This document provides information on canal wall down (CWD) mastoidectomy surgery. It defines CWD mastoidectomy as the removal of the posterior and superior bony walls of the external ear canal and excision of all mastoid air cells, converting the mastoid cavity, middle ear, and ear canal into a single cavity exteriorized through the ear canal. It discusses indications for CWD mastoidectomy such as cholesteatoma, tumors, and anatomical factors like a low-lying tegmen. The document outlines the surgical technique and considerations like facial ridge lowering. It also addresses outcomes, complications, and the challenges of long-term management after CWD mastoidectomy.
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
Cavity obliteration is a procedure done at the end of Mastoidectomy to get a cavity-less mastoid cavity thus solving the problem of discharging post-operative cavity.
Sinus tymapni shape and depth can influence surgical approach in cholesteatoma surgery. In the case of a shallower ST, an exclusive endoscopic exploration is chosen; while in the case of a deeper ST, a retrofacial approach is usually preferred.
Inner ear malformations and ImplantationUtkal Mishra
This slide vividly describes relevant anatomy & embryology of cochlea. It gives the reader insights into various cochlear malformations & implantation.
Mastoid surgery is a commonly performed surgery by ENT surgeons. Although lots of modifications have been made in the techniques of mastoid surgery, the basic is cortical and modified radical mastoid surgery. In this lecture, I shall be discussing about different techniques of performing mastoid surgery, their advantages and disadvantages and complications of mastoid surgery.
Sinus tymapni shape and depth can influence surgical approach in cholesteatoma surgery. In the case of a shallower ST, an exclusive endoscopic exploration is chosen; while in the case of a deeper ST, a retrofacial approach is usually preferred.
Inner ear malformations and ImplantationUtkal Mishra
This slide vividly describes relevant anatomy & embryology of cochlea. It gives the reader insights into various cochlear malformations & implantation.
Mastoid surgery is a commonly performed surgery by ENT surgeons. Although lots of modifications have been made in the techniques of mastoid surgery, the basic is cortical and modified radical mastoid surgery. In this lecture, I shall be discussing about different techniques of performing mastoid surgery, their advantages and disadvantages and complications of mastoid surgery.
Chronic Otitis Media - Squamosal type ( UG)AlkaKapil
Chronic Otitis Media - Squamosal / atticoantral/ unsafe Type
Theories of cholesteatoma
cholesteatoma
levenson's criteria
congenital cholesteatoma
classification of cholesteatoma
sade's classification of retraction of pars tensa
Toss classification of pars flaccida retraction
cholesterol granuloma
clinical features of Squamosal CSOM
Complications of COM/CSOM
Investigations - HRCT Temporal bone
Mastoid exploration
cortical mastoidectomy
modified radical mastoidectomy
Radical mastoidectomy
