This document provides a history and overview of mastoid surgery. It discusses how mastoid surgery has evolved from simple procedures for acute infection to now focus on hearing preservation with techniques like intact canal wall mastoidectomy. It describes different types of mastoid surgeries including cortical mastoidectomy, radical mastoidectomy, modified radical mastoidectomy, and intact canal wall mastoidectomy. The document outlines the anatomical considerations for mastoid surgery and provides details on the technique for performing a modified radical mastoidectomy.

1. My MRM

3. HISTORY
• The first scholarly treatise on mastoid surgery for suppurative disease
was by ‘Schwartze’ in 1873.
• The procedure he described was a ‘cortical mastoidectomy’ with
limited exenteration of mastoid air cells.
• In1890, Zaufal described removing the superior and posterior canal
wall, tympanic membrane, and lateral ossicular chain, a procedure
now known as the ‘radical mastoidectomy

4. • This procedure was modified by Bondy, who recognized that disease
limited to the pars flaccida could simply be exteriorized, leaving the
uninvolved middle ear alone.
• His description of the “modified radical mastoidectomy” or “Bondy
procedure” in 1910 represented one of the first reports addressing
hearing function

5. • Interest in hearing preservation and restoration gained further
attention after Lempert introduced the fenestration operation in
1938, and Zollner and Wullstein described tympanoplasty techniques
in early1950s.
• Lempert popularized the use of a drill and loupe magnification in the
1920s

6. • During the next decade, Jansen, Sheehy, and others extended these
principles of restoring function and maintaining normal anatomy with
the introduction of the intact canal wall mastoidectomy with facial
recess approach.
• With the advent of CWU mastoidectomy, disease control as well as
preservation of anatomy and function became a reality

7. • The first postauricular incision was introduced in 1853 by Sir Willium
Wilde of Dublin.

8. INTRODUCTION
• Descriptions of chronic and suppurative infections of the mastoid
have been discovered dating back to ancient Greece.
• Prior to the advent of surgery and antibiotics, morbidity from acute
mastoiditis was considerable.
• Mastoid surgery has evolved from simple trephination for acute
infection, to the canalwall preserving mastoidectomy employed by
inost otologists today

9. • Chronic otitis media, with or without cholesteatoma, is one of the
more common indications for performing a mastoidectomy.
• Mastoidectomy permits access to remove cholesteatoma matrix or
diseased air cells in chronic otitis media.

10. CLASSIFICATIONS
• Traditionally, classified as :
• 1. Simple (cortical, complete) mastoidectomy
• 2. Modified radical mastoidectomy
• 3. Radical mastoidectomy
•  A fourth procedure, Tympanomastoidectomy , combines the
simple mastoidectomy with a middle-ear procedure, maintaining
the posterior and superior canal walls

11. • Depending on the fact whether postero-superior canal is
removed or not,
•  1. Canal Wall Up mastoidectomy
•  2. Canal Wall Down mastoidectomy

12. SUBCLASSIFICATION
CANAL WALL UP (CWU)
• Simple/ cortical/
complete/Schwartze’s
mastoidectomy
• Classic Intact Canal Wall
Mastoidectomy/ Combined
Approach Tympanoplasty (CAT)
CANAL WALL DOWN (CWD)
• Atticotomy
• Atticoantrotomy
• Radical Mastoidectomy
• Modified Radical
Mastoidectomy/ bondy’s
Procedure
• Retrograde Mastoidectomy

13. • Depending upon the mastoid cavity,
1. Open Technique
2. Closed Technique

14. •ANATOMICAL CONSIDERATIONS

15. • The temporal bone consists of four parts: squamous, tympanic,
mastoid, and petrous
• (Figs.)
• Important surface landmarks on the mastoid include the temporal
line, which extends posteriorly from the zygomatic root and is the
insertion site for the temporalis muscle

