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.
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.
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
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.
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
Paranasal Sinuses (PNS) are air containing bony spaces around the nasal cavity. There are 4 pairs of paranasal sinuses(bilaterally) but maxillary sinus is considered most important to dentists due to proximity of maxillary sinus to orbit, alveolar ridge, diseases involving these structures may produce confusing symptoms. Hence precise information about surgical anatomy is essential to dental practitioners. the close anatomical relationship of the maxillary sinus and the roots of maxillary molars, premolars, and in some instances canines, can also lead to several endodontic complications. Clinicians must be particularly cautious when performing dental procedures involving the maxillary posterior teeth
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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3. 1.INTRODUCTION
Mastoidectomy is a surgical procedure which opens up
the mastoid cavity, cleans up the infected air cells and
improves middle ear ventilation by widening the aditus.
Prior to the advent of surgery and antibiotics,
morbidity from acute mastoiditis was considerable
higher.
Mastoid surgery has evolved from simple trephination
for acute infection, to the canalwall preserving
mastoidectomy employed by most otologists today.
3
4. 2.HISTORY OF MASTOIDECTOMY.
1774 - John Luis Petit performed the first surgical
trephination of the mastoid. Petit described
exposing the mastoid cortex, performing a
trephination, and then enlarging the surgically
created fistula.
1873 - The first scholarly treatise on mastoid
surgery for suppurative disease by Schwartze
(cortical mastoidectomy).
1890 - Zaufal described removing the superior and
posterior canal wall, tympanic membrane and
lateral ossicular chain (radical mastoidectomy).
4
5. History of Mastoidectomy......
1910 – Bondy recognized that disease limited to the pars
flaccida could simply be exteriorized, leaving the
uninvolved middle ear alone. His description of the
“ ” or “Bondy procedure”
represented one of the first reports addressing hearing
function.
1938 - Lempert introduced the fenestration operation.
1950s - Zollner and Wullstein described tympanoplasty
techniques.
1960s - Jansen, Sheehy, and others extended principles
of restoring function and maintaining normal anatomy
with the introduction of the intact canal wall
mastoidectomy with facial recess approach.
5
6. FORMATION OF MASTOID BONE
•The mastoid process is absent or rudimentary in the
neonatal skull.
•Mastoid is invisible and covered by a thin bony plate
that extends to the squamous portion.
• It forms during postnatal and starts to develop after 1-
year-old as the sternocleidomastoid muscle develops
and pulls on the bone. It usually finishes structural
development by 2 years old.
•Mastoid antrum becomes obvious at 5 years.
•During puberty-mastoid thickness increases and
become pneumatic and lined with mucosa.
•20% of adults, their mastoid bone may not contain air
cells. 6
7. 3.SURGICAL ANATOMY
The temporal bone connects to the parietal, occipital,
zygomatic, and sphenoid bones.
It is a pyramidal bone with the apex pointing in the
anteromedial direction.
The temporal bone consists of four embryologically distinct
components:
Squamous part
Tympanic part
7
10. Surgical Anatomy....
The mastoid part is a
bulbous bony structure.
It is shaped by the
expansion of air-filled
spaces within. The
central air cell is called
the antrum.
Temporal line:estimates
the location of the
middle fossa floor
10
11. Surgical Anatomy....
Suprameatal spine of Henle
Is a small bony
protuberance found at the
posterior superior lateral
edge of the ear canal, which
marks the level of the
antrum of the mastoid
Posterior to it is a group of
small holes(Cribriform
area).Lies within Macewen’s
triangle.
11
12. Macewen’s triangle
Is a surgical surface
marking for mastoid
antrum
Borders
• Superior: Temporal line.
• Anterior: Postero-superior
margin of bony EAC.
• Posterior:
.
The mastoid antrum lie
12.5-15mm deep to the
triangle.
12
13. Surgical Anatomy....
Anterior buttress is the point
at which the posterior bony
canal wall meets the tegmen.
Posterior buttress marks the
meeting of the posterior canal
wall andthe floor of the EAC
lateral to facial nerve.
