Mastoid surgery

Iain R C Swan

Perth, 2008

Mastoid surgery
Cholesteatoma

Aims of surgery
Surgeon:

Clearance of cholesteatoma
No complications
Troublefree ear

Patient:

Normal ear

Patients aims of surgery

Normal ear

Hearing
Self-cleaning

Aims of surgery
Normal ear canal
Intact tympanic membrane
Intact ossicular chain

Intact canal wall mastoidectomy

Nothing new
Good results in expert hands
Technically demanding
Two or more operations

CWD vs ICW mastoidectomy

Residual / recurrent cholesteatoma is much
commoner after ICW surgery

Numerous studies
Level 2 evidence

CWD vs ICW mastoidectomy

Is hearing better after ICW?
No difference in hearing results1

Level 2 evidence

Post-op hearing worse in CWD but pre-op also

worse!2

Level 2 evidence
1. Karmarkar et al, 1995
2. Tos & Lay, 1989

The good mastoid cavity

Small cavity
No sumps
No ridges
Adequate meatus
Intact tympanic membrane

Stages in operation
1.
2.
3.
4.

Expose disease
Remove disease
Fashion cavity
Reconstruct ear

Expose disease
Endaural or postauricular incision
Widen canal first
Open attic and follow posteriorly
Drill posteriorly to end of sac

Remove disease
Decompress if large
Dissect out in one piece

careful observation

If in doubt, inspect hidden areas

endoscope
mirror

Fashion cavity
Decide on size
Decide on shape
Avoid ridges and sumps

Small cholesteatoma
Confined to attic
Close attic with tragal cartilage

Cartilage
Concha - meatoplasty
Tragus
Keep perichondrium

blood supply
anchor

Medium cholesteatoma
In aditus and into antrum, but no further
Lower facial ridge as appropriate
Remove ridges
Close cavity

cartilage

Facial ridge
Anatomy
Identification of facial nerve, not avoidance
Facial nerve monitor

Large cholesteatoma
Extends beyond antrum
Take down facial ridge
Reduce cavity size

cartilage
bone
muscle flap

Meatoplasty
Meatoplasty in all ears

unless meatus is large

BUT:

should be cosmetically acceptable

avoid caloric effect

Meatoplasty
Skin incision

Meatoplasty

Cartilage excision

Reconstruct ear
Close tympanic membrane
Reconstruct ossicular chain

Lining the cavity

Line cavity with soft tissue

fascia
canal skin flaps

Meatoplasty
Skin flap

Mastoid surgery follow up

n
5 years
2 years
1 year
6 months
3 months
none

555
33%
42%
57%
75%
93%
7%

Mastoid surgery results

n
Inactive
Intermittently active
Active

Atticotomy CWD mastoid

218
296
92%
87%
5%
6%
3%
6%

Mastoid surgery results

n
Inactive
Intermittently active
Active

Primary
358
93%
2%
5%

Revision
158
81%
9%
10%

Complications of mastoid surgery

n
Temporary facial palsy
Permanent facial palsy
BC loss > 20 dB
Vertigo
Intra-operative CSF leak
Wound infection

555
1
0
6
3
1
4