This document discusses the management and surgical techniques for discharging mastoid cavities, outlining causes, pre-operative preparations, and various surgical methods for cavity obliteration. It includes important terminologies related to the anatomy of the mastoid area and highlights the factors leading to discharging cavities, along with indications and contraindications for cavity obliteration. Key techniques mentioned for obliteration include local flaps and free grafts, alongside postoperative considerations.

2. DISCHARGING MASTOID
CAVITY
&
CAVITY OBLITERATION
Dr. Sayan Hazra, Senior Resident, ENT.
IPGMER

3. 2012- Describe management of postoperative
discharging mastoid cavity.
2016- Outline the causes and management of post
operative discharging mastoid cavity in a
case of CWD mastoidectomy.
2018- Cavity problems in CWD mastoidectomy and
methods of cavity obliteration.
RECENT MS
QUESTIONS

4. IMPORTANT
TERMINOLOGIES

5. IMPORTANT
TERMINOLOGIES
 BRIDGE- Medial part of superior bony canal wall forming
bony bridge overlying ossicles & Horizontal FN
 FACIAL RIDGE- Plate of posterior canal bone covering
Vertical FN

6. IMPORTANT
TERMINOLOGIES
ANTERIOR BUTTRESS-
Point at which posterior
bony canal wall meets
tegmen. (Tegmen antri
becomes continuous with
tegmnen tymapani &
Anterior canal wall)
POSTERIOR BUTTRESS-
marks the meeting of PBCW and
floor of EAC to VII CN.
(Floor of EAC slopes off gently
into mastoid tip)

7. FACTORS FOR
DISCHARGING MASTOID CAVITY

8. 1. HIGH FACIAL RIDGE (FR)
2. INCOMPLETE REMOVAL OF PBCW

9. 3.INCOMPLETE DISEASE REMOVAL (*)
4.GRANULATIONS (GR)

10. 5. BIOFILM

11. 6. INADEQUATE REMOVAL OF AB &
PB

12. 7. INCOMPLETE
SAUCERIZATION
Bony overhangs Posterior canal wall
DICTUM- MORE CORTICAL BONE YOU REMOVE, SMALLER IS THE FINAL SIZ

13. 8. RESIDUAL PERFORATION (RP)

14. 9. NARROW MEATUS/ IN-ADEQUATE
MEATOPLASTY

15. PRE-OP PREPARTIONS:
1. Assessment- aural toilet, otoscopy, EUM, Endo, Diagram
2. Pre-op Counseling.
3. EAC irrigation (Acetic acid) +/- drops (steroids) & Abs
4. Hearing tests
5. Xray sinus & dural plates--HRCT (Preferably delay up to pre-op)
6. LA- Long durn OT (Canal skin, ME in atelectasis, Tragus, concha)
7. Check Audiogram & Recommendation again before scrubbing.
8. Check Facial nerve Status before incision.

17. SURGICAL STEPS

18. POST AURICULAR INCISION &
HARVESTING TEMPORALIS FASCIA
GRAFT

19. SUBCUTANEOUS SOFT TISSUE
INCISION
Blade vertical/ facing surgeon Posterior based Musculo-periosteal flap

20. EXPOSURE OF MASTOID CORTEX AND EAR
CANAL
PRIMARY SURGERY REVISION SURGERY

21. CANAL INCISIONS & ELEVATION OF
PMSF
PRIMARY SURGERY REVISION SURGERY

22. CIRCUMFERENTIAL
SAUCERISATION

23. CIRCUMFERENTIAL
SAUCERISATION

24. CIRCUMFERENTIAL
SAUCERISATION

25. MASTOID DISEASE CLEARANCE
Posterior fossa dural
plate
S-D angle
Retro-lab area
L.S area
Retro facial
Obliterating material used in
previous surgery. (Hydroxyapetite
granules)