Removal of posterior
buttress-floor of the EAC slops
off gently into the mastoid tip.
13
14. Surgical Anatomy....
Facial bridge Is the
portion of the
posterosuperior bony
meatal wall that bridges
over the notch of Rivinus
and overlies the ossicles.
Facial ridge-part of the
bony meatal wall that
houses the posterior
bend and vertical
segment of the facial
nerve. 14
15. Surgical Anatomy...
• Citelli’s angle
(Sinodural angle) is an
angle between the
sigmoid sinus and
middle fossa dural plate.
15
16. Solid angle is an area where three
bony semicircular canal meet.
Subarcuate artery exits
Trautmann’s triangle posterior
SSC anteriorly, sigmoid sinus
posteriorly, and superior petrosal
sinus superiorly.
Contain retrolabyrinthine tract that
leads to the petrous apex, the
endolymphatic sac, and the
vestibular aqueduct
Donaldson’s line is a line passing
through the horizontal
semicircular canal and bisects the
posterior semicircular canal.
This line is a landmark for the
endolymphatic sac.
16
17. Surgical Anatomy...
Facial recess
The facial recess is the
space bounded.
•laterally by the chorda
tympani nerve,
•medially by the facial
nerve,
•superiorly by the fossa
incudis.
17
18. VASCULAR SUPPLY OF TEMPORAL BONE
External carotid artery: 1. Superior temporal artery
2. Stylomastoid artery
The anterior inferior cerebellar artery gives rise to
the internal auditory artery and subarcuate artery.
The venous drainage is from inferior and superior
petrosal veins into the jugular fossa of the skull base,
and then into the internal jugular vein.
18
21. Classification of mastoidectomy…
21
Canal Wall Up Technique
(CWU or ICW)
Canal Wall Down
Technique(CWD)
Cortical mastoidectomy Radical
mastoidectomy
Tympanoplasty with
intact CWM
Modified radical
(Bondy’s procedure)
Canal wall
reconstructive
technique.
Atticotomy
Atticoantrostomy
Mastoid obliteration
22. Types of mastoidectomy.....
CORTICAL MASTOIDECTOMY
Initial stage of any transmastoid surgery of the
middle and inner ear and facial nerve.
Involve removal of disease that is limited to the
mastoid antrum and air cell system.
Preserving the posterior bony EAC wall.
The middle ear contents are not disturbed.
Tympanostomy tube may be placed for improved
ventilation.
22
24. Types of mastoidectomy.....
Indications for cortical mastoidectomy.
Coalescent
Mastoiditis and
Masked Mastoiditis.
CSOM (tubo-
tympanic) Active
Refractory to
antibiotics.
Approach to:
• Endolymphatic sac surgery.
• Facial nerve decompression.
• Vestibulo cochlear nerve
section.
• Translabyrinthine Approach for
CP angle.
• Cochlear implant surgery.
• Combined Approach
Tympanoplasty 24
25. Types of mastoidectomy.....
TYMPANOPLASTY WITH ICW MASTOIDECTOMY
An operation in which disease is removed from the
mastoid and middle ear while preserving the
posterior bony wall of the EAC.
Often the mesotympanum is exposed by
developing a posterior tympanotomy through the
facial recess.
primarily, but it is often staged in cholesteatoma
cases.
25
26. Types of mastoidectomy.....
The first operation is performed to remove all
cholesteatoma and repair the tympanic membrane.
6 months later, the second operation is done to
inspect the mastoid and middle ear for residual or
recurrent cholesteatoma and to
26
27. Types of mastoidectomy.....
Done to eradicate or exteriorize extensive middle
ear disease by removing the posterior bony ear
canal to open the middle ear, mastoid, and
epitympanum into one common cavity.
Remnants of the TM, malleus, and incus are
removed leaving only the remaining portions of the
stapes.
The TM is not reconstructed, and the Eustachian
tube may be left open or permanently obstructed
with tissue grafts.
