional endoscopic sinus surgery Extended total maxillectomy for invasive sinonasal mucormycosis Endoscopic endonasal skull base surgery: CSF leak, angiofibroma and pituitary Total laryngectomy with neck dissection Tracheal resection with end-to-end anastomosis Type I thyroplasty (silicone medialisation)Total thyroidectomy, including large and retrosternal goitre Partial glossectomy with selective neck dissection Selective neck dissection, level by level Parotidectomy with facial nerve preservation Pectoralis major myocutaneous flap

Ear and lateral skull base

Otology · intermediate

Tympanoplasty (type I) with ossicular assessment

Indications

Dry central perforation of the pars tensa with conductive hearing loss or recurrent discharge, after the ear has been dry for several weeks and the audiogram confirms the air–bone gap.

Approach

Endoscopic transcanal for most anterior and central perforations; microscopic post-aural when the canal is narrow, the anterior margin is hidden or the mastoid must be explored.

Operative steps

Freshen the perforation margin and remove the rim of epithelium.
Elevate the tympanomeatal flap from about the 6 to 12 o'clock position and enter the middle ear at the annulus.
Inspect the ossicular chain: mobility of the malleus, continuity of the incudostapedial joint and mobility of the stapes.
Harvest temporalis fascia or tragal perichondrium and dry it.
Place the graft as an underlay medial to the remnant and malleus handle, supported by absorbable gelatin sponge in the middle ear.
Replace the flap and pack the canal.

Landmarks and safety

Chorda tympani lies just under the posterosuperior annulus; elevate it with the flap.
Avoid suction on a mobile stapes.
The facial nerve can be dehiscent over the oval window.

After surgery

Keep the ear dry; canal pack removed at two to three weeks; audiogram at about three months.

Operative videos Book 2 · Pinna to Petrous

Otology · advanced

Mastoidectomy for cholesteatoma: canal wall up and canal wall down

Indications

Cholesteatoma or chronic otitis media with mastoid disease. Canal wall up when disease can be cleared with the posterior wall intact and follow-up is reliable; canal wall down for extensive disease, a contracted mastoid, or when a second-look operation is unlikely.

Approach

Post-aural incision, musculoperiosteal flap, cortical drilling within Macewen's triangle.

Operative steps

Identify the spine of Henle, temporal line and posterior canal wall.
Drill the cortex and open the antrum; identify the lateral semicircular canal and the short process of the incus.
Thin the tegmen and sinodural angle; follow the disease into the attic and facial recess.
Canal wall down: lower the posterior wall to the level of the facial ridge, saucerise the cavity and perform an adequate meatoplasty.
Remove the matrix completely, then reconstruct the drum and, where possible, the ossicular chain.

Landmarks and safety

The lateral semicircular canal and the incus are the guide to the facial nerve's second genu.
Drill parallel to the facial nerve with continuous irrigation.
Do not open the dura or sigmoid sinus while thinning the plates.

After surgery

Mastoid dressing for 24 to 48 hours; regular cavity care; second-look surgery or diffusion-weighted MRI for canal wall up.

Operative videos Book 2 · Pinna to Petrous Within the Temporal Bone

Otology · advanced

Endoscopic stapedotomy

Indications

Otosclerosis with conductive loss, an air–bone gap of about 25 dB or more, and a negative Rinne at 512 Hz.

Approach

Transcanal endoscopic, with a tympanomeatal flap and removal of posterosuperior canal bone (scutum) until the stapes and pyramidal process are seen.

Operative steps

Confirm stapes fixation and a mobile malleus and incus.
Measure from the long process of the incus to the footplate.
Divide the stapedius tendon and separate the incudostapedial joint.
Remove the stapes superstructure.
Make a small fenestra in the footplate with a microdrill or laser.
Place a piston of measured length and crimp it on the incus; seal the fenestra with tissue.

Landmarks and safety

Avoid opening the vestibule widely; a floating footplate is a recognised hazard.
A dehiscent facial nerve may overhang the oval window.

After surgery

Avoid nose-blowing and straining; vertigo is usually brief; audiogram at six weeks.

Operative video Book 2 · Otosclerosis and stapes surgery

Otology · advanced

Cochlear implantation

Indications

Bilateral severe to profound sensorineural hearing loss with limited benefit from hearing aids, after audiological, imaging and counselling assessment.

Approach

Post-aural incision, cortical mastoidectomy and posterior tympanotomy through the facial recess to the round window.