18. • The suprameatal spine of Henle is a small bony protuberance extending
superficially from the posterior and superior bony EAC.
• Posterior to the suprameatal spine, a group of small holes is seen,
described as the cribriform area.
• Small vessels pass through these foramina to the mucosa of the
underlying antrum in infants, and it’s here that a subperiosteal abscess
forms in cases of acute coalescent mastoiditis

19. • This cribriform area lies within Macewen’s triangle, an imaginary
triangle defined by three lines-
1. Temporal line
2. Line formed by the superior and posterior margins of the external
bony meatus (This line goes through the suprameatal spine)
3. Line drawn perpendiular to the first line and tangential to the second

21. • Mastoid antrum lies around 1.25 cm to 1.5 cm deep from the surface
of Macewen’s triangle.
• Cymba concha is the soft tissue anatomical landmark for the mastoid
antrum

22. • Facial Bridge is that portion of posterosuperior bony meatal wall that
bridges over the notch of Rivinus and overlies the ossicles.
• Facial Ridge is that part of the bony meatal wall which houses the
posterior bend and vertical segment of facial nerve.
• Anterior Buttress is the point at which the posterior bony canal wall
meets the tegmen

24. • Posterior buttress marks the
meeting of the posterior canal
wall and the floor of the EAC
lateral to the facial nerve.
• Its removal causes the floor of
EAC to slope off gently into the
mastoid tip.

27. • Citelli’s angle (Sinodural angle)- is an angle between the sigmoid
sinus and middle fossa dural plate.
• Solid angle is an area where three bony semicircular canals meet.
• Trautmann’s triangle is bounded by bony labyrinth (solid angle)
anteriorly, sigmoid sinus posteriorly and dura superiorly

28. • 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.

30. APPROACHES & ROUTES
• The term ‘Approach’ means the method of access to the middle ear
through the soft tissues eg. Endaural approach, Retroauricular
approach
• The term ‘Route’ means the method of access to the middle ear
through the bone eg. Transcortical route, Transmeatal Route

32. MODIFIED RADICAL
MASTOIDECTOMY
• Classically, modified radical mastoidectomy refers to the Bondy
procedure, in which disease limited to the epitympanum is simply
exteriorized by removing portions of the adjacent superior or
posterior canal wall.
• But, Frequently, the term modified radical mastoidectomy is used
interchangeably with canal wall down mastoidectomy
• A primary feature of the modified radical procedure is complete
removal of the posterior canal wall, the major reason for failure of the
Bondy procedure.
• MRM is an effective method to manage cholesteatoma in a ‘single-
stage’ approach (Unlike CAT).

33. • MRM is a surgical procedure where the disease process is eradicated
from the middle ear cleft; followed by converting the mastoid cavity,
middle ear and EAC into a single, smooth, selfcleansing cavity
exteriorised through EAC

35. INDICATIONS
Absolute Indications
1. Unresectable disease
2. Unreconstructable Posterior canal wall
3. Failure of first stage CWU procedure because of poor E T function.
4. Inadequate Patient Follow up.

36. Relative Indications
1. Disease in only hearing ear or in a dead ear.
2. Medical illness
3. Severe otologic or CNS complications
4. Neoplasms
5. Poor E T function

37. Contraindications
Chronic otitis media without cholesteatoma
2. Acute otitis media with coalescent mastoiditis,
3. persistent secretory otitis media, or
4. Chronic allergic otitis media.
5. Tuberculous otitis media.

38. CWU Vs CWD
• The choice for preserving or removing the posterior wall of the EAC,
ie, CWU versus CWD mastoidectomy, has been extensively debated.
• Preservation of the canal wall is preferred.
• The decision to remove the wall is most often made during surgery,
when the extent of the disease is fully appreciated

39. Intraoperative findings that may be indications for a CWD procedure
include
-labyrinthine fistula,
-unresectable disease on the facial nerve orstapes footplate,
-a low-lying tegmen that limits access to the attic,
-unresectable sinus tympani disease, and an unreconstructable
posterior canal wall defect.

