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-- Head and Neck Surgery

Local Anesthesia for Middle Ear Surgery

Gl Caner, Levent Olgun, Grol Gltekin and Levent Aydar
Otolaryngology -- Head and Neck Surgery 2005 133: 295
DOI: 10.1016/j.otohns.2004.09.112
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OtolaryngologyHead and Neck Surgery (2005) 133, 295-297

Local Anesthesia for Middle Ear Surgery

Gl Caner, MD, Levent Olgun, MD, Grol Gltekin, MD, and
Levent Aydar, MD, Bozyaka-Izmir, Turkey

A prospective evaluation of 100 patients, 31 men and 69

women, who were operated under local anesthesia in SSK

Izmir Hospital ENT Clinic for middle ear disease was undertaken. The mean age of the patients was 27.8 years, with
a range of 13 to 55 years.
One-half hour before the patient was taken to surgery, they
received 50 mg of pethidine hydrochlorure and 0.5 mg of
atropine by intramuscular injection. If the patient was still
comprehensive when placed on the operating table, additional
sedation of 5 to 10 mg of diazepam intravenously was given
before the patient became agitated. In the absence of inammation, mastoid bone is devoid of sensation except for its outer
periosteum and, to a lesser degree, its inner mucoperiosteum.
Very satisfactory complete local anesthesia can be secured
using a commercially available solution containing 2% lidocaine with 1:10000 epinephrine for inltration.
Local inltration for the postauricular and the endaural
incisions is as follows: the tympanic branch of the auriculotemporal nerve is blocked by injection of 1 or 2 mL of
solution into the anterior meatal wall at the osteocartilaginous junction. The branches of the great auricular nerve to
the auricle and the meatus are blocked by injections at
several points behind the auricle and over the mastoid process. The auricular branch of the vagus nerve is blocked
injection of the periosteum at the anterior surface of the
mastoid process and the skin of the oor of the meatus. For
endomeatal incisions in stapes surgery, solution is injected
to the posterior meatal wall so as not to cause a bleb. At
approximately the same depth, approximately 0.2 mL of
solution is then injected into the anterior, superior, and
inferior meatal wall.1
In the early postoperative period, patients were asked
to score their discomfort for pain, noise, anxiety, irritability (uneasiness), and position of the body and neck by
means of a questionnaire. The scores ranged from 0 to
4 for each question, 0 for no discomfort and 4
for extreme discomfort. In addition, the surgeon was
asked for the adequacy of anesthesia, discomfort during

From SSK Izmir Education Hospital, Bozyaka-Izmir, Turkey.

Presented at the 21st Meeting of the Politzer Society, Antalya, Turkey,
1998.

Reprint requests: Gl Caner, 125 sok No:4/5, 35050 Bornova-Izmir,

Turkey.
E-mail address: gulc@isbank.net.tr.

The adequacy of anesthesia and comfort during surgery was assessed

for 100 consecutive patients undergoing middle ear surgery using
local anesthesia, both by the patients themselves and by the surgeon.
The possibility of inducing an iatrogenic facial weakness was also
evaluated. Both the surgeon and the majority of patients were pleased
with the quality of anesthesia and little adverse effects occured as a
consequence of local anesthesia itself.
2005 American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. All rights reserved.

perating without pain is a fancy which human senses

cannot pursue. This fancy in the pessimistic opinion of
Velpeau in 1839 has left its place today for more complex
problems. Every new technique and drug in anesthesia is more
effective and less toxic than the previous one, increasing the
safety of general anesthesia so that many otologic surgeons
now prefer it for the majority of operations. General anesthesia
and local anesthesia each have advantages. Some surgeons
believe that patients may not tolerate the otologic intervention
under local anesthesia. Local anesthesia allows the anesthetic
capacity to be employed for other major operations, may result
in slightly less bleeding and allows hearing to be tested during
surgery.
In this prospective study, data collected by means of a
questionnaire from 100 patients undergoing middle ear surgery under local anesthesia and sedation were reviewed. In
addition, the surgeon was asked for the adequacy of anesthesia, discomfort during surgery, and postoperative transient facial weakness.

MATERIALS AND METHODS

0194-5998/$30.00 2005 American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. All rights reserved.
doi:10.1016/j.otohns.2004.09.112
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296

OtolaryngologyHead and Neck Surgery, Vol 133, No 2, August 2005

Table 1
Scores for complaints both by patients and the
surgeon

Anxiety
Pain
Noise
Irritability

1 2 3 4

44
42
50
32

10
44
19
28

28
11
18
26

12
2
7
13

6
1
6
1

Mean
value

Surgeons
mean

1.11
0.94
0.96
1.19

1.46

1.28

surgery, and postoperative transient facial palsy. Additional questions were asked about the most disturbing
sensation during the operation and whether they would
prefer local anesthesia for a second procedure.