Operative steps

Mark the receiver–stimulator position and drill the seat and tie-down.
Cortical mastoidectomy; identify the short process of the incus.
Open the facial recess between the facial nerve and the chorda tympani.
Identify the round window niche and remove its overhang.
Insert the electrode slowly through the round window membrane.
Seal the opening with tissue, fix the device and perform intraoperative telemetry.

Landmarks and safety

The facial recess is bounded by the facial nerve medially and the chorda tympani laterally.
Atraumatic, slow insertion preserves residual hearing.
Check imaging for cochlear malformation or ossification before surgery.

After surgery

Switch-on at about two to four weeks, followed by mapping and auditory rehabilitation.

Operative videos Cochlear implant pathway Book 2 · Cochlear implantation

Lateral skull base · advanced

Lateral skull base approach for glomus jugulotympanicum with facial nerve grafting

Indications

Glomus tumour extending from the middle ear to the jugular bulb, after imaging, angiography and assessment of lower cranial nerves.

Approach

Infratemporal fossa approach (type A pattern): canal closure, mastoidectomy, control of the sigmoid sinus and internal jugular vein in the neck, and facial nerve management.

Operative steps

Expose the great vessels and lower cranial nerves in the upper neck.
Close the external canal as a blind sac and perform a radical mastoidectomy.
Skeletonise or reroute the facial nerve as the tumour requires.
Control the sigmoid sinus proximally and the internal jugular vein distally.
Remove the tumour from the jugular bulb and middle ear.
Reconstruct the facial nerve with a cable graft where it is involved; obliterate the cavity.

Landmarks and safety

Lower cranial nerves (IX–XI) lie on the medial wall of the jugular bulb.
Bleeding from the inferior petrosal sinus is controlled with packing, not cautery.

After surgery

Swallowing assessment; eye care until facial function returns; imaging surveillance.

Operative videos Case report Book 2 · Pinna to Petrous

Nose, sinuses and anterior skull base

Rhinology · beginner

Endoscopic septoplasty

Indications

Deviated septum or septal spur causing nasal obstruction, or limiting access for sinus surgery.

Approach

Endoscopic, through a hemitransfixion or Killian incision; targeted to the deviated segment.

Operative steps

Infiltrate and make the incision on the side of the deviation.
Raise the mucoperichondrial flap and cross under the cartilage to the opposite side.
Remove or reposition the deviated cartilage and bony spur, preserving an L-strut.
Check the airway endoscopically on both sides.
Close the incision and place quilting sutures or splints.

Landmarks and safety

Keep at least 1 cm of dorsal and caudal strut to protect nasal support.
Avoid opposing tears in the flaps, which lead to perforation.

After surgery

Saline irrigation; splints, if used, removed at about one week.

Operative video Book 3 · Septoplasty

Rhinology · intermediate

Functional endoscopic sinus surgery

Indications

Chronic rhinosinusitis with or without polyps after an adequate trial of medical treatment, guided by CT.

Approach

Endoscopic transnasal, extent matched to disease: uncinectomy and middle meatal antrostomy through to full ethmoidectomy, sphenoidotomy and frontal sinusotomy.

Operative steps

Study the CT for the lamina papyracea, skull-base height, Onodi cells and anterior ethmoidal artery.
Uncinectomy and identify the natural ostium of the maxillary sinus.
Open the ethmoid bulla and posterior ethmoid cells, keeping lateral to the middle turbinate.
Identify the skull base posteriorly and dissect forwards along it.
Sphenoidotomy medially, and frontal recess clearance as indicated.

Landmarks and safety

Stay medial to the lamina papyracea and lateral to the middle turbinate attachment.
The skull base is thinnest at the lateral lamella of the cribriform plate.

After surgery

Saline irrigation and topical steroid; endoscopic debridement in clinic.

Operative videos Sinusitis care Book 3

Skull base · advanced

Extended total maxillectomy for invasive sinonasal mucormycosis

Indications

Invasive fungal sinusitis with non-viable maxillary and pterygoid tissue, after diagnosis and with systemic antifungal treatment and control of diabetes.

Approach

Combined endoscopic and open (Weber–Ferguson or sublabial) approach, extended to the infratemporal fossa and transpterygoid region as required.

Operative steps

Assess orbit, palate and skull base on contrast imaging.
Raise the cheek flap or sublabial exposure.
Perform the osteotomies of the maxilla and remove it en bloc where possible.
Clear the pterygopalatine and infratemporal fossae to bleeding, viable tissue.
Debride the skull base endoscopically.
Obturate the palatal defect.