27
29. Types of mastoidectomy.....
Indications for radical mastoidectomy
Unresectable cholesteatoma extending down the
Eustachian tube or into the petrous apex.
Promontory cochlear fistula caused by cholesteatoma
Chronic perilabyrinthine osteitis or cholesteatoma that
cannot be removed and must be cleaned or inspected
periodically.
Resection of temporal bone neoplasms with periodic
monitoring.
29
30. Types of mastoidectomy....
An attempt is made to preserve or reconstruct the
middle ear.
Sometimes healthy TM and ossicular remnants are
preserved.
In the classic Bondy modified radical procedure,
atticoantral cholesteatoma is exteriorized without
disturbing the intact pars tensa of the TM or the
intact ossicular chain.
30
31. MODIFIED RADICAL MASTOIDECTOMY
Indications
Absolute Indications
Unresectable disease
Unreconstructable
Posterior canal wall.
Failure of first stage
CWU procedure
because of poor ET
function.
Inadequate Patient
Follow-up.
Relative Indications
Disease in only hearing
ear or in a dead ear.
Medical illness or
severe otologic/CNS
complications
Neoplasms
Poor E T function
31
32. MODIFIED RADICAL MASTOIDECTOMY
Contraindications:
Chronic otitis media without cholesteatoma
Acute otitis media with coalescent mastoiditis,
Persistent secretory otitis media, or
Chronic allergic otitis media.
Tuberculous otitis media.
32
33. Types of mastoidectomy....
ATTICOTOMY
Removal of ear canal bone including the lateral wall
(scutum) of the epitympanum to expose and
exteriorize limited attic disease, usually lateral to
healthy ossicles.
33
34. Types of mastoidectomy......
Done by entering the attic from the ear canal and
then proceeding posteriorly, gradually removing
posterior ear canal bone and exposing disease in the
aditus and antrum until it is fully exteriorized.
It is synonymous with modified radical
mastoidectomy but is carried out from anterior to
posterior ie. exposing the attic first and then
proceeding posteriorly into the aditus and antrum.
The surgeon’s intent is to exteriorize rather than
resect the matrix of the cholesteatoma.
34
35. Types of mastoidectomy.....
MASTOID OBLITERATION
A procedure in which graft is used to obliterate a portion of
the cavity following a canal wall down mastoidectomy.
Mastoid reconstruction and obliteration procedures can be
classified into two main categories: (a) Free grafts
(b) local flaps.
If successful, the size of the defect is minimized, which may
avoid the need for long-term cavity care.
35
36. Types of mastoidectomy......
Intraoperative findings that may be indications for a CWD
procedure include
Labyrinthine fistula
Unresectable disease on the facial nerve or stapes
footplate
A low-lying tegmen that limits access to the attic
Unresectable sinus tympani disease.
Unreconstructable posterior canal wall defect.
36
37. INTACT CANAL WALL UP MASTOIDECTOMY…
Advantages
•Physiological TM position.
•No mastoid bowl.
•Hearing aids easier to fit.
Disadvantages
•Technically difficult.
•Residual disease harder to detect.
•Second stage often required.
•Periodic follow up is needed
37
38. CANAL WALL DOWN MASTOIDECTOMY….
Advantages
•Residual cholesteatoma is visible on follow-up.
•Recurrent cholesteatoma is rare.
•Total exteriorization of facial recess.
Disadvantages
•Position of the pinna may be altered.
•Mastoid bowl-life long problem
•Hearing aids, difficult to fit.
38
40. Preoperative Assessment
Audiology
PTA – Assess Hearing loss
Tympanometry- assess the status of EAC and middle ear
Speech Discrimination Test –Assess possibility of Middle ear
reconstruction.
CT scan – HRCT
Diagnostic and surgical planning
40
41. HRCT of the temporal bones
Normal Coalescent mastoiditis
41
42. Preoperative Assessment
CT Scan – HRCT
Can show temporal bone
pneumatization, middle
ear and mastoid air cells
ventilation, EAC, sigmoid
sinus, jugular bulb, tegmen
tympany, facial nerve,
extent of disease and
status of ossicular chain
MRI
Non specific in COM
Better for IC involvement
42
43. 5.SURGICAL TECHINIQUES
Preparations:
General anesthesia without
paralytic agents and with
continuous facial nerve monitoring.
