Transcript Mastoidectomy

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
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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
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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
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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
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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
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Regular diet
Oral or IV ATB
Antihistamine, decongestant
Pain control
Postoperative
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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