26. REMOVAL OF BONY CANAL

27. REMOVAL OF BRIDGE

28. ATTIC DISEASE CLEARANCE
Incus removed
+/-Malleus removed
+/- Cog removed
Peri-geniculate
Dehiscent FN

29. ATTIC DISEASE CLEARANCE
Supra-tubal recess
Anterior epitympanum
Debulking before elevating over OW

30. LOWERING FACIAL RIDGE

31. REMOVAL OF ANTERIOR
BUTTTRESS
Medial most part
preserved for M.E
augmentation

32. REMOVAL OF POSTERIOR
BUTTTRESS

33. MIDDLE EAR DISEASE
CLEARANCE
Round Window clearance Oval window clearance

34. MIDDLE EAR DISEASE
CLEARANCE
Drilling on Pyramidal
Process to expose Sinus
tympani
Sinus Tympani clearance
using Sickle knife

35. MIDDLE EAR DISEASE
CLEARANCE

36. MEATOPLASTY

37. MEATOPLASTY
SMS
F
IMSF
PF
Helico-tragal
extension

38. CAVITY PROBLEMS
ADDRESSED
1. High Facial Ridge
2. Incomplete removal of PBCW
3. Incomplete disease removal
4. Granulations
5. Biofilm
6. Inadequate removal of AB & PB
7. Incomplete Saucerization
8. Residual perforation
9. Narrow meatus/In-adequate meatoplasty

39. CHECK-LIST:
 Dissection of Cholesteatoma matrix & granulations
 Fistula/matrix over LSCC leave for the end
 Dural, Sinus plates & S-D angle
 Retro & peri facial
 Tip (med & lat)
 Obliterating Material (FB removed)
 Retro, peri & supra-labyrintine area
 Posterior atticcogAnterior attic (Supra-tubal recess)
 Adequate lowering Ridge, AB, PB
 E. tube opening, Promontory, OW, RW, Hypotymp, Sinus
tympani.
 Stapes footplate/ Inter-Crural area
 Facial Nerve integrity

41. CAVITY OBLITERATION

42. CAVITY OBLITERATION
 CONCEPT- Mosher 1911 (Post auricular soft tissue flap)
 TYPES: a) Local flaps- Muscle,Periosteum,Fascia
b) Free grafts- Bone,Crtlg,Ceramic
 Kisch- Pedicled Temporalis Muscle flap
 Popper- Periosteal flap to line cavity
 Palva- Musculo-periosteal flap
+
Bone chips, Bone pâté

43. WHY TO OBLITERATE ?
 Persistent otorrhea
 Need for frequent cleaning
 Difficulty in using Hearing aid
 Water intolerance (infection)
 Vertigo by caloric stim (warm/cold, air/water)
In other terms, problems of large open cavities:

44. INDICATIONS OF CAVITY
OBLITERATION
BOX-1:
Indications
of cavity
obliteration
 CWD- Primary/ Revision after CWD
 CSF leaks:
 Acoust Neuroma TRANS-LAB
 Meningo-ecephelocele
 Severe temporal bone trauma
 Reconsctruction following Sx T/T for Malig
(LTBR,Subtotal,Total resection)
 CI with H/O COM
 Coclear Drill-out CI (Laby ossificans)

45. RELATIVE CONTRA-
INDICATIONS OF CAVITY
OBLITERATION
BOX-2:
Relative
Contra-
Indications of
cavity
obliteration
 Persistent active ds:
 Cholesteatoma
 Malignancy
 Active infection
EXCEPTION- EXTENSIVE
MALIGNANCY
Obliteration done following subtotal
resection --- preparing for RT

46. OBLITERATION
TECHNIQUES
BOX -3
Techniques
of Mastoid
obliteration
Local flaps
 Meatally based musculoperiosteal flap (Palva
flap)
 Inferiorly based periosteal-pericranial flap
 Superiorly based musculoperiosteal flap
 Temporalis muscle flap
 Temporoparietal fascial flap (TPFF)
Free grafts
 Bone chips/bone pate´
 Fat
 Cartilage
 Fascia
 Hydroxyapatite

47. MIDDLE EAR SPACE
AUGMENTATION
AREAS:
Retro-Lab
Supra-Lab
Under AB
Vertical FN if Dehiscent
MATERIALS:
•Fibro-periosteal
over cortex
•Sub-cut tissue
behind conchal
crtlg

48. MIDDLE EAR SPACE
AUGMENTATION

49. BONE pâté
Sheehy Bone pate collector
Particular attention is paid to obliterate t
sinodural, retrofacial, and mastoid tip ar

