MASTOIDECTOMY

Rosario R. Ricalde, MD, DPBO-HNS

Quirino Memorial Medical Center October 17, 2009 Veterans Memorial Medical Center

OUTLINE
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Development and anatomy of the temporal bone Development and anatomy of the mastoid air cells Normal versus sclerotic mastoid Purposes of mastoidectomy Definitions Radical versus modified radical vs tympanoplasty with mastoidectomy Canal wall-up versus canal wall-down Tips in decision making Steps in ear surgery to eradicate disease and/or restore hearing Surgical principles and techniques in mastoidectomy Meatoplasy

TEMPORAL BONE ANATOMY AND DEVELOPMENT

DEVELOPMENT OF THE MASTOID AIR CELLS

Birth Infantile type
air cells appear

Transitional type
mastoid enlarges with migration of air cells toward periphery

Mature system
Pneumatization ceases

Conception

0 Air cells develop 22-24 weeks Mastoid antrum develops

2 years

5 years

Diploic type

DEVELOPMENT OF THE MASTOID AIR CELLS

Mastoid Antrum 1-6 years old - well developed at birth, size is 1-1.5 cm2 - mastoid cells about 3.5-4 cm2 at 1 year, linear growth till the age of 6 (1-1.2 cm2/year), having a slower increment up to adult size at puberty - adult size: 12 cm2

Puberty

DEVELOPMENT OF THE MASTOID AIR CELLS

An aircell is lined by a single flat layer of epithelium separated from bone by subepithelial connective tissue. Epithelium + connective tissue = mucus membrane of the air cell Development of air cells is preceded by the formation of bone cavities. After the epithelial mucous membrane has invaginated, it in turn undergoes atrophy, leaving a thin residual lining membrane attached to the periosteum. Recession of the lining membrane and subepithelial bone resorption then further enlarge air cells by the presence of AIR. Pneumatization of the temporal bone divided into five (5) regions: middle ear, mastoid, perilabyrinthine, petrous apex, and accessory regions

ADULT ANATOMY OF THE MASTOID AIR CELL SYSTEM

ADULT ANATOMY OF THE MASTOID AIR CELL SYSTEM

NORMAL VS SCLEROTIC MASTOID

PURPOSES OF MASTOIDECTOMY
1. Eradication of disease removal of diseased mastoid 2. Exploration to ensure that there is no disease if without CT scan 3. Enlarge the air-conditioning of middle ear-antral space 4. Access or exposure removal of healthy mastoid to reach a certain structure or area such as in cochlear implantation, lateral skull base (translabyrinthine approach)

DEFINITIONS
Radical Mastoidectomy Modified Radical Mastoidectomy (Bondy Procedure) Tympanomastoidectomy or Tympanoplasty with mastoidectomy Atticotomy Canal Wall-up Mastoidectomy(CWU) Canal Wall-down Mastoidectomy (CWD)

DEFINITIONS
Radical Mastoidectomy Mastoid antrum, tympanum, and external auditory canal are converted into a common cavity exteriorized through the external meatus Removal of the tympanic membrane, ossicular remnants with exception of the stapes and does not involve any reconstructive or grafting procedure Surgeon may plug the eustachian tube or lay soft tissue over the middle ear to assist healing

DEFINITIONS
Modified Radical Mastoidectomy (Bondy Procedure) Epitympanum, mastoid antrum, and external auditory canal are converted into a common cavity exteriorized through the external meatus Tympanic membrane and or its remnants and ossicular remnants are retained to preserve hearing Does not involve any reconstructive procedure

DEFINITIONS
Tympanomastoidectomy or Tympanoplasty with mastoidectomy Performed to eradicate disease on the middle ear and mastoid and to reconstruct the hearing mechanism with or without tympanic membrane grafting

DEFINITIONS
Atticotomy For disease that is confined to the central epitympanic area attic retraction pockets Drilling of the scutum around the epitympanic area. The area has to be reconstructed with cartilage or bone pate to prevent recurrence of the retraction pocket If the disease extends to the antrum then a mastoidectomy has to be performed

DEFINITIONS
Canal Wall-up (CWU) Posterior canal wall is PRESERVED 2 cavities: 1. mastoid 2. middle ear and external auditory canal Canal Wall-down (CWD) Posterior canal wall is REMOVED 1 cavity

RADICAL MASTOIDECTOMY

MODIFIED RADICAL MASTOIDECTOMY

TYMPANOPLASTY WITH MASTOIDECTOMY OR

TYMPANOMASTOIDECTOMY

PURPOSE

Eradicate disease

Eradicate disease and preserve hearing Mastoid air cells, diseased tissue, posterior canal wall

REMOVE

PRESERVE

Mastoid air cells, diseased tissue (granulation), posterior canal wall, tympanic membrane, ossicular remnants Stapes

Eradicate disease and reconstruct hearing mechanism Mastoid air cells, diseased tissue

Healthy tympanic membrane and ossicular remnants

OTHER POINTS

Eustachian tube plugging Soft tissue grafting

+/- posterior canal wall Healthy tympanic membrane and ossicular remnants +/- tympanic membrane grafting

