I.

Definition

A mastoidectomy is a surgical procedure that removes an infected portion of the

mastoid bone when medical treatment is not effective.

II. Purpose

A mastoidectomy is performed to remove infected mastoid air cells resulting from ear
infections, such as mastoiditis or chronic otitis, or by inflammatory disease of the middle
ear (cholesteatoma). The mastoid air cells are open spaces containing air that are
located throughout the mastoid bone, the prominent bone located behind the ear that
projects from the temporal bone of the skull. The air cells are connected to a cavity in
the upper part of the bone, which is in turn connected to the middle ear. Aggressive
infections in the middle ear can thus sometimes spread through the mastoid bone.
When antibiotics can't clear this infection, it may be necessary to remove the infected
area by surgery. The primary goal of the surgery is to completely remove infection so as
to produce an infection-free ear. Mastoidectomies are also performed sometimes to
repair paralyzed facial nerves.

III. Demographics

According to the American Society for Microbiology, middle ear infections increased in
the United States from approximately three million cases in 1975 to over nine million in
1997. Middle ear infections are now the second leading cause of office visits to
physicians, and this diagnosis accounts for over 40% of all outpatient antibiotic use. Ear
infections are also very common in children between the ages of six months and two
years. Most children have at least one ear infection before their eighth birthday.

IV. Surgical description

A mastoidectomy is performed with the patient fully asleep under general anesthesia.
There are several different types of mastoidectomy procedures, depending on the
amount of infection present:

• Simple (or closed) mastoidectomy. The operation is performed through the ear or
through a cut (incision) behind the ear. The surgeon opens the mastoid bone and
removes the infected air cells. The eardrum is incised to drain the middle ear.
Topical antibiotics are then placed in the ear.
• Radical mastoidectomy. The procedure removes the most bone and is usually
performed for extensive spread of a cholesteatoma. The eardrum and middle ear
structures may be completely removed. Usually the stapes, the "stirrup" shaped
bone, is spared if possible to help preserve some hearing.
• Modified radical mastoidectomy. In this procedure, some middle ear bones are
left in place and the eardrum is rebuilt by tympanoplasty.

After surgery, the wound is stitched up around a drainage tube and a dressing is
applied.

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 V. Diagnosis/Preparation

The treating physician gives the patient a thorough ear, nose, and throat examination
and uses detailed diagnostic tests, including an audiogram and imaging studies of the
mastoid bone using x rays or CT scans to evaluate the patient for surgery.

The patient is prepared for surgery by shaving the hair behind the ear on the mastoid
bone. Mild soap and a water solution are commonly used to cleanse the outer ear and
surrounding skin.

VI. Aftercare

The drainage tube inserted during surgery is typically removed a day or two later.

Painkillers are usually needed for the first day or two after the operation. The patient
should drink fluids freely. After the stitches are removed, the bulky mastoid dressing can
be replaced with a smaller dressing if the ear is still draining. The patient is given
antibiotics for several days.

The patient should inform the physician if any of the following symptoms occur:

• bright red blood on the dressing

• stiff neck or disorientation (These may be signs of meningitis.)
• facial paralysis, drooping mouth, or problems swallowing

VII. Risks and complications

Complications do not often occur, but they may include:

• persistent ear discharge

• infections, including meningitis or brain abscesses
• hearing loss
• facial nerve injury (This is a rare complication.)
• temporary dizziness
• temporary loss of taste on the side of the tongue

VIII. Normal results

The outcome of a mastoidectomy is a clean, healthy ear without infection. However,

both a modified radical and a radical mastoidectomy usually result in less than normal
hearing. After surgery, a hearing aid may be considered if the patient so chooses.

A. Morbidity and mortality rates

In the United States, death from intracranial complications of cholesteatoma is

uncommon due to earlier recognition, timely surgical intervention, and supportive
antibiotic therapy. Cholesteatoma remains a relatively common cause of
permanent, moderate, and conductive hearing loss.

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IX. Alternatives

Alternatives to mastoidectomy include the use of medications and delaying surgery.

However, these alternative methods carry their own risk of complications and a varying
degree of success. Thus, most physicians are of the opinion that patients for whom
mastoidectomy is indicated should best undergo the operation, as it provides the patient
with the best chance of successful treatment and the lowest risk of complications.