40. • Removal of the canal wall does not improve access to the sinus
tympani.
• Rarely, our preoperative evaluation may result in the decision to take
down the canal wall.
1.Obvious posterior wall erosion,
2.larger labyrinthine fistula on CT scan,
3.elderly or infirmed patients in which second look is unadvisable.
4.Occasionally with disease in an only hearing ear, are preoperative
conditions that may warrant a CWD procedure.

41. Advantages and disadvantages of canal wall-
up and canal-down procedures
Advantages Disadvantages
Canal wall-up
Physiologic position of tympanic membrane Residual and recurrent cholesteatoma may occur
Enough middle ear space Incomplete exteriorization of facial recess
No mastoid cavity problem Second stage operation often required
Canal-down
Residual cholesteatoma easily found on follow-up
evaluation
Mastoid cavity problem often
Recurrent cholesteatoma is rare Middle ear is shallow and difficult to reconstruct
Total exteriorization of facial recess
Position of pinna may be altered; second stage operation
sometimes required

42. TECHNIQUE OF MODIFIED RADICAL
MASTOIDECTOMY(MRM)
• Also known as complete mastoidectomy and tympanoplasty
Major goal
→cholesteatoma surgery (i.e., exteriorization of disease) with sealing
of the middle car space
• A primary feature of the MRM is complete removal of the posterior
canal wall

43. Preoperative Assessment
• Decision to perform a MRM depends on:
the extent and location of the disease
previous surgery
 Eustachian tube function
 and patient age, medical condition, and aftercare preference
Careful microscopic inspection and cleaning of the ear aid in the decision
• Pus, mucus, and cholesteatomatous debris should be removed under
microscopic suction

44. • Active suppuration →controlled prior to surgery whenever possible.
(Acetic acid (1.5%solution) irrigations followed by antibiotic otic drops
should be instituted for several weeks prior to surgery)
• In cases of extensive mucosal Infection and cellulitis 10 - l4-day
course of oral fluoroquinolones with gram-positive coverage is
indicated prior to surgery

45. Surgical Procedure
• After induction of G.A
• Ear prepared by pouring povidone-
iodine solution into the ear canal and
scrubbing the auricle and postauricular
area with povidone-iodine
• 1 % lidocaine with 1:100,000
epinephrine injected postauricular
region & ear canal for hemostasis

46. • Incisions ear canal for the vascular strip
• A postauricular incision Plane
developed between the subcutaneous
tissue and the temporalis muscle and
periosteum of the mastoid
• Several large pieces of areolar tissue and
temporalis fascia are harvested and set
aside to dry
FIG: Standard tympanoplasty canal incisions
outline the vascular strip as well as the
superior and inferior canal wall flaps

47. • Horizontal incision superior to the
temporal line through the temporalis
muscle & vertical incision mastoid
tip perpendicular to and bisecting
the horizontal incision ( “T” shaped
Incision)
Fig: Loose areolar fascia is harvested from
temporal muscle, and a T-shaped incision
is made in soft tissue over mastoid.

48. • Mastoid bone is exposed using a
Lempert elevator
• Periosteum raised into the ear canal
vascular strip elevated & reflected
out of the ear canal anteriorly using
a self-retaining retractor
Fig:Exposure of mastoid in
crosssection showing vascular
strip held forward under anterior
blade of retractor.

49. • In revision casesElevation of the scarred
musculoperiosteum carefully to avoid
injury to exposed dura or sigmoid sinus
• Canal wall flaps elevated and rotated
anteriorly prior entering middle ear
• Disease in the mesotympanum is first
removed malleus handle and incus as
landmarks
Fig:The inferior flap is elevated to the fibrous
annulus

50. • Cholesteatoma, polyps, and granulation tissue are removed from all
areas except the posterosuperior quadrant(PSQ)
• Any atrophic tympanic membrane removed & middle ear
prepared for grafting
• Once all available landmarks have been identified  PSQ
inspected.
• If disease extends into the attic dissection of disease ceases and
Gelfoam with epinephrine  packed middle ear