Patient is positioned in supine
position with the head turned to
the contralateral side to expose the
diseased ear.
“Pre-scrub" the ear and the entire
side of the head, including hair,
with betadine.
43
45. Surgical Technique....
Tragus and postauricular
skin are injected with 1%
lidocaine with
epinephrine (1: 100,000)
to provide hemostasis and
local anesthesia.
45
46. Surgical Technique....
Surgical approach to the ear in CWU
a).Postaural/Retroauricul
ar incision
A C-shaped incision.
Starts from the highest
attachment of the pinna,
follows the curve 0.8-
1cm behind the retro
auricular groove, and
ends at the mastoid tip.
46
49. Surgical Technique....
b). Endaural incision approach
Lempert I incision.
The semicircular incision from 12
o’clock to 6 o’clock position in the
posterior meatal wall at the bony-
cartilaginous junction.
Lempert II
Starts from the first incision at 12 o
clock and then passes upward
curvilinear between tragus and crus
of helix through incisura terminalis.
49
51. Surgical Technique....
Elevate the skin flap
•Towards the ex-ternal
ear canal.
•Cut through the post-
auricular muscle to reach
the correct plane just
superficial to temporalis
fascia.
•large rake can be used
to retract the pinna
forward.
51
52. Surgical Technique....
An anteriorly based
musculoperiosteal flap is
developed, about 1.5cm in
length
A T-shaped incision is made in
the mastoid periosteum to
expose the mastoid cortex
• The 1st incision-Along the linea
temporalis to the level of the
underlying bone.
• The 2nd incision-Perpendicular
to the linear temporalis down
to the mastoid tip.
52
55. Surgical Technique....
•In an adult two self-
retaining retractors are
placed between the skin
edges and soft tissue for
exposure.
•One self-retaining
retractor is usually
sufficient in a child.
55
57. Surgical Techniques......
Initial Drilling:
When the mastoid cortex
becomes fully exposed
The first bur cut is made along
the temporal line, which
approximates the level of the
middle cranial fossa dural plate
The second bur cut is made
perpendicular to this and
tangential to the bony EAC
It should be carried inferiorly to
the mastoid tip. 57
60. Surgical Technique....
Appropriate irrigation is necessary
To clear bone dust from the field of dissection,
To prevent excessive heat transfer to underlying
structures (especially the facial nerve), and
To maintain a clean cutting surface on the bur.
60
61. Surgical Techniques.......
•As the dissection is
carried medially and the
antrum is approached, a
bony septum (Körner’s
septum) may be
encountered.
•This plate is a remnant
of the petrous-
squamous septum.
61
62. Surgical Techniques.......
A key landmark in
performing mastoid
surgery is the antrum
with the dome of the
horizontal semicircular
canal (HSCC) along its
floor.
62
64. Surgical Technique....
64
Key principles that assist in
locating the antrum include
saucerization, identification
of the tegmen plate, and
thinning of the posterior
canal wall.
Consideration should also
be made during posterior
dissection where the
sigmoid sinus is located.
67. Surgical Techniques....
Drilling tips:
Avoid keyhole surgery;
work through a wide
space.
The tip of the drill
should always be
visible
Never drill behind
edges of bone.
Drilling should always be
parallel to any structure you
are trying to preserve e.g.
facial nerve, sigmoid sinus.
67
68. Surgical Techniques....
Drilling tips:
When drilling deeper in
the mastoid cavity the
burr needs to be
lengthened.
However, one cannot
lengthen a cutting burr
as this will cause the drill
to jump with the risk of
injuring structures.
Therefore if it is
necessary to lengthen
the burr, then change
to a rough diamond or
smooth diamond burr.
