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Mastoidectomy NIYADA TEERASUWANAJUG • Cumming otolaryngology head and neck surgery (5th ed) • Bailey Head and neck surgery-otolaryngology (4th ed) • Glasscock-Shambaugh surgery of the ear (5th ed) • Temporal bone surgical dissection manual by Ralph A. Nelson • เอกสาร collective review mastoid surgery อ. เพิ่มทรัพย์ Mastoid • All major components of the temporal bone are present in infants, but there is one notable difference that has surgical implications. In infants, the mastoid tip has yet to develop, and the stylomastoid foramen is located more superficially, making the facial nerve vulnerable to surgical trauma. Mastoid Surgery Acute infection Chronic infection with or without cholesteatoma Trauma Facial nerve disorder Vestibular disorder Mastoid Surgery Canal wall up Simple mastoidectomy Facial recess approach Atticotomy Canal wall down Radical mastoidectomy Modified radical mastoidectomy Bondy procedure Mastoid Surgery Canal wall up technique Definition Mastoidectomy and ME exploration with removal of disease in contiguous area and preservation of osseous EAC Maintain the superior and posterior canal walls intact More recent include removing a portion of canal wall reconstruction defect with bone, cartilage, or alloplastic material To maintain the normal anatomic barrier between the external ear canal and mastoid cavity. Lt ear Canal wall up Mastoid Surgery Canal wall up technique Indication COM with persistent drainage refractory to medical Rx Cholesteatoma of ME and mastoid ME tumor involving ossicular chain and extending into attic Persistent ME effusion refractory to medical Rx Contraindication Extensive cholesteatoma which makes it difficult for surgeon to be sure that all disease has been eradicated Cholesteatoma invasion of labyrinth or cochlea Mastoid Surgery Canal wall down technique Definition – Through removal of mastoid air cells, aggressive saucerization of cortical edges of mastoid, a complete removal of superior and posterior canal walls, and a meatoplasty Mastoid Surgery Canal wall down technique Indication Extensive disease Poorly pneumatized mastoid Poor ET tube function Previous failure CWU mastoidectomy Contraindication Disease limited to attic or antrum Simple mastoidectomy Definition - Removing the mastoid cortex and varying amounts of the air cell system, depending on the disease process. - Drain a coalescent mastoiditis with subperiosteal abscess. Radical mastoidectomy • • • • • • Definition canal wall down procedure No attempt at restoring middle ear function is made. The eustachian tube is occluded, and the malleus and incus (and possibly the stapes superstructure) are removed. The TM remnant is excised, and no graft is placed, leaving the middle ear open. The expectation is for squamous epi. to grow over the middle ear and mastoid cavity. Indication : cholesteatoma cannot be completely excised (e.g., cochlear fistula, disease tracking into the petrous apex). Modified radical mastoidectomy • Used interchangeably with canal wall down mastoidectomy. • Classically, modified radical mastoidectomy refers to the Bondy procedure, in which disease limited to the epitympanum is simply exteriorized by removing portions of the adjacent superior or posterior canal wall. • The uninvolved middle ear is not entered, and the cholesteatoma matrix on the lateral surface of the ossicular heads is maintained in place as a lining for the created cavity. • Small cholesteatomas are frequently amenable to the Bondy approach Mastoid obliteration • The indications for and extent of obliterating mastoid air cells varies considerably from surgeon to surgeon. • Various materials are used, including autogenous bone and cartilage, free or vascularized soft tissue, and bioactive or biocompatible alloplastic materials. • Mastoid obliteration is typically used when the canal wall has been removed to decrease the size of the mastoid cavity and make it as care-free as possible. • In rare cases, the eustachian tube and external ear canal are closed, completely isolating the mastoid from the exterior. Surgical approach Mastoidectomy Postauricular incision Endaural incision Surgical approach Mastoidectomy Post auricular incision (Children < 2 yr: inferior portion of incision must be more posterior to prevent facial n. injury) Endaural incision Less commonly use limit exposure Simple mastoidectomy Bondy procedure Atticotomy Simple mastoidectomy Simple mastoidectomy Simple mastoidectomy Superior Inferior Periosteum incision: Linea temporalis <-> Mastoid tip Simple mastoidectomy Drilling intersection 2 line - Temporal line - Medial to Henle spine Compare Well pnuematized mastoid with Sclerotic mastoid - Tegmen tympani more locate superiorly - Sigmoid sinus more posteriorly Simple mastoidectomy Superior Remove mastoid air cells to