RESULTS
Of the patients, 11 underwent stapes surgery, myringoplasty
was performed in 8 patients, and tympanoplasty was performed in 69 patients. Of the patients, 10 underwent tympanoplasty and mastoidectomy; 6 of these were canal-walldown and 4 were canal-wall-up procedures. Radical
mastoidectomy was mandatory in 2 patients. The operation
was terminated in 1 patient because of claustrophobia. This
patient underwent stapedotomy later under general anesthesia.
Of the patients, 38 had a history of surgery under local
anesthesia for ENT or other diseases, 11 patients were
previously operated under general anesthesia for different
diseases, 1 had had both local and general anesthesia, and
50 patients had no history of surgery.
The number of incisions for entrance to the temporal
bone was 82 retroauricular, 6 endaural, and 11 transcanal.
The average time of stay on the operation table was 72
minutes. The average total amount of lidocaine with epinephrine injected was 7.3 cc. Of the patients, 24 needed
additional medication, diazepam IV, for their increasing
anxiety.
Patients scored their distress for pain with a main
value of 0.94. The mean score was 1.11 for anxiety, 0.96
for sensation of noise during surgery, and 1.19 for irritability. Of the patients, 23 complained of backache.
From the surgeons point of view, mean value of scores
for anxiety was 1.46 and for irritability 1.28 (Table 1).
One patient had a transient facial weakness. The majority
(96%) of patients undergoing stapes surgery or tympanoplasty without mastoidectomy noted that they had no
pain during surgery. The most distressing sensation for
this group of patients was the noise caused by the instruments.
The most distressing sensation during surgery was anxiety for 44 of the patients. Noise was the greatest discomfort
for 33 patients and pain was distressing for 22 of them. In

spite of these discomforts, 73 patients still preferred local

anesthesia for a similar operation.

DISCUSSION
Although it has long been known that middle ear surgery can be carried out under local anesthesia, many
surgeons prefer local anesthesia. Less bleeding, costeffectiveness, postoperative analgesia, mobilization
of the patient in a short time, reduced aspiration risk
because of normal cough reex, release of anesthetic
capacity for other major procedures, and that the hearing
can be tested during surgery are the advantages of local
anesthesia. Preoperative sedation and local anesthesia
allows the patient to undergo a comfortable procedure.
Sensation of pain is related to personal psychological
status and previous experiences. Personal variations are
more important than the degree of surgical trauma. Patients
should be assessed meticulously by the experienced surgeon
so that local anesthesia is not to be performed in unsuitable
patients. The less the patient is informed, the greater his or
her anxiety will be.
Yung2 reported that although the intense sensation of
noise and anxiety were the most common discomforts, the
majority of patients preferred local anesthesia. Lancer and
Fisch3 and Andreassen and Larson4 have reported no adverse effects in their 2 different studies on local anesthesia
for middle ear surgery.
In our questionnaire survey, patients scored their discomfort of pain as a mean value of 0.94 corresponding to
a value lower than 1, indicating means mild. Most
patients noted that they felt pain only at the beginning of
the surgery because of numerous injections of the local
anesthetic. Beause the maximum discomfort from any of
the sensations during the procedure was scored by 4,
the mean values for anxiety (1.11), noise (0.96), and
irritability (1.19) are acceptable and not important
enough to decide to abandon local anesthesia for middle
ear surgery. In rating the most disturbing sensation, 44%
of patients complained mostly of their irritability, 33%
complained of the noise during the procedure, and 22%
complained of their anxiety.
The choice of patients in favor of local anesthesia for
a similar procedure in spite of these discomforts has
various reasons. Mobilization of the patient in a short
time, little pain in early postoperative period and the
chance of being informed by the surgeon during the
procedure are the most common reasons. In highly anxious and less-educated patients, fear of not waking up
again after general anesthesia may be another reason for
preferring local anesthesia.
From the surgeons point of view, the ability to test
hearing during surgery and less bleeding are the most striking advantages. Transient facial weakness lasted no longer
than 1 hour in our series and can be overcome by injecting

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Caner et al

Local Anesthesia for Middle Ear Surgery

the solution meticulously especially in the inferior meatal

wall.
Our choice for local anesthesia for middle ear surgery
is especially for ears for which a stapedotomy or tympanoplasty is to be performed. As all ENT surgeons know,
the situation may differ from the preoperative examination, when the tympanic cavity or mastoid cavity is entered and a canal-wall-down procedure or a radical mastoidectomy can be necessary. Nevertheless, local
anesthesia allows us an increased capacity of the operating room that means a closer time of appointment for the
patient.

297
patients and by the surgeon. Good patient selection and
adequate selection are the important factors for the success
of local anesthesia. The majority of patients still prefer local
anesthesia for a similar procedure in the future.

REFERENCES
1. Glasscock ME III, Shambaugh GE Jr. Surgery of the ear, 4th edition.
Philadelphia: WB Saunders Company; 1990.
2. Yung MW. Local anesthesia in middle ear surgery: survey of patients
and surgeons. Clin Otolaryngol 1996;21:404 8.

CONCLUSIONS

3. Lancer JM, Fisch U. Local anesthesia for middle ear surgery. Clin
Otolaryngol 1988;13:36774.

Middle ear surgery under local anesthesia is safe and feasible. It causes less bleeding and is well tolerated both by

4. Andreassen UK, Larsen CB. [Anesthesia in ear surgery. A source

economical analysis and patient assessment of general anesthesia versus
local anesthesia in ear surgery]. Ugeskr Laeger 1990;28;152:15957.

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