The nasal septum is the cartilage and bone in your nose. The septum divides the nasal cavity (inside your nose) into a right and left side. When the septum is off-center or leans to one side of the nasal cavity, it has “deviated.” Healthcare providers call this a deviated nasal septum.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
1. CANAL WALL DOWN MASTOIDECTOMY
DR KANU LAL SAHA
ASSOCIATE PROFESSOR
OTOLOGY DIVISION
DEPT. OF OTOLARYNGOLOGY-HEAD AND NECK
SURGERY
BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY
SHAHBAG,DHAKA
2. CANAL WALL DOWN (CWD) CAN BE DEFINED AS :
REMOVAL OF POSTERIOR AND SUPERIOR BONY
WALL OF EXTERNAL EAR CANAL(EAC)
EXENTERATION OF ALL MASTOID AIR CELLS
CONVERTING MASTOID CAVITY, MIDDLE EAR AND
EAC INTO A SINGLE CAVITY EXTERIORIZED
THROUGH EAC
4. CWD MASTOIDECTOMY- INDICATIONS
CHOLESTEATOMA
CONTRACTED MASTOID
VERY LOW LYING TEGMEN AND ANTERIORLY PLACED SIGMOID SINUS
ERODED BONY EAC
RECURRENCE AFTER CWU MASTOIDECTOMY
CLEFT PALATE AND DOWN’S SYNDROME
ONLY HEARING EAR
BILATERAL CHOLESTEATOMA
LARGE LABYRINTHINE FISTULA
SEVERE SENSORINEURAL HEARING LOSS
SOME BENIGN TUMOURS INVOLVING THE MIDDLE EAR
SOME MALIGNANCY IN THE EAC
11. CWD IN CHOLESTEATOMA INDICATION PATIENT FACTORS
INVESTIGATION FACILITIES
UNRELIABLE FOLLOW UP
UNWILLING TO UNDERGO A SECOND STAGE PROCEDURE
HIGH RISK FOR GENERAL ANESTHESIA
LACK OF RELIABLE IMAGING FACILITIES
12. CWD IN OTHER CONDITIONS: NOW REPLACED BY STP
PARAGANGLIOMA
FACIAL NERVE TUMOR
EAC MALIGNANCY
16. MODIFIED BONDY MASTOIDECTOMY
THE MODIFIED BONDY MASTOIDECTOMY
A CWD MASTOIDECTOMY PROCEDURE
REMOVAL OF POSTERIOR CANAL WALL
INVOLVES EXTERIORIZING THE LATERAL EPITYMPANIC SPACE AND MASTOID CAVITY
REMOVAL OF CHOLESTEATOMA
PRESERVATION OF THE OSSICULAR CHAIN
PLACING A FASCIA GRAFT ONTO THE MEDIAL ASPECT OF THE OSSICULAR CHAIN
17. BASIC SURGICAL STEPS
APPROACH:
RETROAURICULAR
ENDAURAL
ROUTES:
TRANSCORTICAL OR OUTSIDE-IN :
DRILLING STARTS ON THE SURFACE OF THE CORTICAL BONE
CORTICAL MASTOIDECTOMY-ANTROTOMY-REMOVAL OF BONY
EAR CANAL.
TRANSMEATAL OR INSIDE-OUT :
DRILLING STARTS IN THE EAR CANAL
ATTICOTOMY-ATTICOANTROSTOMY-MASTOIDECTOMY
18. RULES OF INITIAL DRILLING
• BONE COVERING THE MIDDLE FOSSA DURA
AND SIGMOID SINUS IS THINNED USING LARGE
BURRS.
• BURRS ARE MOVED PARALLEL TO THE
STRUCTURES.
• CAVITY MUST ALWAYS BE WELL SAUCERIZED AND
GRADUALLY DEEPENED.
• BONY OVERHANGS SHOULD BE REMOVED FROM
THE EDGES.
19. LOWERING FACIAL RIDGE
• THE FACIAL RIDGE IS LOWERED EVENLY USING A LARGE
CUTTING BURR WITH CONTINUOUS SUCTION IRRIGATION.
• DRILLING PARALLEL TO THE COURSE OF THE FACIAL NERVE.
• DIAMOND BURRS - FINAL DRILLING TO THIN THE BONY
COVERAGE OF THE NERVE.
• THE NERVE IS SKELETONIZED BUT NEVER EXPOSED
• INFERIOR CANAL WALL SHOULD BE CONTOURED
SMOOTHLY IN ITS JUNCTION WITH THE CAVITY.
20. REMOVAL OF ANTERIOR BUTTRESS AND CANALPLASTY
If prominent protrusion of anterior and inferior wall,
canalplasty should be done.
Meatal skin is cut laterally,detached from the bone
towards annulus and protected with a sheet.
Removal of anterior buttress produces a continuous
plane between middle fossa plate and anterior canal.
21. MASTOID CAVITY SAUCERIZATION
BY BEVELING THE EDGES OF THE CAVITY (BLUE),
THE LATERAL SOFT TISSUES (RED) ARE INVITED TO
COLLAPSE INWARD, WHICH ACTS TO REDUCE CAVITY
VOLUME.