level Korner septum Inferior Simple mastoidectomy Korner septum: Remnant of petrosquamous suture line Divide air cell superficial from deep cell Lateral to TM annulus Simple mastoidectomy Superior 2 techniques improve exposure to antrum and attic: - Thinning tegmen - Thinning posterior canal wall Inferior Simple mastoidectomy Superior Inferior LSCC landmark to attic and facial nerve Not damage to endolymphatic sac and duct Digastric ridge: starting inferior to sigmoid <-> ending at stylomastoid foramen Simple mastoidectomy Incus Inferior Superior Ossicular chain (in epitympanum) anterior to LSCC Simple mastoidectomy Superior Inferior P86 op tech Trautmann’s triangle Location of posterior fossa - Sigmoid sinus - Tegmen - SCC Simple mastoidectomy Complete mastoidectomy Superior After procedure important to irrigate ME to remove residual bone dust new bone formation and consequent CHL Simple mastoidectomy Superior Inferior Facial recess approach (Posterior Tympanotomy ) Facial recess approach (Posterior Tympanotomy ) Indication When disease in ME, attic, and antrum is not adequate visualized via complete mastoidectomy Access to ME through mastoid cavity Facial recess approach (Posterior Tympanotomy ) FN Facial recess approach (Posterior Tympanotomy ) Superior Landmark for facial nerve LSCC Short process incus medial and inferior (1-2mm deeper) Posterior wall of EAC Digastric ridge Chorda tympani Facial recess approach (Posterior Tympanotomy ) ME space Superior View of Facial n., Chorda tympani, Stapes, Incus, Fossa incudis, LSCC Area for risk of residual disease Sinus tympani Exam with Buckingham mirror or Tele 30 Facial recess approach Extended facial recess approach -Remove chorda tympani -Inferior: remove bone between bony annulus TM and fallopian canal -Good expose for RW and hypotympanum area Anterior tympanotomy Unroofing epitympanum Most common involve by cholesteatoma Disarticulating IS joint is first IM joint is separate Remove incus Facial recess approach Remove bony spicule Remove bone overlying facial n. Anterior tympanotomy Amputate head of malleus Good access to anterior epitympanum Atticotomy Atticotomy Definition Removal of epitympanic wall (scutum) Eradication of ME and attic cholesteatoma and attic retraction pockets Preserving posterior canal wall Scutum defect repaired with cartilage to prevent attic retraction Atticotomy Indication Repair of retraction pockets Excision of cholesteatoma limited to epitympanum Repair of ossicular fixation Contraindication (relative) Mucopurulent discharge Extensive mastoid involvement Revision surgery Atticotomy Superior Atticoantrotomy Superior Antrum LSCC Not perform simoid sinus Inferior Atticotomy Blunt instrument prevent complication - LSCC fistula - Dehiscent facial n. Atticotomy Inferior Superior Lt Atticotomy and ME exploration Expose ME structures The scutum drilled down to visualization: Incus Malleus Chorda tympani nerve Facial nerve Lt canal wall up mastoidectomy cholesteatoma sac in attic Radical mastoidectomy Radical mastoidectomy Definition Make ME cavity, external ear canal and mastoid cavity to be common cavity Posterior canal is removed without grafting Removed all TM remnants, ME mucosa, and ossicular chain +/- stapes (may preserve hearing) Conchaplasty (Meatoplasty) is performed Radical mastoidectomy Indications Unresectable disease involving: Facial nerve Ossicular chain (stapes suprastructure or footplate) Sinus tympani Jugular bulb Labyrinth ET tube Multiple failed prior MRD Radical mastoidectomy Contraindication Large exposed portions of major vessels in temporal bone CSF leakage from a dural defect Radical mastoidectomy Complete mastoidectomy P299 300 19-3jen Circumferrential incision around annulus to prepare for removal of TM Radical mastoidectomy Transect tensor tympani with Bellucci scissors Remove TM with malleus Drilling posterior canal wall to level annulus Remove the incus Radical mastoidectomy Remove overhang of anterior canal wall (prevent visualization post op) Remove canal wall Radical mastoidectomy Enlarge orifice of ET tube with diamond burr Strip off mucosa with microcuret Pack orifice of ET tube first with bone wax follow by muscle plug Radical mastoidectomy Complete RMD Modified radical mastoidectomy Modified radical mastoidectomy Definition Make ME cavity, EAC and mastoid cavity to be common cavity Posterior canal is removed with grafting of ME space Preserve some part of ossicles Conchaplasty (Meatoplasty) is performed Modified radical mastoidectomy Indication Extensive cholesteatoma in mastoid COM with cholesteatoma involve sinus tympani area not accessible through facial recess or transcanal approach SCC fistula with adherent cholesteatoma matrix Unresecable matrix on the dura of tegmen or posterior cranial fossa Modified radical mastoidectomy Indication Attic cholesteatoma with