Describe the complications of ear surgery.

Complications of Ear Surgery

• Every otological operation carries a characteristic set of risks, and knowing them is what makes consent meaningful rather than a formality
• Facial nerve injury is the most feared, occurring at mastoidectomy, stapes surgery and parotid surgery. The nerve is at greatest risk where the canal is dehiscent (10 to 15%), where anatomy is distorted by disease or previous surgery, and in the infant, whose stylomastoid foramen is superficial
• Its prevention — knowing the landmarks (the lateral semicircular canal, the digastric ridge, the short process of the incus); working from known to unknown; preoperative CT; and facial nerve monitoring, which is now standard in revision surgery
• If a palsy is noticed postoperatively — first exclude the effect of local anaesthetic.
• Sensorineural hearing loss or a dead ear — from drilling on an intact ossicular chain (which transmits enormous acoustic energy to the cochlea, and is why the incus is removed before drilling near a fixed chain), from opening the labyrinth, from suction on an open vestibule, and from noise
• Vertigo — from labyrinthine injury, a fistula, or perilymph leak
• Chorda tympani injury, causing metallic taste and dry mouth, which is common, temporary, and should be mentioned at consent because it distresses patients who were not warned
• Dural exposure and CSF leak, and rarely encephalocele
• Sigmoid sinus injury with troublesome bleeding, controlled by pressure and surgicel rather than by ligation
• Graft failure, residual and recurrent cholesteatoma, and cavity problems
• Wound infection, perichondritis, meatal stenosis and keloid
• Specific to stapes surgery — dead ear in 1%.
• Specific to grommets — otorrhoea, blockage, early extrusion, persistent perforation and tympanosclerosis
• Anaesthetic considerations — the oculocardiac-like reflex and bradycardia on traction, postoperative nausea and vomiting.
• The medicolegal point — the majority of complaints after ear surgery concern outcomes that were not discussed beforehand, particularly taste disturbance, tinnitus, vertigo, a persistent cavity and failure to improve hearing. Document the discussion, not merely the consent form
• Exclude local anaesthetic first in a postoperative facial palsy, then remove the pack, before considering exploration
• Immediate complete palsy suggests transection and delayed incomplete palsy suggests oedema.
• Use facial nerve monitoring in revision surgery, where the landmarks are distorted and the nerve unpredictable
• Work from known landmarks toward the unknown, keeping the lateral canal and digastric ridge in view throughout
• Warn about taste disturbance explicitly; it is common, temporary, and greatly distresses patients who were not told