22. CONTOURING THE TYMPANIC BONE JUNCTION WITH MASTOID CAVITY
DRILLING OF THE TYMPANIC BONE INFERIOR TO THE
TYMPANIC RING AND ANTERIOR TO THE FACIAL NERVE IS
NECESSARY TO ELIMINATE THE “KIDNEY SHAPE” OF THE
RESULTANT CAVITY AND TO PROVIDE A SMOOTH JUNCTION
BETWEEN THE NATIVE EXTERNAL AUDITORY CANAL AND
MASTOID CAVITY
24. RECONSTRUCTION
BLEEDING SHOULD BE STOPPED COMPLETELY BEFORE RECONSTRUCTION OF MIDDLE EAR
USUALLY THE TEMPORALIS FASCIA IS GRAFTED IN UNDERLAY TECHNIQUE
ANTERIOR END OF GRAFT IS PLACED UNDER THE ANNULUS
THE GRAFT MUST HAVE ABUNDANT POSTERIOR EXTENSION TO COVER THE WHOLE MIDDLE EAR AND OBLITERATED
CELLS
IF NECESSARY, ANOTHER PIECE OF GRAFT MAY BE PLACED TO COVER EXPOSED BONE IN MASTOID CAVITY
EPITHELIALIZATION IS FACILITATED IF THE EXPOSED BONE IS COVERED WITH THE FASCIA
OSSICULOPLASTY MAY BE DONE IN FIRST-STAGE OR SECOND-STAGE
28. MEATOPLASTY
USING NASAL SPECULUM A CONCHAL INCISION IS MADE TOWARD THE ANTIHELIX, PARALLEL TO
CRUS OF THE HELIX
CONCHAL CARTILAGE IS DISSECTED FROM SKIN AND UNDERLYING CONNECTIVE TISSUE
A TRIANGULAR PIECE OF CARTILAGE IS REMOVED
THE AMOUNT OF CARTILAGE TO BE REMOVED DEPENDS ON THE SIZE AND CONTOUR OF THE CAVITY
IMPORTANT TO PRESERVE THE CARTILAGE IN THE CRUS OF THE HELIX TO PREVENT COSMETIC
DEFORMITY
30. PROPERLY PERFORMED CANAL WALL DOWN MASTOIDECTOMY
A. SAUCERIZED EDGES
B. MASTOID TIP AMPUTATED FROM DIGASTRIC MUSCLE
C. CELLS DRILLED AWAY UP TO SMOOTH DURAL PLATE
D. FACIAL RIDGE LOWERED
E. TYMPANIC BONE SMOOTHLY FRACTURED WITH
JUNCTION OF MASTOID
F. INTACT TYMPANIC MEMBRANE
G. MIDDLE EAR SEALED FROM EPI
F
E
31. UNFAVOURABLE MASTOID CAVITY
A. THE STEEP NON-SAUCERIZED EDGES
B. THE POTHOLES FROM RESIDUAL AIR CELLS
C. THE INTACT OPEN MASTOID TIP WITH DEBRIS
D. THE HIGH FACIAL RIDGE
E. THE UNCONTOURED TYMPANIC BONE FORMING A
KIDNEY-SHAPED CAVITY
F. TYMPANIC MEMBRANE PERFORATION
G. UNSEALED COMMUNICATION WITH EPITYMPANUM
A
B
C
D
E
F
G
32. CAUSES OF FAILURE IN CANAL WALL DOWN MASTOIDECTOMY
POOR EXECUTION OF SURGICAL TECHNIQUE
HIGH FACIAL RIDGE
BONY OVERHANGS
NARROW MEATUS
Anatomical irregularity Percentage
High Facial ridge 67%
Stenotic meatus 64%
Bony overhang 29%
Canal wall down mastoidectomy: causes of failure,
pitfalls and their management. Mario Sanna et al
Journal of laryngology and otology,1995,vol-105
33. FAILURE IN CANAL WALL DOWN MASTOIDECTOMY :OTHER CAUSES
PROMINENT OR INACCESSIBLE MASTOID TIP
RECURRENT RETRACTION OR CHOLESTEATOMA
REMUCOSALIZATION OF RESIDUAL MASTOID CELL
VERY LARGE AND UNEVEN MASTOID CAVITY
OPEN EUSTACHIAN TUBE OR PERFORATED
37. CWD MASTOIDECTOMY: DISADVANTAGES
DIFFICULTY IN FITTING A HEARING AID
RESTRICTION TO WATER EXPOSURE/SWIMMING
DIZZINESS FOLLOWING TEMPERATURE OR PRESSURE CHANGES
REGULAR CLEANING OF KERATIN DEBRIS
ENLARGED MEATUS
39. LONG TERM RESULTS OF CWD
MASTOIDECTOMY
Demographic and clinical data
n=259
Age 2-96(mean-35)
Male 39%
Female 61%
Type III tympanoplasty 175(67.4%)
Recurrent infection in cavity 17(6.5%)
Meatal stenosis 5(1.9%)
Residual cholesteatoma 5(1.9%)
Recurrent cholesteatoma 1(0.4%)
Sensorineural hearing loss 2(0.7%)
Facial paralysis 1(0.3%)
Persistent vertigo 4(1.5%)