CANAL WALL-UP HEARING HEALING RESIDUAL DISEASE RECURRENT DISEASE EXPOSURE POST-OP HEARING REHABILITATION FOLLOW-UP Better hearing Faster healing 1.5 to 2 months No difference if surgeon is competent 20-40 % recurrence No problem swimming Good fit no feedback Every 1 to 2 years for 10 years

CANAL WALL-DOWN +/- Poor hearing Slower healing 3 to 8 months No difference if surgeon is competent <5 % recurrence Water easily goes into ear - vertigo Hard to fit - feedback Every 6 to 12 months for the rest of the patients life

TIPS IN DECISION MAKING

PRE-OP Physical examination collapsed posterior canal wall, subperiosteal abscess, facial nerve involvement complications of CSOM, extensive disease Hearing status Operate on the worse ear first. But remember, that you have to operate on both ears eventually if indicated. Worse ear does not necessarily mean the worse hearing ear. REMEMBER that cholesteatoma can conduct sound. In a person with bilateral cholesteatoma look at the overall clinical picture and the BONE CONDUCTION Imaging NOT ALWAYS NECESSARY. Computed tomography: density in the mastoid, blunting of the scutum, dehiscences INTRA-OP Almost always the case Start with canal wall-up then convert to canal wall-down

BASIC PROCEDURES IN EAR SURGERY

Inspection of the external auditory canal and inspection of the tympanic membrane / remnant Infiltration of lidocanineepinephine 1:100,000 around 1-2 mm lateral to the non-hair bearing area

6 oclock 12 oclock incision 8 mm from the position of the annulus

BASIC PROCEDURES IN EAR SURGERY

Post-auricular incision start superiorly and incise to the level of the temporalis fascia then proceed inferiorly Harvest temporalis fascia graft, press and let it dry Make an incision to the bone from temporal line to mastoid tip (take note that you can use the periosteal flap to line or obliterate the mastoid cavity) Develop the periosteal flap until you see the meatal incision (laterally) , tympanomastoid fissure (inferiorly) and tympanosquamous fissure (superiorly)

BASIC PROCEDURES IN EAR SURGERY

Use self-retaining retractors for better visualization of the middle ear Freshen the perforation or the edges of the tympanic membrane remnant Develop the tympanomeatal flap

BASIC PROCEDURES IN EAR SURGERY

Inspection of the middle ear chorda tympani Inspection of malleus and incus Removal of scutum using stapes curette to visualize the incudostapedial joint

BASIC PROCEDURES IN EAR SURGERY

If disease is confined to the epitympanum then do ATTICOTOMY. Reconstruct defect with cartilage or bone pate. Flap back the tympanomeatal flap. If disease is extensive and extends to the antrum then separate the incudostapedial joint before MASTOIDECTOMY

MASTOIDECTOMY

Burr cut perpendicular to temporal line and tangent to external auditor canal Expose mastoid antrum - in a sclerotic mastoid, sometimes this is the only air cell left Saucerization Visualize the field better Instruments can fit Use the side of the burrs not the tip Start antero-superior. This is the deepest part and the location of the antrum. Locate the sinodural angle where the tegmen and sigmoid sinus intersect. This is the postero-lateral extent. Locate the lateral fossa incudis and the lateral semicircular canal to locate position of the facial nerve Note the course of the facial nerve The canal wall should be brought down to the level of the facial nerve in a CANAL WALL DOWN MASTOIDECTOMY Removal of cholesteatoma capsule and diseased tissue

Promontory

Short process of incus

Mastoid segment of the facial nerve

Lateral semicircular canal

Fossa Incudis

BASIC PROCEDURES IN EAR SURGERY

Identify ossicles and continuity Tap each ossicle starting with malleus, incus, then stapes Look for rippling or movement of fluid at the round window nitch to confirm ossicular continuity

BASIC PROCEDURES IN EAR SURGERY MEATOPLASTY

Meatoplasty if CANAL WALL-DOWN is performed; no meatoplasty if CANAL WALL-UP IS performed

BASIC PROCEDURES IN EAR SURGERY

Obliteration techniques temporalis muscle or musculoperiosteal flap Ossicular reconstruction Tympanoplasty Pack with medicated and dry gelfoam Medicated gauze or silk If CANAL WALL-DOWN close postauricular incision in 2 layers If CANAL WALL-UP suture back periosteal flap then close postauricular incision in 2 layers Dressing

REFERRENCES
Atlas, Marcus D. A Guide to Temporal Bone Dissection 2nd edition. Lions Ear and Hearing Institute, Perth, 2004. Brackmann, Derald E. (ed). Otologic Surgery 2nd edition. WB Saunders, Philadelphia, 2001. Virapongse, Chat, Mohammad Sarwar, Sultan Bhimanoi, et. al. Computer Tomography of Temporal Bone Pneumatization: Normal Pattern and Morphology. American Journal of Radiology: 145 (173-481), September 1985. Nelson, Ralph A. Temporal Bone Dissection Manual. House Ear Institute, Los Angeles, 1991. Portmann, Michel and Didier Portmann. Otologic Surgery: Manual of Oto-surgical Techniques. Singular Publishing Group, Inc. San Diego, 1998.