sclerotic mastoid Incomplete excised cholesteatoma invading aircell of retrofacial, jugular bulb or supralabyrinthine tracts Destruction of canal wall by cholesteatoma Cholesteatoma in pt. unstable to maintain FU or with medical problem that risk for GA Neoplasm of mastoid and jugular fossa Modified radical mastoidectomy Contraindication Unresectable disease in ME involving ET tube, sinus tympani, and infralabyrinthine space (RMD indicated) Chronic mucoid or secretory otitis media Large dural defects, which are susceptible to CSF otorrhea or brain Modified radical mastoidectomy Complete mastoidectomy Elevate skin off post. EAC wall+ annulus with TM Remove incus before canal wall down may decrease risk of SNHL by acoustic transmission Modified radical mastoidectomy Drilling Posterior canal wall Lowering facial ridge to level of head of stapes 3 key factor to trouble free cavity - No bony overhang - Low facial ridge - Adequate meatoplasty Modified radical mastoidectomy Modified radical mastoidectomy Pack with gelfoam Modified radical mastoidectomy Temporalis graft place over the gelfoam Cover TM perforation Modified radical mastoidectomy After eradicate disease Reconstruction of TM or ME may be done For TM : Underlay technique Place graft over facial ridge Modified radical mastoidectomy Modified radical mastoidectomy Bondy procedure Bondy procedure Definition A modified radical procedure by removing posterior canal wall but leaving TM and ossicular chain intact Indication Poorly pneumatized mastoid with cholesteatoma limited to the lateral epitympanic space and mastoid without ME involvement Bondy Atticotomy Endaural incision Small atticoantrotomy Bondy Atticotomy Drilling post. Canal wall Identified ossicular chain Bisection skin flap Bondy Atticotomy Drilling post. buttress Skin flap place over ant. and post.buttress Meatoplasty Meatoplasty Cartilagenous to EAC narrow than osseous portion Principle: remove excessive conchal cartilage and bone Enlargement of opening of EAC Indication for Meatoplasty Presence of mastoid bowl during radical or modified radical mastoidectomy Inadequate visualization of mastoid cavity in Pt previous radical mastoidectomy Chronic otorrhea from mastoid bowl due to entrapment of debris Chronic otitis externa secondary to collapsible meatus and canal Reconstruction of EAC stenosis Meatoplasty P 33 Incision post. meatus extend to middle of conchal bowl Expose underlying cartilage Meatoplasty Elevate skin off perichondrium for ½ to ¾ cm all direction Concha cartilage Resects 1x1 cm of cartilage (U - sharp) Meatoplasty Cartilage Postauricular incision Pack gauze in mastoid bowl and pass through newly enlarge meatus Skin flap Skin flap overlying cartilage Meatoplasty Periosteum Suture skin flap to posterior soft tissue Approximate periosteum Mastoidectomy Postoperative care Remove mastoid dressing post op day 1 Packing in mastoid and meatus for 1-2 wk Oral ATB ATB ear drop until cavity has healed Clean mastoid cavity q 2 wk until healing complete CWD mastoid care q 6-12 mo 2nd look procedure after 1 yr Ossiculoplasty can be perform at 6 mo Post op care Immediated post op Regular diet Oral or IV ATB Antihistamine, decongestant Pain control Postoperative Post op day 1 remove mastoid dressing D/C and advice Not to blow nose Keep ear dry ATB for 3 wk Follow up 1 wk - Stitch off postauricular suture - Remove packing (conchaplasty) - Aural toilet - Topical ATB - Granulation tissue (TCA cautery q 1 wk until complete healing) 3 wk - Aural toilet 8 wk - Audiogram Then F/U q 6 mo x 2 time, then q 1 year Complication Mastoidectomy Complication Mastoidectomy Facial nerve trauma Injury to neural sheath may result in facial n. herniation Most common site of mastoid segment facial n. injury is just inferior to HSCC after 2nd genu Tympanic segment of facial n. is most common injured Prevention: Use small diamond burrs and moderate speed Rx: Bone overlying nerve should be remove 5-6 mm. and sheath should be incised -> reduce amount of herniation Complication Mastoidectomy SCC fenestration Rx: Plug immediately with bone wax and cover with temporalis fascia Risk: in inflamed or sclerotic mastoid Avoid suction over the open SCC Identified: Flood physiologic solution in injury area Complication Mastoidectomy Vascular injury: Lateral sinus Large opening Surgical suture Using inflated fogarty catheters for control bleeding during repair Cause: Tear from drilling Rx: Surgicel and Cottonoid covered Pressure maintain 10-15 min until bleeding subside -> remove cottonoid Place pt. to reverse trenderlenburg’s position (head down) to prevent air embolism Complication Mastoidectomy Bleeding in jugular bulb area Cause: Air cells overlying jugular bulb Rx: Plug with bone wax then pressure with cottonoid to press the wax to the surrounding cells CWU VS CWD Mastoidectomy CWU VS CWD Thank You