Kos et al, Canal Wall-Down Mastoidectomy
Ann Otol Rhinal LaryngoI 113:2004
40. CWD MASTOIDECTOMY PERSONAL SERIES
Category Percentage
Modified radical mastoidectomy 124 (92.53%)
Modified bondy mastoidectomy 10(7.46%)
Category Percentage
Primary procedure 113(84.33%)
Revision surgery 21(15.67%)
41. CHOLESTEATOMA
Type of Cholesteatoma Percentage
Epitympanic cholesteatoma 53(40.45%)
Sinus cholesteatoma 42(32.06%)
Pars Tensa cholesteatoma 15(11.45%)
Unclassified 21(16.03%)
53. CWD MASTOIDECTOMY CHALLENGES
PROPER EXECUTION OF SURGICAL TECHNIQUE
KEEP THE PATIENT IN REGULAR FOLLOW UP
OSSICULOPLASTY AND OPTIMUM HEARING IMPROVEMENT IN ONLY MOBILE
FOOTPLATE
54. CONCLUSION
IT IS NOT WHICH TECHNIQUE ONE USES BUT HOW WELL ONE USES THE TECHNIQUE –THAT IS, THE INDIVIDUAL
SURGEON’S JUDGEMENT AND ABILITY -SHEEHY
CWD IS RATHER MORE CRITICIZED OR DEFAMED FOR FAILURE THAN IT IS PERFECTLY PERFORMED
A PERFECTLY PERFORMED CWD MASTOIDECTOMY RESULTS IN A TROUBLE-FREE, DRY EAR
IN DEVELOPING COUNTRY LIKE US WHERE REGULAR FOLLOW-UP AND TECHNICAL SUPPORTS ARE LIMITED
CWD IS THE SINGLE STAGE SAFE PROCEDURE
55. THANK YOU
Otology Dr Kanu BSMMU Bangladesh
drklsaha@gmail.com
www.drkanuotology.com
Editor's Notes
Canal wall down mastoidectomy is one of the common procedures done in otolaryngological practice..
Approach:
Retroauricular
Endaural
Routes:
Transcortical or Outside-in :
Drilling starts on the surface of the cortical bone
Cortical mastoidectomy-Antrotomy-Removal of bony
ear canal.
Transmeatal or Inside-out :
Drilling starts in the ear canal
Atticotomy-Atticoantrostomy-Mastoidectomy
Bone covering the middle fossa dura and sigmoid sinus is thinned using large burrs.
Burrs are moved parallel to the structures.
Cavity must always be well saucerized and gradually deepened.
Bony overhangs should be removed from the edges.
The facial ridge is lowered evenly using a large cutting burr with continuous suction irrigation.
Drilling parallel to the course of the facial nerve.
Diamond burrs - final drilling to thin the bony coverage of the nerve.
The nerve is skeletonized but never exposed
Inferior canal wall should be contoured smoothly in its junction with the cavity.
If prominent protrusion of anterior and inferior wall, canalplasty should be done.
Meatal skin is cut laterally,detached from the bone towards annulus and protected with a sheet.
Removal of anterior buttress produces a continuous plane between middle fossa plate and anterior canal.
The edges of the mastoid cavity should be widely beveled superiorly over the lateral aspect of the middle fossa dura and posteriorly over the lateral edge of the sigmoid sinus, with removal of all retrosigmoid air cells.
Using nasal speculum a conchal incision is made toward the antihelix, parallel to crus of the helix
Conchal cartilage is dissected from skin and underlying connective tissue.
A triangular piece of cartilage is removed
The amount of cartilage to be removed depends on the size and contour of the cavity.
Important to preserve the cartilage in the crus of the helix to prevent cosmetic deformity
Operated in 6th January 2018.Serial follow up findings are recorded till March 2019