X. Nursing Process:

THE PATIENT UNDERGOING MASTOID SURGERY

Although several otologic surgical procedures are performed under moderate sedation,
mastoid surgery is performed using general anesthesia.

A. Assessment

The health history includes a complete description of the ear problem, including
infection, otalgia, otorrhea, hearing loss, and vertigo. Data are collected about the
duration and intensity of the problem, its causes, and previous treatments. Information
is obtained about other health problems and all medications that the patient is taking.
Medication allergies and family history of ear disease also should be obtained. Physical
assessment includes observation for erythema, edema, motorrhea, lesions, and
characteristics such as odor and color of discharge. The results of the audiogram
should be reviewed.

B. Nursing Diagnoses

Based on the assessment data, the patient’s major nursing diagnoses may include the
following:

• Anxiety related to surgical procedure, potential loss of hearing, potential taste

disturbance, and potential loss of facial movement

• Acute pain related to mastoid surgery

• Risk for infection related to mastoidectomy, placement of grafts, prostheses,

electrodes, and surgical trauma to surrounding tissues and structures

• Disturbed auditory sensory perception related to ear disorder, surgery, or packing

• Risk for trauma related to balance difficulties or vertigo during the immediate
postoperative period

• Disturbed sensory perception related to potential damage to facial nerve (cranial nerve
VII) and chorda tympani nerve

• Impaired skin integrity related to ear surgery, incisions, and graft sites

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• Deficient knowledge about mastoid disease, surgical procedure, and postoperative
care and expectations

C. Planning and Goals

The major goals of caring for a patient undergoing mastoidectomy include reduction of
anxiety; freedom from pain and discomfort; prevention of infection; stable or improved
hearing and communication; absence of injury from vertigo; absence of or adjustment to
sensory or perceptual alterations; return of skin integrity; and increased knowledge
regarding the disease, surgical procedure, and postoperative care.

D. Nursing Interventions

REDUCING ANXIETY

Information that the otologic surgeon has discussed with the patient, including
anesthesia, the location of the incision (postauricular), and expected surgical results
(eg, hearing, balance, taste, facial movement), is reinforced. The patient also is
encouraged to discuss any anxieties and concerns about the surgery.

RELIEVING PAIN

Although most patients complain very little about incisional pain after mastoid surgery,
they do have some ear discomfort. Aural fullness or pressure after surgery is caused by
residual blood or fluid in the middle ear. The prescribed analgesic may be taken for the
first 24 hours after surgery and then only as needed. The patient is instructed in the use
of and side effects of the medication. A tympanoplasty may also be performed at the
time of the mastoidectomy. A wick or external auditory canal packing is used after a
tympanoplasty to stabilize the tympanic membrane. Patients should be informed that
they may experience intermittent sharp, shooting pains in the ear for 2 to 3 weeks after
surgery as the eustachian tube opens and allows air to enter the middle ear.

PREVENTING INFECTION

Measures are initiated to prevent infection in the operated ear. The external auditory
canal wick, or packing, may be impregnated with an antibiotic solution before instillation.
Prophylactic antibiotics are administered as prescribed, and the patient is instructed to
prevent water from entering the external auditory canal for 6 weeks. A cotton ball or
lamb’s wool covered with a water-insoluble substance (eg, petroleum jelly) and placed
loosely in the ear canal usually prevents water contamination. The postauricular incision
should be kept dry for 2 days. Signs of infection such as an elevated temperature and
purulent drainage are reported. Some serosanguineous drainage from the external
auditory canal is normal after surgery.

IMPROVING HEARING AND COMMUNICATION

Hearing in the operated ear may be reduced for several weeks because of edema,
accumulation of blood and tissue fluid in the middle ear, and dressings or packing.
Measures are initiated to improve hearing and communication, such as reducing
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environmental noise, facing the patient when speaking, speaking clearly and distinctly
without shouting, providing good lighting if the patient relies on speech reading, and
using nonverbal clues (eg, facial expression, pointing, gestures) and other forms of
communication. Family members or significant others are instructed about effective
ways to communicate with the patient. If the patient uses assistive hearing devices, one
can be used in the unaffected ear.