50. GRAFTING & OSSICULOPLASTY
Placing back Supr & Infr TM Flaps

51. TIP RECESS
Superficial- pedicled flap rotated to
tip
Deep- falls to saucerised cavity over
LS

52. SINO-DURAL ANGLE
RECESS
Temporalis fascia &
muscle pedicled flap

53. OBLITIERED CAVITY FINAL
LOOK

54. FREE-SKIN GRAFTING

55. 1. Meatally based musculoperiosteal flap (Palva
flap)
2. Inferiorly based periosteal-pericranial flap
3. Superiorly/Anteriorly based
musculoperiosteal flap
4. Temporoparietal fascial flap (TPFF)
5. Temporalis muscle flap
LOCAL FLAPS

56. 1. Meatally based
Musculo-periosteal Flap(Palva flap)
No Meatoplasty
PCW reconstruction
Trans-lab approach (CP Tumor)
Petrosectomy

57. 2. Inferiorly based
Peri-osteal Peri-cranial Flap

58. PERI-OSTEAL PERI-CRANIAL
FLAP
• Width of the flap 2-3cm
• Anterior limit just posterior the
EAC.
• Extension 3-4cm above temporal
line deep to the temporalis
muscle.
• Pedicled at the mastoid tip.

59. 3. Anteriorly/Superiorly Based
MUSCULO-PERIOSTEAL FLAP

60. FASCIAL FLAPS

61. 1. TPFF (Temporo-Parietal Fascial Flap)
1A- Supf Temp art
1B- Frontal Br of
FN
 When standard pedicled muscle
or periosteal flaps are not
available.
 Revision cases with scar tissue
or in
patients with previous irradiation.
 TPFF is well vascularized and
accepts both full and split-

62. TPFF
(1) Skin/subcutaneous
tissue
(2) TPFF
(3) loose areolar tissue
(4) temporalis fascia
(5) temporalis muscle.

63. 2. HONGKONG FLAP
Fig. 2A. End-aural incision on right
ear.
Fig. 2B. The deep temporal fascia is
separated from the temporalis
muscle. 1cm pedicle is preserved.
Fig. 2C. The temporal fascia is
swung on its pedicle to overlay the
mastoid cavity.
Fig. 2D. The fascia lining the
mastoid cavity.

64. SAGGITAL SECTION- FINAL
REVIEW

65. In cases with NO useful residual hearing
 EAC closed off = Water-tight seal
 E. Tube drilled plugged with fascia & Bone
wax
 T-M cavity filled with abdominal fat graft
 Re-inforced with Local flap
Total tympanomastoid
obliteration

66. Total tympanomastoid
obliteration
The external auditory canal is
transected and the auricle is
reflected anteriorly
The auricle is reflected
anteriorly based on a small
musculofascial pedicle

67. Total tympanomastoid
obliteration
Cartilage is removed from the auricle side of the external auditory canal

68. Total tympanomastoid
obliteration
The skin flaps are sutured together in an H pattern closing the external auditory me

69. Total tympanomastoid
obliteration
The meatal closure is reinforced medially by closure of additional soft tissue

70. RESULTS
Young male
6m p/o
Young female
9m p/o
55yr male
18m p/o

71. TAKE HOME MESSAGE
 Pre-op Diagnosis & Preparation
 Counselling of patient
 HRCT reading & surgical planning
 LA infiltration
 Quick decision on Surgical approach/route/extent
 Respect & preserve landmarks and soft tissue
 Factors for discharging cavity
 Prepare for obliteration from beginning of surgery
 Management of complications/mistakes
 Senior consultation
 OT Note & post op counselling- f/u regime, discharge, pain, cavity
drying time.
 Self follow up
 Audit your results
 Never repeat mistakes

72. Follow any one rational
technique,
make it perfect and do not
change it.

73. OCNA, Elsevier
2006, Vol 39.
Issue 6.
MASTOID
OBLITERATIO
N
Page 1129-
1142
REFERENCES
VIJEYANDRA SIR VIDEOS:
1.https://www.youtube.com/watch?v=Up
c1vmnW3jY&t=2681s
2.
https://www.youtube.com/watch?v=Hncu
-0uP_As&t=1557s

75. THANK