42. A small congenital cholesteatoma was found at time of a well-child visit. The tumor is seen through an intact tympanic membrane. Only the anterosuperior quadrant of the middle ear space appears involved. At surgery, the tumor was encapsulated and did not involve the ossicles or extend beyond the middle ear

43. A large congenital cholesteatoma, found subsequent to hearing loss identified at time of a school hearing screening test. The tumor completely fills all visible middle ear space beneath the tympanic membrane. At surgery, ossicular erosion was present as well as tumor extension into the attic and mastoid.

45. Primary acquired cholesteatoma

62. Canal-wall-down

63. a canal wall down operation, the entire mastoid is exteriorized into the ear canal and the posterior and superior portion of the ear canal is removed down to the region of the facial nerve. The facial nerve is left intact covered by a ridge of bone called the facial ridge. This leaves a large cavity called a mastoid bowl which has to be cleaned by the doctor every 3 to 12 months. In order to clean this cavity, the meatus or the external opening into the ear canal is surgically widened -

64. Picture of a left mastoidectomy, surgeon's view. Picture of a right mastoidectomy, surgeon's view. Note the blue color of the skeletonized sigmoid sinus .

65. Picture of a left mastoidectomy, surgeon's view.

66. A large, adequate meatoplasty. Such a meatoplasty is usually necessary to create a problem-free cavity.

67. L Canal Wall Down Mastoidectomy. This patient had a modified radical mastoidectomy with tympanoplasty. The posterior bony canal has been removed and part of the dry "mastoid bowl" is visible posterior and superior to the reconstructed tympanic membrane

68. Magnification of the above photograph. A meatoplasty has been performed to enlarge the external auditory canal and allow easy access to the mastoid bowl for inspection and cleaning. The reconstructed eardrum is seen anteriorly.

70. Intact-canal wall procedure

71. In this left canal wall up mastoidectomy, the tympanic membrane has been elevated forward and a cholesteatoma sac is visible in the attic. This is a "canal wall up" mastoidectomy because the posterior bony canal has been preserved.

72. In this picture of a right tympano- mastoidectomy, a prosthesis has been interposed between the manubrium of the malleus and the capitulum of the stapes.

73. Transcanal anterior atticotomy

85. Glue ear with fluid level behind right eardrum Abnormally thin right eardrum damaged by glue ear and showing ossicles - malleus incus and stapes

88. Correct position for putting in eardrops Tragal massage Ear plugs held in place by neoprene headband

91. grommet in position right eardrum - abnormally thin due to longstanding retraction prior to fitting grommet. Head of stapes visible, long process of incus partially eroded Long term ventilation tube in position right ear eac = external ear canal vt = ventilation tube tm = tympanic membrane (eardrum) The long term ventilation tube is larger than the standard grommet