DR.RIC AND VIC-MASTOIDECTOMY

1. MASTOIDECTOMY
PRESENTERS
1.DR.RICHARD LUNYONGA
2.DR.VICTORIA BUKUKU
MODERATOR:
DR.AVELINE KAHINGA 1

2. OUTLINE
•Introduction
•History
•Surgical Anatomy
•Types of Mastoidectomy
• Indication of mastoidectomy
•Surgical Techniques
•Complications of Mastoidectomy
•Controversies
2

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

8. Surgical anatomy….
8

9. Surgical anatomy…..
9

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

19. Traditionaly classified as
1. Simple (cortical, complete) mastoidectomy.
2. Radical mastoidectomy
3. Modified radical mastoidectomy
4. Tympanomastoidectomy (
).
19

20. Classification of mastoidectomy…
Broadly can be classified into two type;
Open or Canal Wall Down Mastoidectomy
Closed or Canal Wall Up Mastoidectomy
20

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

23. Cortical mastoidectomy……
23

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

28. Canal wall down(CWD) mastoidectomy….
28

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

39. Preoperative Assessment
History
Chronic otorrhoea
Hearing loss
Previous surgery
Otoscopy
TM perforation
Retraction pockets
Choleteatoma, polys
39

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

44. Surgical Technique....
Aseptic drapping of the
surgical site.
44

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

47. Surgical Technique....
47

48. Surgical Technique....
Slanting posteriorly in
<2years children due to
underdeveloped mastoid
with the superficial facial
nerve.
48

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

50. Surgical Technique....
50

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

53. Surgical technique.....
Periosteal incisions are
made, the periosteum
elevated a lampert
elevator and retracted
forward with the auricle.
53

54. Surgical Technique....
54
•Elevation of the flap
from the bone is done
until the spine of Henlé
and the entrance to bony
canal come into view.

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

56. Surgical Technique....
Drilling
56

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

58. Surgical Techniques....
58

59. Surgical Techniques....
59

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

63. Surgical Technique....
63

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.

65. Surgical Technique....
65

66. Surgical Technique....
66

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

71. Surgical Techniques....
Opening the Facial Recess:
provides access to the
middle ear from the
mastoid.
71

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

78. Surgical Techniques....
Canal wall down mastoidectomy…
78

79. Canal wall down mastoidectomy…
79

80. Mastoid obliteration
80

81. 81

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

95. 95