cavityobliteration3sayan-200821151929 2.pptx

Cavity obliteration

1. Discharging mastoid cavity & CAVITY OBLITERATION Dr. Sayan Hazra, Senior Resident, ENT. IPGMER

2. 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

3. IMPORTANT TERMINOLOGIES

4. 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

5. 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 )

6. FACTORS FOR DISCHARGING MASTOID CAVITY

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

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

9. 5. BIOFILM

10. 6. INADEQUATE REMOVAL OF AB & PB

11. 7. INCOMPLETE SAUCERIZATION Bony overhangs Posterior canal wall DICTUM- MORE CORTICAL BONE YOU REMOVE, SMALLER IS THE FINAL SIZE OF CAVITY

12. 8. RESIDUAL PERFORATION (RP)

13. 9. NARROW MEATUS/ IN-ADEQUATE MEATOPLASTY

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

15. SURGICAL STEPS

16. POST AURICULAR INCISION & HARVESTING TEMPORALIS FASCIA GRAFT

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

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

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

20. CIRCUMFERENTIAL SAUCERISATION

21. CIRCUMFERENTIAL SAUCERISATION

22. CIRCUMFERENTIAL SAUCERISATION

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

24. REMOVAL OF BONY CANAL

25. REMOVAL OF BRIDGE

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

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

28. LOWERING FACIAL RIDGE

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

30. REMOVAL OF POSTERIOR BUTTTRESS

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

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

33. MIDDLE EAR DISEASE CLEARANCE

34. MEATOPLASTY

35. MEATOPLASTY SMSF IMSF PF Helico-tragal extension

36. CAVITY PROBLEMS ADDRESSED High Facial Ridge Incomplete removal of PBCW Incomplete disease removal Granulations Biofilm Inadequate removal of AB & PB Incomplete Saucerization Residual perforation Narrow meatus/In-adequate meatoplasty

37. 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

38. CAVITY OBLITERATION

39. 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

40. 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:

41. 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)

42. 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

43. 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

44. 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

45. MIDDLE EAR SPACE AUGMENTATION

46. BONE  pâté Sheehy Bone pate collector Particular attention is paid to obliterate the sinodural, retrofacial, and mastoid tip areas.

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

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

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

50. OBLITIERED CAVITY FINAL LOOK

51. FREE-SKIN GRAFTING

52. Meatally based musculoperiosteal flap ( Palva flap) Inferiorly based periosteal- pericranial flap Superiorly/Anteriorly based musculoperiosteal flap Temporoparietal fascial flap (TPFF) Temporalis muscle flap LOCAL FLAPS

53. 1 . Meatally based Musculo-periosteal Flap ( Palva flap ) No Meatoplasty PCW reconstruction Trans-lab approach (CP Tumor ) Petrosectomy

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

55. 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.

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

57. FASCIAL FLAPS

58. 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-thickness skin grafts.

59. TPFF Skin/subcutaneous tissue TPFF loose areolar tissue temporalis fascia temporalis muscle.

60. 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.

61. SAGGITAL SECTION- FINAL REVIEW

62. 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

63. 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

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

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

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

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

68. 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

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

70. OCNA, Elsevier 2006, Vol 39. Issue 6. MASTOID OBLITERATION Page 1129-1142 REFERENCES VIJEYANDRA SIR VIDEOS: 1. https://www.youtube.com/watch?v=Upc1vmnW3jY&t=2681s 2. https://www.youtube.com/watch?v=Hncu-0uP_As&t=1557s

71. THANK YOU