Landmarks and safety

Debridement continues until tissue bleeds; repeat look procedures are often needed.
The internal maxillary artery is controlled in the pterygopalatine fossa.

After surgery

Antifungal therapy, glycaemic control, serial endoscopy and prosthetic rehabilitation.

Operative videos Case report

Skull base · advanced

Endoscopic endonasal skull base surgery: CSF leak, angiofibroma and pituitary

Indications

CSF rhinorrhoea or encephalocele, juvenile angiofibroma, and sellar lesions such as pituitary macroadenoma, planned with the neurosurgical team where needed.

Approach

Endoscopic transnasal: transethmoidal for the cribriform plate, transpterygoid for angiofibroma, and transsphenoidal for the sella.

Operative steps

Localise the defect or lesion on CT and MRI.
Raise a nasoseptal flap where a large repair is expected.
Expose the target: cribriform plate, pterygopalatine fossa or sphenoid face.
Remove the lesion or reduce the encephalocele.
Repair in layers (fat, fascia, vascularised flap) and support with packing.

Landmarks and safety

The internal carotid artery and optic nerve lie on the lateral wall of the sphenoid.
Angiofibroma is embolised beforehand where available and removed from its pterygoid base.

After surgery

Avoid straining and nose-blowing; watch for CSF leak and endocrine changes after pituitary surgery.

Operative videos Skull base care Book 3

Larynx, airway and thyroid

Head and neck oncology · advanced

Total laryngectomy with neck dissection

Indications

Advanced laryngeal or hypopharyngeal cancer, cartilage destruction, a non-functional larynx, or salvage after failed chemoradiation.

Approach

Apron or U-shaped cervical incision, with neck dissection as indicated, and closure in layers or with a pectoralis major flap.

Operative steps

Raise subplatysmal flaps and perform the neck dissection.
Divide the strap muscles, the thyroid isthmus and, where required, one thyroid lobe.
Free the larynx from the hyoid and divide the constrictors along the thyroid cartilage.
Enter the pharynx away from the tumour, under vision, and remove the larynx.
Fashion the tracheostome; create a tracheo-oesophageal puncture where planned.
Close the pharynx without tension; add a pectoralis major flap after radiation.

Landmarks and safety

Ligate the superior laryngeal pedicle early to keep the field dry.
Preserve enough pharyngeal mucosa for a closure that will not stricture.

After surgery

Nasogastric or oral feeding as healing allows; stoma care; voice rehabilitation with a valve or electrolarynx.

Operative videos Resect, Rebuild, Restore Voice after laryngectomy

Airway · advanced

Tracheal resection with end-to-end anastomosis

Indications

Symptomatic post-intubation or post-tracheostomy stenosis of limited length that has failed or is unsuitable for endoscopic treatment.

Approach

Low collar incision with anterior tracheal exposure; release manoeuvres as needed for tension-free anastomosis.

Operative steps

Assess the length and grade of stenosis on endoscopy and CT.
Expose the trachea and mark the stenotic segment.
Divide below the stenosis, intubate across the field and resect the segment.
Mobilise the trachea in the pretracheal plane.
Perform the anastomosis with interrupted sutures, posterior wall first.
Keep the neck flexed to protect the anastomosis.

Landmarks and safety

Dissect directly on the trachea to protect the recurrent laryngeal nerves.
Limit lateral dissection to preserve the segmental blood supply.

After surgery

Chin-to-chest position for about a week; bronchoscopy before discharge.

Operative videos Case report

Laryngology · intermediate

Type I thyroplasty (silicone medialisation)

Indications

Unilateral vocal fold palsy with glottic gap and breathy voice or aspiration, after an adequate period for recovery or when recovery is not expected.

Approach

Open, under local anaesthesia so that the voice can be tuned during surgery.

Operative steps

Horizontal neck incision over the thyroid cartilage.
Mark the window on the thyroid lamina at the level of the vocal fold, about 5 mm above the inferior border.
Cut the cartilage window, preserving the inner perichondrium.
Insert and adjust a silicone implant while the patient phonates.
Confirm voice and airway endoscopically, then close.

Landmarks and safety

A window placed too high medialises the ventricular fold instead of the vocal fold.
Over-medialisation can narrow the airway.

After surgery

Voice rest for a few days; observe for airway oedema in the first night.

Operative video Case report Voice, swallowing and breathing

Endocrine · intermediate

Total thyroidectomy, including large and retrosternal goitre

Indications

Multinodular goitre with compression, suspected or confirmed malignancy, or toxic goitre not controlled medically.

