BY, Dr Sharwak Ramlan
History
 Louis Petit was credit with first describing the
procedure in the 1736 with a trochar, although
trephination was done since prehistoric times.
 A chisel and gouge where used extensively
throughout the 1800’s
cont….
 Schwartze popularized mastoidectomy in 1870
with detailed drawings. He described the cortical
mastoidectomy, which was used extensively in
preantibiotic era.
 Bondy described a technique in 1910 in which
mastoidectomy was performed and the posterior
canal wall removed while leaving the pars tensa
and ossicular chain intact
Cont…
 1922 Lempert introduced electrically driven drills in
ear surgery, which were already used in dentistry
 1930’s Wullstein introduced the operating microscope
 1958, the canal wall up mastoid was then popularized
by House. He also introduced the suction irrigation
system and retractors in mastoid surgery
Middle Ear Regions
 Named based on position relative to superior and
inferior aspect of external auditory canal (EAC)
 Epitympanum
 Mesotympanum
 Hypotympanum
Middle ear spaces
Middle ear spaces
Goals
 Treat complication
 Remove disease
 Obtain dry and safe ear
 Preserve normal anatomy as much as possible
 Improve hearing
Types
 Canal wall up mastoidectomy
 Canal wall down mastoidectomy
Canal wall up mastoidectomy
 Cortical mastoidectomy
 Anterior atticotomy
 Posterior tympanotomy/Facial recess approach
 Combined approach
Canal wall down mastoidectomy
 Radical mastoidectomy
 Modified radical mastoidectomy
 Bondy’s procedure
Canal wall up mastoidectomy
 CWU may be indicated in patients with large
pneumatized mastoid and well aerated middle ear
space
 Suggests good eustachian tube function
Indications
 CSOM T.T.D. active refractory to antibiotics
 Secretory otitis media refractory to antibiotics
 Coalescent mastoiditis & Masked mastoiditis
 Cochlear implant surgery
 Combined approach tympanoplasty
 Approach to:
Endolymphatic sac surgery
Facial nerve decompression
Vestibulo-cochlear nerve section
Translabyrinthine approach for C.P. angle
 CWU procedures are contraindicated in:
 Only hearing ear
 Patients with labyrinthine fistula
 Long-standing ear disease
 Poor eustachian tube function
 Advantages:
 Rapid healing time
 Easier long-term care
 Hearing aids easier to fit
 No water precautions
 Disadvantages:
 Technically more difficult
 Staged operation often necessary
 Recurrent disease possible
 Residual disease
Cortical mastoidectomy
 It is an operation performed to remove disease from
mastoid antrum and air cell system(when present) and
aditus ad antrum, with preservation of an intact
posterior external auditory canal without disturbing
the middle ear contents.
Procedure
Infiltration with Lignocaine
Marking of incision
Wilde’s post-aural incision
Incision deepened till periosteum
Temporalis fascia graft
Musculo-periosteal flap elevated
Mastoid cortex exposed
Posterior canal wall incision
Posterior canal wall vascular strip
Vascular strip retracted laterally
Drill cuts on mastoid cortex
Mac Ewan’s triangle
Cortical mastoidectomy begun
Exposure of mastoid antrum
Widening of aditus
Aditus widened
Final Cavity (right)
Mastoid dressing
Anterior atticotomy
 It is an operation performed to remove all or part of
outer attic wall (scutum) and adjacent deep posterior
meatal wall to expose the attic and when necessary the
aditus ad antrum in order to gain access to these sites
and their contents or removal of disease limited to
these sites.
classification
 Lateral
 Medial
anterior
posterior
indication
 Lateral atticotomy:
Attic retraction pocket
TS patch fixing anterior malleolar fold
Ankylosis retricting mobility of malleus
 Medial atticotomy:
Cholesteatoma sac confined to attic
Transcanal facial nerve decompression
Attic tympanosclerosis
Procedure:
 Tympanotomy performed creating wide
tympanomeatal flap exposing the lateral process of
malleus and anterior malleolar ligament.
 Extent depends on disease process
Lateral atticotomy:
 Is performed by drilling the scutum using 1mm
diamond burr thus unroofing lateral attic space to
visualize IS joint and malleus.
Medial atticotomy: exposure of
posterior attic space
 Dislocation of IS joint to prevent subluxation of stapes
 Remove the incus
Medial atticotomy :exposure of
anterior attic space
 Amputate head of malleus
Facial recess approach:
 Facial recess is a group of cells seen lateral to second
genu of facial nerve and in the upper part of vertical
segment of facial nerve.