68
69. Surgical Techniques.....
Facial Nerve Identification:
Identifying the facial
nerve is fundamental to
performing good
mastoid surgery.
The most important
landmarks for the facial
nerve are the HSCC, the
short process of the
incus, and the posterior
bony EAC.
69
70. Surgical Techniques....
The genu and proximal
portion of the mastoid
segment of the facial nerve
lie anterior and just medial
to the dome of the HSCC
The mastoid segment
facial nerve also lies medial
to the plane of the short
process of the incus at the
base of the posterior canal
wall.
70
72. Surgical Techniques....
The promontory, round window niche, stapes, long
process of the incus, cochleariform process, medial
side of the tympanic membrane and malleus handle,
and eustachian tube all are well seen.
72
73. Surgical Techniques....
The facial recess can be extended superiorly and
inferiorly, providing a large “posterior
tympanotomy.”
Sacrificing the chorda tympani nerve permits
additional dissection inferiorly with good exposure
of the hypotympanum.
73
74. Surgical Techniques........
Opening the Epitympanum
Smaller, diamond burs
are required in the
epitympanic dissection
Involves thinning dura
bone and the superior
canal wall.
The Cog: landmark from
tegmen towards malleus
head and separates the
epitympanum into ant.
And post. portion 74
75. Surgical Techniques....
Facial nerve takes a slight medial course in the
epitympanum as it is traced anteriorly from the
mastoid genu to the geniculate ganglion.
It passes superior to the oval window and
cochleariform process.
75
76. Surgical Techniques......
Canal Wall Down Mastoidectomy
Removing the posterior
bony canal wall to the
level of the facial nerve:
only a thin shell of bone
remains over the nerve,
creating a smooth, gently
curving transition from
the anterior
epitympanum to the
anterior canal wall.
76
77. Surgical Techniques....
This dissection is continued toward the
stylomastoid foramen until there is no bony spur
(inferior or posterior buttress) between the floor of
the external bony canal and the mastoid cavity.
In a similar manner, the anterior extent of the
superior canal wall (anterior buttress) is completely
removed.
77
82. Postoperative Care
Mastoid pressure
dressing is preferred
Mastoid dressings are
typically removed 48 -
72 hours after surgery.
Patients are typically
instructed to keep the
operative ear dry.
82
83. Postoperative Care..
Monitor of vital signs (BP, PR, T, RR)
Appropriate analgesia within the first 5-7 days.
Patients can start topical antibiotic drops the
following day after surgery for several days before
the initial postoperative visit.
Remove packing in the ear canal 1-2 weeks after
surgery. Depends merely on the type of ear surgery
done.
83
84. Postoperative Care
The topical antibiotic drops serve a dual purpose of
decreasing the risk of a post-surgical infection and
keeping the packing moist to ease removal at their
initial postoperative visit
Long term monitoring
Patients with cholesteatoma need to be followed
long term.
Access for Recurrence.
84
85. 6.COMPLICATIONS OF MASTOIDECTOMY
Facial Nerve Injury
Facial nerve paralysis is the most dreaded complication
of mastoidectomy. The risk of iatrogenic facial nerve
injury increase in:
Revision surgery
Extensive disease
Facial nerve dehiscence
Poor operator experience or misadventure with
the drill
85
86. Complications of mastoidectomy…
Facial nerve injury….
Minimal injury intra-op
•-Decompress the fallopian
canal proximal and distal to
the site.
Partial transection.
•Anastomose the separated
fassicles.
•Decompress the fallopian
canal proximal and distal to
the site.
Complete transection-intra-op
•Attempt primary anastomosis
without tension, cable graft if
necessary.
Immediate post OP early
facial weakness
-Reassess after 4hours,
allow the anesthesia to
wear off.
Mild paresis-observe, give
steroid.
Severe paresis-Return to
the operating room for
exploration and repair.
More than 8HRS post.OP
Mild paresis-Observe, give
steroid.
Severe paresis-Observe,
give steroid. 86
87. Complications of Mastoidectomy....
Dural injury
A dural tear or significant abrasion with herniation of
arachnoid tissue with or without a cerebrospinal fluid leak
requires repair.