Approach

Cervical collar incision; most retrosternal goitres are delivered through the neck, with lateral or midline extension used only when required.

Operative steps

Raise subplatysmal flaps and separate the strap muscles.
Ligate the superior pole vessels close to the gland.
Mobilise the lobe medially; identify the recurrent laryngeal nerve and parathyroid glands.
Divide the inferior thyroid artery branches close to the capsule.
Deliver the retrosternal component by gentle traction and finger dissection.
Remove the gland and check haemostasis and nerve function.

Landmarks and safety

Preserve the parathyroids on their blood supply; reimplant one that is devascularised.
The external branch of the superior laryngeal nerve lies close to the superior pole.

After surgery

Calcium monitoring; voice check; thyroid hormone replacement.

Operative videos Case report Thyroid care

Oral cavity, neck and salivary glands

Head and neck oncology · intermediate

Partial glossectomy with selective neck dissection

Indications

Carcinoma of the oral tongue, staged clinically and on imaging; neck dissection is advised for most tumours because of the risk of occult nodes.

Approach

Transoral for most tongue tumours; a lip-split or pull-through approach only when access requires it.

Operative steps

Mark a margin of about 1 cm around the palpable tumour.
Excise in three dimensions, palpating for depth.
Send margins for frozen section where available.
Close primarily or reconstruct with a local or free flap.
Perform the selective neck dissection (levels I–III or I–IV).

Landmarks and safety

Preserve the lingual nerve and hypoglossal nerve unless involved.
Depth of invasion guides the decision on the neck.

After surgery

Swallowing and speech therapy; review of histology for adjuvant treatment.

Operative videos Case report Head and neck cancer care

Head and neck oncology · intermediate

Selective neck dissection, level by level

Indications

Staging or treatment of the neck in head and neck cancer, with levels chosen by the primary site.

Approach

Transverse incision in a skin crease, with subplatysmal flaps.

Operative steps

Level I: identify the marginal mandibular nerve, then clear the submental and submandibular triangles.
Release the fascia from the sternocleidomastoid.
Level II: identify the spinal accessory nerve and clear IIa and IIb.
Levels III and IV: dissect along the internal jugular vein; preserve the phrenic nerve and brachial plexus deep to the fascia.
Deliver the specimen in continuity and label the levels.

Landmarks and safety

The spinal accessory nerve crosses the internal jugular vein in the upper neck.
At level IV, look for the thoracic duct on the left and lymphatic leak on the right.

After surgery

Drain until output is low; shoulder exercises; watch for chyle leak.

Operative videos Resect, Rebuild, Restore

Salivary · advanced

Parotidectomy with facial nerve preservation

Indications

Parotid tumours after imaging and fine-needle aspiration; superficial, total or radical parotidectomy according to the pathology and facial nerve involvement.

Approach

Modified Blair incision, with neck extension for nodal disease.

Operative steps

Raise the skin flap over the parotid fascia.
Mobilise the gland from the sternocleidomastoid and the cartilaginous canal.
Identify the facial nerve trunk using the tragal pointer, the posterior belly of digastric and the tympanomastoid suture.
Follow the branches forward, lifting the gland off the nerve.
Remove the tumour with a cuff of normal tissue; sacrifice the nerve only when it is involved, and graft where possible.

Landmarks and safety

The nerve trunk lies about 1 cm deep and inferior to the tragal pointer.
Nerve monitoring and a dry field help in revision surgery.

After surgery

Facial nerve assessment; drain care; watch for salivary collection.

Operative videos Case report

Reconstruction · intermediate

Pectoralis major myocutaneous flap

Indications

Reconstruction of head and neck defects, cover of the pharyngeal closure after salvage laryngectomy, and protection of the carotid artery.

Approach

Pedicled flap based on the thoracoacromial artery, tunnelled over the clavicle to the neck.

Operative steps

Mark the pedicle line from the acromion to the xiphoid.
Design the skin paddle medial to the nipple over the muscle.
Raise the muscle from medial to lateral, identifying the pedicle on its deep surface.
Divide the humeral attachment and narrow the pedicle.
Tunnel the flap and inset it without tension or twisting.

Landmarks and safety

Keep the skin paddle over muscle to protect its perforators.
Preserve the deltopectoral flap territory when designing the incision.

After surgery

Monitor flap colour; drains in chest and neck; shoulder physiotherapy.

Operative videos Case report: deltopectoral flap Resect, Rebuild, Restore

Prepared by Dr Bhushan Kathuria & Team. Corrections from colleagues are welcome through the contact page.