 Rarely exceeds 2-3mm
 Bone in this area is cellular even in poorly developed
mastoid
Boundries
 Superiorly: fossa incudis
 Laterally: chorda tympani
 Medially: proximal part of vertical segment of facial
nerve
 Anteriorly: annulus
Indications
 Cochlear implant insertion
 Facial nerve decompression
Procedure
 Wide cortical mastoidectomy
 Thinning of posterior meatal wall
 Thinning the posterior wall of poterior tympanum,
during this dilineation of chorda tympani, vertical
segment of facial nerve and incus buttress is done
 Bone thinned using 1mm diamond burr
 Once air cells viualised continue drilling to enter
middle ear
Procedure
Structures visualised
 IS joint
 Pyramidal process
 Stapedial tendon
 Long process of incus
 Stapes superstructure
 Oval window
 Round window
 promontry
Combined Approach
Tympanoplasty
 Cortical Mastoidectomy
 Anterior tympanotomy: via tympano-meatal
flap
 Posterior tympanotomy: via facial recess
 Tympanoplasty
Canal Wall Down Mastoidectomy
Indications for CWD approach
 Cholesteatoma in an only hearing ear
 Significant erosion of the posterior bony canal wall
 History of vertigo suggesting a labyrinthine fistula
 Recurrent cholesteatoma after canal-wall-up surgery
 Poor eustachian tube function
 Sclerotic mastoid with limited access to epitympanum
Advantages
 Residual disease is easily detected
 Recurrent disease is rare
 Facial recess is exteriorized
Disadvantages:
 Open cavity created
 Takes longer to heal
 Mastoid bowl maintenance can be a lifelong problem
 Dry ear precautions are essential
Modified Radical Mastoidectomy
Definition
 This operation differs from radical mastoidectomy in
that the tympanic membrane or remnents and
ossicular remnents are retained.
Indications
 Cholesteatoma in an only hearing ear
 Significant erosion of the posterior bony canal wall
 History of vertigo suggesting a labyrinthine fistula
 Recurrent cholesteatoma after canal-wall-up surgery
 Poor eustachian tube function
 Sclerotic mastoid with limited access to epitympanum
Surgical Steps
Perform cortical mastoidectomy
Lower facial ridge & break facial bridge
Remove cholesteatoma & granulations from mastoid air cells &
middle ear cavity
Preserve healthy mucosa, T.M. remnant & ossicles
Mastoid cavity & E.A.C. become a single cavity seperated by middle
ear cavity
Perform tympanoplasty. Do concho-meatoplasty.
Facial ridge lowering started
Breaking of facial bridge
Retrofacial & labyrinthine cells
removed
MRM cavity
MRM cavity (ossicles preserved)
Meatoplasty
 The successful canal wall down mastoidectomy
requires a generous meatoplasty with removal of
conchal cartilage and underlying soft tissues, with
beveling of the cavity edges.
Korner’s meatoplasty incision
Flap elevated
Conchal cartilage cut
Flap sutured posteriorly
Healed Concho-meatoplasty
Post-aural incision closed
Radical Mastoidectomy
Definition
 It is an operation to eradicate all middle ear and
mastoid disease, in which mastoid antrum and air cell
system, aditus ad antrum, attic and middle ear are
converted to common cavity, exteriorised to external
auditory meatus.
 Here tympanic membrane, malleus, incus, stapes
superstructure and middle ear mucosa is removed
with plugging of eustachian tube opening.
Indications
 CSOM attico-antral disease with
Intra-cranial complication
Recurrence after MRM
 2. Limited malignancy of middle ear
 3. Glomus jugulare
 4. Osteomyelitis of temporal bone
Surgical Steps
 Perform cortical mastoidectomy. Lower facial ridge &
break facial bridge. Remove cholesteatoma &
granulations from mastoid air cells & middle ear.
 Remove normal middle ear mucosa, T.M. remnant &
ossicles (except stapes footplate).
 Close Eustachian tube opening. No tympanoplasty
done. Concho-meatoplasty performed.
 Mastoid, E.A.C. & middle ear become single cavity
ET orifice plugged with malleus
head
Complications:
 Hearing Loss
 Facial Paralysis
 Chronic draining ear
 Csf ottorhea
 Vertigo
 Injury to durameter
Sites of facial nerve injury
Causes of discharging mastoid
cavity
 1. Inadequate concho-meatoplasty
 2. Recurrence of cholesteatoma
 3. Residual cholesteatoma: facial ridge, facial bridge,
anterior + posterior buttress, mastoid tip, sinus
tympani, anterior epitympanum
 4. Persistent infection: petrositis, T.B., sinusitis
 5. Persistent allergy
 6. Retained foreign body: cotton ball
 7. Persistent extra-dural abscess
Thank you