Mastoidectomy

4/2/2021
Outline
• Introduction
• Incisions
• Types
• Procedures
• Hearing Reconstruction
• Complications
Introduction
• Mastoidectomy
• an operation undertaken on the mastoid air cells to remove disease
• The disease is usually infective but may occasionally be neoplastic
• May also be performed as part of a procedure for access to deeper
structures, for example endolymphatic sac surgery or insertion of a
cochlear implant
 Incisions
• Either an endaural or postaural incision is used

• A properly performed endaural incision will allow

good access to the attic, tegmen and sigmoid sinus
even in well-aerated mastoids.

• It provides better access to the sinus tympani and

is ideally suited for a small cavity mastoidectomy.
• It will not allow sufficient posterior access for a
subtotal petrosectomy.
Postaural Incision
• Neither will the endaural incision allow an adequate angle of
approach to the middle ear in those who perform a posterior
tympanotomy (required for combined approach tympanoplasty and
to access the round window in cochlear implants)
Types
• Cortical mastoidectomy
• Modified radical mastoidectomy
• Combined approach tympanoplasty
 Cortical mastoidectomy
• This is also known as the Schwartze
operation and is used for the
treatment of the acute
noncholesteatomatous mastoiditis
when medical treatment has failed or
complications have set in.
• If cholesteatoma is found, the
posterior canal wall may be removed
and the procedure converted to a
modified radical mastoidectomy .
• A cortical mastoidectomy can also be used as treatment for CSOM
when there is no cholesteatoma, to clear granulation tissue from the
mastoid air cells and the antrum .
• A myringoplasty is performed at the same time, if indicated.
• Occasionally a cortical mastoidectomy is performed for severe glue
ear.
Procedure
• A postaural incision is made at least 1 cm behind the skin fold down
to the periosteum , which is elevated to expose the whole of the
mastoid, including the tip.
• A high-speed drill is used to remove the outer cortex of the mastoid
bone and then all air cells, leaving cortical bone over the sigmoid
sinus and middle fossa dura.
• The posterior canal wall is left intact and the middle-ear contents are
not disturbed.
Modified radical mastoidectomy
• The routine procedure for cholesteatoma is a modified radical
mastoidectomy.
• This is an operation to remove all middle-ear and mastoid
disease, exteriorizing both into a common cavity .
• Disease-free remnants of the tympanic membrane and ossicular
chain are preserved.
• If all the TM, the malleus and incus are removed, the procedure is
termed a ‘radical mastoidectomy’
• In a modified radical
mastoidectomy the disease is either
approached from behind or
followed back from the attic .
• When approached from behind, a
cortical mastoidectomy is
performed and the bridge of the
posterior canal wall drilled away to
continue removal of the disease
from the antrum, attic and middle
ear (atticoantrostomy).
• When followed backwards , the attic
is removed first , the middle ear
explored and then the antrum
opened and the bone removed
only as far back as the disease .
• This has the advantage that the cavity is only as big as the extent of
disease.
• Some cases require an atticotomy only.
• There are a large number of modifications in the way this operation is
performed, for instance some surgeons try to remove the canal wall
in one piece and then replace it at the end of the procedure.
• There are even more variations in the way the reconstruction is done
to minimize the chances of chronic or repeated discharge and
maximize the hearing .
• The basic reconstruction involves including the Eustachian tube
opening in a reconstructed middle ear using a fascial graft.
• The graft, usually temporalis fascia, is placed under the drum remnant
and often over the whole of the mastoid cavity.
• This appears to encourage squamous epithelium to cover the cavity
and it may allow air from the Eustachian tube to fill deep to it and
effectively reform a soft posterior canal wall and a near-normal ear
canal.
• The cavity can also be obliterated with bone dust, muscle flaps,
artificial substances, e.g. hydroxyapatite, or free muscle.
• The bony work on the cavity itself is of greater importance than the
obliteration substance.
• All air cells should be removed, the cavity edges must be well
saucerized, the mastoid tip removed as far medially as the digastric
ridge, the facial ridge lowered to the level of the inferior canal wall
and a wide meatoplasty fashioned.
• These procedures will improve the chance of a dry ear and are
especially useful in revision surgery.
• When all the cells of the mastoid
are removed, in particular those
in Trautman’s triangle, the
perifacial, the retrosigmoid, the
zygomatic root, and all
perilabyrinthine cells, the
operation is called a subtotal
petrosectomy.
• This may be combined with
Eustachian tube obliteration,
closure of the external auditory
meatus and filling the cavity with
free abdominal fat graft in
particularly difficult ears.
Hearing reconstruction
• The reconstruction of hearing is dealt with elsewhere, but has to be
considered at the same time as the primary surgery even if the
tympanoplasty is done as a second stage.
• Most British surgeons prefer to accept a type III tympanoplasty with
the new eardrum in direct contact with the head of the stapes if it is
present.
• This gives a 5–25 dB conductive loss but profers long-term stability.
• This type III can be encouraged if the posterior annulus is medialized
when lowering the facial ridge so that the head of the stapes is
relatively more prominent.
• It is also useful if an edge of bone is formed for the new tympanic
membrane to take off from.
• If the stapes superstructure is not present, the hearing reconstruction
is best left to a second stage.
• Many patients opt for no further surgery or a hearing aid if given the
choice.
• If a second stage is performed, a deep middle ear is helpful and this
should be encouraged at the first stage by leaving a lateral annulus.
• At the second stage a piece of bone or an artificial total ossicular
chain prosthesis is placed between drum and footplate.
Combined approach tympanoplasty
• This operation removes disease from the mastoid and middle ear.
• A cortical mastoidectomy is extended to remove bone posteriorly
over the lateral sinus to allow an adequate angle to visualize the
middle-ear contents via a posterior tympanotomy in which the
posterior part of the middle ear is entered lateral to the mastoid
segment of the facial nerve in the angle between it and the chorda
tympani.
• This allows access to disease via the ear canal as well as via the
mastoid.
• The combined approach tympanoplasty is the main canal wall up
procedure.
• It has a high rate of recurrent cholesteatoma, but if performed
skillfully it is suitable for patients who are available for long-term
follow-up and second- and third-look surgery.
Complications of mastoidectomy
• Injury to the anatomical structures of the temporal bone is the main
danger for the patient.
• The facial nerve is always at risk and damage to it is the most obvious
disaster that can occur.
• The dura and lateral sinus are also at risk, as is the otic capsule.
• Great care is necessary when removing disease from the lateral
semicircular canal as a fistula can be opened and the resulting loss of
perilymph may lead to a dead ear .
• Indeed it may be better to leave disease in situ on such occasions.
• The middle-ear part of a mastoidectomy needs equal care to avoid
damage to undiseased ossicles.
• Prior to mastoid surgery each patient should be warned about the
risk to the VIIth cranial nerve , the risk of deterioration in hearing , the
possibility of a dead ear and a chance of postoperative vertigo .
• It is important to document this discussion in the case notes.
Thank You