Dural defects are best repaired with a layered closure
using soft tissue such as fascia or perichondrium combined
with a more rigid support material such as bone or
cartilage.
87
88. Complications of Mastoidectomy....
Firmly packing the mastoid (or epitympanum) with
absorbable gelatin sponge (Gelfoam) (with or
without fibrin glue) can be used to support the repair
as needed
Instituting a broadspectrum antibiotic with
cerebrospinal fluid penetration should also be
considered. 88
89. Complications of Mastoidectomy......
Vascular injury (sigmoid sinus/ jugular bulb)
The sigmoid sinus and jugular bulb (variable
anatomy).
These low-pressure, but high-volume, venous
structures is initially treated with digital pressure.
For small tears, bone wax may suffice
For larger rents, cellulose-type surgical packing is
required
A significant injury to the sigmoid sinus can result
in thrombosis of that vessel.
89
90. Complications of Mastoidectomy......
Hearing loss
A temporary CHL is very common as blood, serous
fluid and packing fill the middle ear space.
A significant SNHL is rarely encountered in patients
undergoing surgical intervention for COM.
SNHL may arise from the high-speed drill
contacting an intact ossicular chain, labyrinthine
fistula or noise exposure from the drill.
90
91. Complications of Mastoidectomy....
Horizontal Semicircular Fistula
Iatrogenic injury to the HSCC predisposes the
patient to bacterial labyrinthitis with resulting
vertigo and severe sensorineural hearing loss.
Immediate closure, usually with bone wax is
required.
A short course of a broad-spectrum antibiotic and
steroids can be considered.
91
92. Complications of Mastoidectomy...
Change in taste
Chorda tympani nerve may need to be sacrificed if
it is encased in cholesteatoma or inflammatory
tissue especially in patients undergoing revision
surgery or a canal wall down procedure.
Patients typically notice an altered sensation of
taste, typically described as a metallic or sour taste
on the affected side. This sensation may be
persistent but often resolves over a period of
months.
92
93. 7.CONTROVERSIES.
The choice for preserving or removing the posterior
wall of the EAC, ie, ICW versus CWD mastoidectomy,
has been extensively debated.
Preservation of the canal wall is preferred vs Canal
wall down leads to a ‘safe’ and technically less
demanding.
Judgment depends on the patient's reliability, and
the surgeon's experience, and often decision is made
during surgery.
Mastoid obliteration-Cartilage and hydroxyapatite vs
bone dust
Schapola et al, India,2014
94. References
Paul W. Flint et al, Cummings Otolaryngology-Head & Neck Surgery, Fifth Edition
John Jacob Ballenger, ‘Ballenger’s Otorhinolaryngology-Head and Neck Surgery’
Sixteenth Edition
Bailey, Byron J.; Johnson, Jonas T.; Newlands, Shawn D. Head & Neck Surgery -
Otolaryngology, 4th Edition
• Professor Tuncay Ulug, MD Istanbul University Atlas of temporal bone surgery,2010
• Glasscock-Shambaugh, Surgery of the Ear, 5th Edition
Leliever, W C (1983), Temporal Bone Surgical Dissection Manual. Archives of
Otolaryngology-Head and Neck Surgery
Eugene N. Myers, MD, FACS, FRCS Edin (Hon), Head and neck surgery,volume 1,
2014.
94
Cymba concha is the soft tissue anatomical landmark for the mastoid antrum.
Dissecting at this margins of triangle is safer because of vital neurovascular structure are absent
Cribriform-passage of vessels
NOTE: other important landmarks and structures will be highlighted with the surgical steps.
stylomastoid artery give rises to posterior tympani arter
free graft can be biological (bone chips) or non-biological(hydroxyopatite)
local flap-pedicle flap or musculoperiostal flap-palva
An otologist’s road map though has poor specificity with mass lesions e.g cholesteatoma
This plate is a remnant of the petrous squamous septum, and simply separates more superficial air cells from deeper ones