MASTOIDECTOMY PPT

MASTOIDECTOMY PRESENTATION PPT

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
Mastoidectomyis 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 Petitperformed 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 diseaseby Schwartze
(cortical mastoidectomy).
1890 -Zaufaldescribed removing the superior and
posterior canal wall, tympanic membrane and
lateral ossicular chain (radical mastoidectomy).
4

5. History of Mastoidectomy......
1910 –Bondyrecognized 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 -Lempertintroduced the fenestration operation.
1950s -Zollner and Wullsteindescribed tympanoplasty
techniques.
1960s -Jansen, Sheehy, and othersextended principles
of restoring function and maintaining normal anatomy
with the introduction of theintact canal wall
mastoidectomy with facial recess approach.
5

6. FORMATION OF MASTOID BONE
•The mastoid process is absent or rudimentaryin 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-oldas the sternocleidomastoid muscle develops
and pulls on the bone. It usually finishes structural
development by 2 yearsold.
•Mastoid antrumbecomes obvious at 5 years.
•During puberty-mastoid thickness increasesand
become pneumaticand 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 embryologicallydistinct
components:
Squamous part


Tympanic part
7

8. Surgical anatomy….
8

9. Surgical anatomy…..
9

10. Surgical Anatomy....
The mastoid partis 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 antrumlie
12.5-15mm deep to the
triangle.
12

13. Surgical Anatomy....
Anterior buttressis the point
at which the posterior bony
canal wall meets the tegmen.
Posterior buttressmarks 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 bridgeIs 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 angleis an area where three
bony semicircular canal meet.
Subarcuate artery exits
Trautmann’s triangleposterior
SSC anteriorly, sigmoid sinus
posteriorly, and superior petrosal
sinus superiorly.
Contain retrolabyrinthine tractthat
leads to the petrous apex, the
endolymphatic sac, and the
vestibular aqueduct
Donaldson’s lineis 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.
•laterallyby the chorda
tympani nerve,
•mediallyby the facial
nerve,
•superiorlyby 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 arteryand subarcuate artery.
The venous drainage is frominferior and superior
petrosal veinsinto the jugular fossa of the skull base,
and then into theinternal jugularvein.
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 surgeryof 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 tubemay be placed for improved
ventilation.
22

23. Cortical mastoidectomy……
23

24. Types of mastoidectomy.....
Indications for cortical mastoidectomy.
Coalescent
Mastoiditisand
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 operationis performed to remove all
cholesteatomaand repair the tympanic membrane.
6 months later, the second operation is done to
inspect the mastoid and middle ear forresidual or
recurrent cholesteatomaand to
26

27. Types of mastoidectomy.....
Done to eradicate or exteriorizeextensive middle
ear diseaseby removing the posterior bony ear
canalto open the middle ear, mastoid, and
epitympanuminto one common cavity.
Remnants of the TM, malleus, and incus are
removedleaving 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 cholesteatomaextending down the
Eustachian tube or into the petrous apex.
Promontory cochlear fistulacaused by cholesteatoma
Chronic perilabyrinthineosteitisor cholesteatomathat
cannot be removed and must be cleaned or inspected
periodically.
Resection of temporal bone neoplasmswith periodic
monitoring.
29

30. Types of mastoidectomy....
An attempt is made to preserveor 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
Unresectabledisease
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 mediawith 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 canaland
then proceeding posteriorly, gradually removing
posterior ear canal boneand exposing disease in the
aditus and antrum until it is fully exteriorized.
Itis synonymous with modified radical
mastoidectomy but is carried out from anterior to
posteriorie. 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 graftis 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
Unresectabledisease on the facial nerve or stapes
footplate
A low-lying tegmenthat limits access to the attic
Unresectable sinus tympani disease.
Unreconstructableposterior 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 ossicularchain
MRI
Non specific in COM
Better for IC involvement
42

43. 5.SURGICAL TECHINIQUES
Preparations:
General anesthesia without
paralytic agentsand with
continuousfacial nerve monitoring.
Patient is positioned in supine
positionwith the head turned to
the contralateral sideto 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 incisionfrom 12
o’clock to 6 o’clockposition 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 muscleto 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
musculoperiostealflap 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
elevatorand 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-
retainingretractors are
placed between the skin
edges and soft tissue for
exposure.
•One self-retaining
retractoris usually
sufficient in a child.
55

56. Surgical Technique....
Drilling
56

57. Surgical Techniques......
Initial Drilling:
When the mastoid cortex
becomes fully exposed
Thefirst bur cut is made along
thetemporal line, which
approximates the level of the
middle cranial fossa duralplate
The second bur cutis made
perpendicular to thisand
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 dustfrom the field of dissection,
To prevent excessive heat transferto 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 isthe 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 antruminclude
saucerization, identification
of the tegmen plate, and
thinning of the posterior
canal wall.
Consideration should also
be made during posterior
dissection where the
sigmoid sinusis 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.
Drillingshould 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 deeperin
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, thenchange
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
segmentof 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 tympaninerve permits
additional dissection inferiorly with good exposure
of the hypotympanum.
73

74. Surgical Techniques........
Opening the Epitympanum
Smaller, diamond burs
are required in the
epitympanicdissection
Involves thinning dura
boneand the superior
canal wall.
The Cog: landmark from
tegmentowards malleus
head and separates the
epitympanuminto 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
stylomastoidforamen 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
decreasingthe 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 duraltear 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 ossicularchain, 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 labyrinthitiswith resulting
vertigo and severe sensorineuralhearing 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 cholesteatomaor 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
Schapolaet 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 TuncayUlug, MD Istanbul University Atlas of temporal bone surgery,2010
•Glasscock-Shambaugh, Surgery of the Ear, 5
th
Edition
Leliever, W C (1983), Temporal Bone Surgical Dissection Manual. Archives of
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