In an adequately consented, anaesthetised and positioned patient, I would infiltrate local anaesthetic at the site of my postauricular skin incision.
I would perform a limited cortical mastoidectomy and periosteal pocket for the receiver package. I would perform a posterior tympanotomy and drill away the round window niche followed by a round window cochleostomy. I would then very gently insert the electrode array and receiver stimulator and seal the round window with muscle. I would perform electrical/physiological testing and close the wound in two layers and dressed.
In an adequately consented, anaesthetised and positioned patient, I would infiltrate local anaesthetic at the site of my horizontal skin incision midway between the cricoid cartilage and suprasternal notch.
I would excise the subcutaneous fat and divide the midline muscular raphe continuing the dissection until the anterior tracheal wall is identified. I would bipolar the isthmus of the thyroid although this is uncommonly encountered. I would place Prolene stay sutures either side of my planned vertical incision at the level of the second and third tracheal rings. Following the incision, I would place Vicryl maturation sutures. I would liase with the anaesthetist to withdraw the endotracheal tube slowly under direct visualisation and insert the tracheostomy tube and connect this to the ventilation circuit. I would confirm correct placement with with chest expansion, capnography and flexible nasoendoscopy and then secure the tracheostomy in place.
In an adequately consented, anaesthetised and positioned patient, I would mark out my inverted-v collumella incision and infiltrate local anaesthetic into the nasal tip, along the columella, nasal septum and dorsum of the nose.
I would make my trans-columella and infra-cartilagenous incisions and raising a collumella flap extending into marginal incisions bilaterally along the caudal edge of the lower lateral cartilages.
I would continue elevating superiorly lifting the skin and pericondrium off the dome, nasal septum, and cartilaginous and bony nasal dorsum.
I would expose the caudal end of the nasal septum and perform a septoplasty, harvesting cartilage as required and re-aligning the septum and re-attaching it on the maxillary crest.
I would insert bilateral spreader grafts to strengthen the dorsal nasal septum in the midline and prevent collapse of the internal nasal valve.
Spreader grafts are strut-shaped cartilage grafts, which are placed unilaterally or bilaterally between anterior edge of the nasal septal and the upper lateral cartilages.
I would perform lateral nasal stab incisions (11 blade) followed by lateral osteotomies with a sharp straight 2-mm osteotome and align the nasal bones.
Lateral osteotomies can be used to correct assymetry of the nasal bones, close an open roof deformity following hump removal and narrow the upper third of the nose. They are usually performed in a 'high-low-high' fashion by starting high on the piriform aperture preserving a small triangle of maxillary bone (Webster's triangle) that provides support to the lateral nasal cartilages.
I would mattress suture the nasal septal (4-0 vicryl rapide) followed by the closure of the columella incision, taping the dorsum and applying plaster of Paris.