51. Bone Work
• Simple mastoidectomy begunlarge
cutting bur.
• All mastoid air cellsremoved with
exposure of the middle fossa and
posterior fossa dural plates, the sigmoid
sinus, digastric ridge, and bony canal wall
• Cholesteatoma and granulations filling
the central mastoid tract removed at
this time.
FIG: With the posterior external auditory
canal (EAC) wall preserved, a complete,
simple mastoidectomy demonstrates

52. • As the labyrinth is approached lateral
capsule of the cholesteatoma opened
cholesteatoma should be removed
leaving the medial matrix of the
cholesteatoma on the bony labyrinth
• Under higher-power magnification the
matrix inspected labyrinthine fistula
• The vertical segment of the facial nerve
now identified opening of the facial
recess

53. • If the incus is involved with
cholesteatoma incudostapedial joint is
identified through the facial recess and cut
and the incus is removed
• The posterior canal wall now be safely
taken down rongeur
• Facial ridge lowered
Fig:The posterior EAC wall must be lowered
to the visible facial nerve. The chorda
tympani is sacrificed. Canal wall flaps are
preserved

54. • Chorda tympani nerve sacrificed
• Disease now be removed from the oval window region and
horizontal segment of the facial nerve.
• The malleus or any remnant of the malleus removed  which
provides access anterior epitympanum
• Anterior epitympanum  drilled down continuous with the
anterior canal wall.

55. • Inferior canal wall drilled until the inferior canal wall and mastoid
tip are confluent with no bony overhang to obscure the mastoid tip
• This dissection more widely exposes the middle ear reinspected for
residual disease
• Sinus tympani most difficult region to investigate If disease extends
into this region  if the stapes is absent the pyramidal eminence
can be removed with a small diamond bur
• Tympanoplasty should not be performed residual cholesteatoma in
the sinus tympani or hypotympanum

56. • At this point cavity should be smooth-
walled and free of active disease
• Copious irrigation lower the bacterial count
and aid in hemostasis.
• The cavity should approach an ovoid or
rectangular shape with the facial ridge low Fig:The facial ridge must be lowered to the
visible facial nerve.The chorda tympani is
sacrificed.

57. • Stapes if present, should be the only remaining ossicle
• A portion of the anterior tympanic membrane may remain after
removal of disease.
• Mastoid bowl saucerized makes a gentle transition into the
depths of the mastoid bone without ledges.

58. Meatoplasty
• 1% lidocaine with 1:100,000
epinephrine infiltrated into the
conchal bowl
• The entire posterior aspect of the
conchal bowl is exposed With
finger in conchal bowl  semilunar
incision cartilage posteriorly
• Crescent-shaped cartilage measures
about 1.5 x 2 cm
Fig: meatoplasty beginsby excising, from behind,
conchal cartilage

59. • Korner flap incisions through external
auditory canal skin
• Inferior incision inferior canal at 6
o'clock conchal bowl curved around
the inferior margin of the bowl.
• A superior incision 12 o'clock tragus
and anterior helix
• These incisions create a long (vascular
strip) flap posterosuperior aspect of
the conchal bowl constitute the back
wall of the mastoid cavity Fig: Superior and inferior meatal incisions create
a posterior Korner's flap, shown here as it will
be sutured in place

60. Grafting
• Auricle and flap retracted
anteriorly to expose the mastoid
and middle ear
• Epinephrine-soaked absorbable
gelatin sponge removed 
middle ear and Eustachian tube
packed with saline-moistened
absorbable gelatin sponge level
of the anterior annulus Fig:An absorable gelatin sponge (Gelfoam) bed is
prepared for the tympanic membrane graft. Note
the Korner's flap free in the meatus

61. • Fascia graft placed medial to the
anterior annulus and drum remnant
extending over the stapes to the
facial ridge into the mastoid bowl
Fig:The graft is placed medial to the tympanic
membrane remnant, superiorly over the labyrinth
and posteriorly over the facial ridge. The graft is
applied directly atop the stapes superstructure