PREVENTING INJURY

Vertigo may occur after mastoid surgery if the semicircular canals or other areas of the
inner ear are traumatized. This symptom is relatively uncommon after this type of ear
surgery and usually is temporary. Antiemetics or antivertiginous medications (eg,
antihistamines) can be prescribed if a balance disturbance or vertigo occurs. The
patient should be instructed about the expected effects and potential side effects. Safety
measures such as assisted ambulation are implemented to prevent falls. Safety
measures must also be implemented at home to prevent falls and injury.

PREVENTING ALTERED SENSORY PERCEPTION

Facial nerve injury is a potential, although rare, complication of mastoid surgery. The
patient is instructed to report immediately any evidence of facial nerve (cranial nerve
VII) weakness, such as drooping of the mouth on the operated side. A more frequent
occurrence is a temporary disturbance in the chorda tympani nerve, a small branch of
the facial nerve that runs through the middle ear. Patients experience a taste
disturbance and dry mouth on the side of surgery for several months until the nerve
regenerates.

PROMOTING WOUND HEALING

The patient is instructed to avoid heavy lifting, straining, exertion, and nose blowing for
2 to 3 weeks after surgery to prevent dislodging the tympanic membrane graft or
ossicular prosthesis.

INCREASING KNOWLEDGE

The patient is informed about the surgery and operating room environment. Discussing
postoperative expectations helps to decrease anxiety about the unknown. Because
postoperative instructions for mastoid surgery vary among otologic surgeons, it is
important for the nurse to be aware of the surgeon’s preferences when teaching the
patient.

E. Promoting home and community based care

Teaching Patients Self-Care

Patients require instruction about prescribed medication therapy, such as analgesics,

antivertiginous agents, and antihistamines prescribed for balance disturbance. Teaching

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includes information about the expected effects and potential side effects of the
medication. Patients also need instruction about any activity restrictions. Possible
complications such as infection, facial nerve weakness, or taste disturbances, including
the signs and symptoms to report immediately, should be addressed (see Chart 59-5).

F. Continuing Care

Some patients, particularly elderly patients, who have had mastoid surgery may require
the services of a home care nurse for a few days after returning home. However, most
people find that assistance from a family member or a friend is sufficient. The caregiver
and patient are cautioned that the patient may experience some vertigo and will
therefore require help with ambulation to avoid falling. Any symptoms of complications
are to be reported promptly to the surgeon. The importance of scheduling and keeping
follow-up appointments is also stressed.

G. Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1. Demonstrates reduced anxiety about surgical procedure

a. Verbalizes and exhibits less stress, tension, and irritability

b. Verbalizes acceptance of the results of surgery and adjustment to possible hearing

impairment

SENSORINEURAL FUNCTION

2. Remains free of discomfort or pain

a. Exhibits no facial grimacing, moaning, or crying, and reports absence of pain

b. Uses analgesics appropriately

3. Demonstrates no signs or symptoms of infection

a. Has normal vital signs, including temperature

b. Demonstrates absence of purulent drainage from the external auditory canal

c. Describes method for preventing water from contaminating packing

4. Exhibits signs that hearing has stabilized or improved

a. Describes surgical goal for hearing and judges whether the goal has been met

b. Verbalizes that hearing has improved

5. Remains free of injury and trauma because of vertigo

a. Reports absence of vertigo or balance disturbance

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 b. Experiences no injury or fall

c. Modifies environment to avoid falls (eg, night light, no clutter on stairs)

6. Adjusts to or remains free from altered sensory perception

a. Reports no taste disturbance, mouth dryness, or facial weakness

7. Demonstrates no skin breakdown

a. Lists ways to prevent dislodging graft or prosthesis

b. Is aware of limitations in activities (eg, bathing, lifting, air travel) and for how
long

8. Verbalizes the reasons for and methods of care and treatment

a. Shares knowledge with family about treatment protocol

b. Describes treatment and the time frame for the recovery phase

c. Discusses the discharge plan formulated with the nurse with regard to rest
periods, medication, and activities permitted and restricted

d. Lists symptoms that should be reported to health care personnel

e. Keeps follow-up appointments

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