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| The Surgical Technologist | FEBRUARY 2017 62 The stapes is given two points and the other entrees are given one point. The best score is 10. If a patient scores six or more, he/she is a candidate for surgery. With a score of five or less, the complications outweigh the potential benefits.6 Prompt diagnosis and early assessment of hearing helps to avoid the late sequelae of speech problems. 7 Surgery to open the ear canal and restore the natural sound by conducting a pathway of the ear canal and mid- dle ear to the inner ear (cochlea, which is usually healthy in these children) is a challenging operation that is per- formed in a single stage generally taking about four to five hours. There are essentially seven steps to the operation: 1. Skin incision, fascia graft harvest, exposing the cortex of the temporal bone 2. Drilling the bony canal, releasing the ossicles, examining the ossicular motion 3. Harvesting the split thickness skin graft 4. Placing the temporalis fascia graft as the new eardrum 5. Placing the split thickness skin graft to line the bony canal 6. Meatoplasty – creating an opening in the outer ear for the skin graft; connects the bony canal to the outside world 7. Delivering the skin graft through the newly cre- ated meatus, suturing the edges of the skin graft to the edge of the native skin of the concha, closing the post auricular incision P R E P A N D D R A P I N G The back table preparation typically will take the surgi- cal technologist about 30 minutes. About eight small pea- shaped pieces of cotton will be placed into 1.5 ml of epi- nephrine 1:1000 dilution for hemostasis. The remaining 0.5 ml of epinephrine will be added to 20 ml of 1% Lidocaine plain in 3 cc syringe and 27-gauge hypodermic needle that will make a dilution of 1:40,000 for local anesthesia. Triam- cinolone acetonide will be placed in a tuberculin syringe with a 27-gauge hypodermic needle to prevent an inflamma- tory reaction. An ofloxacin otic solution will be dispensed in a 3 cc syringe and 23-gauge hypodermic needle to inflate the ear canal dressing sponges. Silastic sheeting, that is 0.04 mm thick, will be cut into circles 4 mm-7mm for holding the skin graft against the canal. The four ear canal sponge dressings will be cut with a knife to two-thirds of the length leaving five whole-length sponges for holding the skin graft in place. A plastic skin carrier will be cut to one-third length for preparation of the skin graft. Three metal medicine cups will be filled ¾-full with warm lactated ringers to rinse the skin graft. A 3-0 absorbable suture will be used to close the post-auricular incision. A 4-0 absorbable suture will be used to anchor the anterior conchal flap. A 5-0 fast-acting tissue suture will be used to anchor the skin graft to the skin at the canal’s new edge. The skin harvest dressing will involve a Xeroform gauze cut to size, a non-adherent gauze cut to size, three 4x4 gauze dressings and a gauze roll that will hold the dressings in place. This will be applied to either the upper extremity or lower extremity. The ear dressing will start with a cotton ball covered in bacitracin ointment, a non-adherent dressing cut into a crescent shape to wrap around the auri- cle, five 4x4 gauzes folded over to cover the incision, two unfolded 4x4 gauze to cover the auricle, 10-inch gauze roll strips to hold the dressings off of the eye, three gauze rolls to wrap the dressings around the head and a cloth towel for under the patient’s head while wrapping to keep the dress- ings clean. The instruments will be set up like any ear case with some additional pieces. A #7 knife handle will be used with the #11 knife blade for the meatoplasty. Two smooth jew- elers’ forceps will be used to handle the skin graft during preparation and placement. Two plastic white cutting blocks will be used to prepare the skin graft and to place the fascia graft under the overhead light for drying. A larger cutting block will be used to save cut up muscle tissue pieces to anchor the edge of skin graft to any air cells present in the canal after the graft is placed. A moistened angled ball probe Parameter Points Stapes present 2 Oval window open 1 Middle ear space 1 Facial nerve normal 1 Malleus-incus complex present 1 Mastoid well pneumatized 1 Incus-stapes connection 1 Round window normal 1 Appearance of external ear 1 Total available points 10