62. • Ossicular reconstruction is
limited If the stapes is
presentfascia graft placed
directly onto capitulum
• If stapes lower than facial
ridge height can be
augmented by using malleus
head goblet prosthesis atop the
capitulum
Fig:When the facial ridge is high, a sculpted homograft
malleus head can be constructed to augment the height
of the stapes superstructure

63. Fig:The sculpted homograft fits atop the stapedial
capitulum, ready for grafting

64. • With absent stapes ossicular
reconstruction with autologous tissue
preferred over alloplastic prostheses
• Once the fascia graft is in place
surface covered with polymixin B and
bacitracin ophthalmic ointment
Fig: Ointment "packing" fills the cavity.

65. Fig: cross-section, the low facial ridge, graft bed, with graft
and initial ointment, is demonstrated.The posterior meatal
flap is illustrated in the desired position

66. • Korner flap secured
musculoperiosteum at edge
of the mastoid cavity
• Tension of these sutures
adjusted until meatus has
desired shape
Fig: The posterior flap is sewn to the
posterior soft tissue margins of the incision

67. • Postauricular incision closed subcuticular absorbable suture
• Mastoid bowl filled with ointment or packed with gauze
• Mastoid dressing applied

68. Postoperative Care
• Mastoid dressing removed on first postoperative day
• Large piece of cotton kept in meatus postauricular dressing placed
• Copious drainage occurs meatus  1 week requiring frequent
cotton changes
• Postauricular dressing removed second postoperative day 
antibiotic ointment applied to incision for 1 week

69. • Patient instructed keep ear dry and avoid nose blowing
• Pain medication prescribed
• Oral antibiotics not used routinely
• Patient returns in 2 to 3 weeks first postoperative visit
any area that has not been grafted is covered by layer of granulation
tissue
Exuberant granulation tissue debrided and treated with silver
nitrate

70. • Granulation tissue then painted 2% gentian violet instructed to
use antibiotic drops 2-3 times next visit
• Drainage decreases re-epithelialization occurs
• As epithelialization progresses acetic acid irrigations can replace
antibiotic otic drops.
• Once cavity is healed patient should return for yearly visit & given
full water sport privileges

71. COMPLICATIONS OF OPEN CAVITY PROCEDURES
Facial paralysis
Wound infection
Deafness or further hearing loss
Vestibular symptoms
Cerebrospinal fluid leak
Recurrent cholesteatoma or drainage.

72. • Facial nerve paralysis most common major complication

73. wound infection
2nd most common complication
perichondritis of auricle
 Pseudomonas aeruginosa causative organism
Treatment
High-dose fluoroquinolones and antibiotic-corticosteroid drops

74. “Chocolate" or mucous retention cyst
• Can occur in healed mastoid cavity
• Result of collection of serum within a mucous membrane-lined
pocket
Management
• Simple aspiration reduce the size of the cyst
• Recurrence common
Definitive management
• Exposure of the cyst & complete removal of mucoperiosteal pocket

75. Cholesteatoma recurrence
• In open cavity procedures  4 to 28% cases
Etiology
• Inaccessible disease or a remnant of matrix that was amputated at
the time of surgery
Management
• Routine follow-up these "pearls" of recurrent cholesteatoma
identified and removed in the office

76. Recurrent aural drainage
• Previously healed and dry cavity result of poor aural toilet
• Breakdown of epithelial lining & formation of granulation tissue
occurs when epidermal debris is allowed to accumulate and becomes
infected
Management
• Careful microscopic debridement of granulation tissue and
application of gentian violet followed by antibiotic corticosteroid
otic drops re-epithelialization & dry ear

77. Development of scar bands within mastoid defect
• Lead to keratin debris accumulation and subsequent infection
Management
• Transmeatal removal ofscar bands under local anesthesia
In extensive cases
• Transmeatal removal of scar bands under G.A.re-epithelialization of
mastoid bowl
• It is critical that the patient understand the need for
periodicusually annual examination to prevent such occurrence

78. Bibliography

79. Next presentation

80. Thank you