Mastoidectomy; Types, Indications, Procedure

Mastoidectomy; Types, Indications, Procedure

1. MASTOIDECTOMY

2. History
Infections of the ear were recorded as early as 380
sc in the Hippocratic canon, and surgery of the
mastoid and petrosadeveloped as a treatment
modality for suppurativeear disease.
Riolanthe Younger described a procedure skin
to mastoidectomyin 1649, and
John Luis Petit performed the first surgical
trephination /цлиндр хөрөөгөөр/of the mastoid in
1774.

3. Petit exposed the mastoid cortex,. performed a
trephination, and then enlarged the surgically
created fistula.
procedure fell into disrepute after the
sensationaldeath of Danish physician
JohanneGust Von Berger in1792.
He died of meningitis 12 days after a
mastoidectomyperformed by Koelpinand
Callisen.

4. The first postauricularincision was introduced
in 1853 by Sir WilliumWilde of Dublin.
Fortunately,Schwartzerepopularizedthe
operation in 1873.
Sincethen, technological advancements
such as the operatingmicroscope. the high-
speed drill, and specialized microsurgical
instruments have led to significant
improvements in the treatment of mastoid
disease.

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

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

8. SUBCLASSIFICATION (M.Tos)
CANALWALL UP (CWU) CANAL WALL DOWN (CWD)
1. Simple/ cortical/ complete/
Schwartze’smastoidectomy
1. Atticotomy
2.Classic Intact Canal Wall
Mastoidectomy/ Combined
Approach Tympanoplasty(CAT)
2. Atticoantrotomy
3. RadicalMastoidectomy
4. ModifiedRadical
Mastoidectomy/ bondy’s
Procedure
5. Retrograde Mastoidectomy

9. Depending upon the mastoid cavity,
1. Open Technique
2. Closed Technique

10. ANATOMICAL
CONSIDERATIONS

11. 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 posteriorlyfrom the
zygomaticroot and is the insertion site for the
temporalismuscle.
Хөхөнцөрийн чухал таних тэмдгүүдийн нэг болох чамархайн шугам нь шанаа
ясны угнаас арагш байх бөгөөд чамархайн булчинд руу орсон байж болно.

14. The suprameatalspine of Henleis a small bony
protuberance extending superficially from the
posterior and superior bony EAC.
Posterior to the suprameatalspine, a group of small
holes is seen, described as the cribriformarea.
/suprameatalspine-н ард жижиг нүхнүүдийн бүрдэл байна


15. This cribriformarea lies within Macewen’striangle,
an imaginary triangle defined by three lines-
1. Temporal line
2. Line formed by the superior and posterior margins
of the external bony meatus/сонсголын гадна сувгийн ар дээд ирмэг /
3. Line drawn perpendicular to the first line and
tangential to the second. /эхний шугаманд перпендикуляр татаад хоёр дахь
шугамруу шүргэх төдий

18. Mastoid antrumlies around 1.25 cm to 1.5 cm deep
from the surface of Macewen’striangle./Macewen’s
гурвалжингаас 1,25-1,5 см гүнд хөхөнцөрийн хөндий оршино
Cymbaconchais the soft tissue anatomical
landmark for the mastoid antrum.

22. Citelli’sangle (Sinoduralangle)-is an angle
between the sigmoid sinus and middle fossadural
plate./сигмойд синус , гавлын дунд хотгорын хооронд /
Solid angle is an area where three bony
semicircular canals meet./ 3 тал цагирган сувгийн уулзах цэгт/
Trautmann’striangle is bounded by bony labyrinth
(solid angle) anteriorly, sigmoid sinus posteriorlyand
durasuperiorly.Дотор чихний урд ясан хана , синус сигмойдын хойд тал хатуу
хальсаар хязгаарлагдана

23. Donaldson’s line is a line passing through the
horizontal semicircular canal and bisects the
posterior semicircular canal.Тал цагирган суьгийн хөндлөн зүслэгийг 2 хувааж
түүний арийн сувгийг дайруулан татсан шугам
This line is a landmark for the endolymphaticsac.

26. APPROACHES And ROUTES
The term ‘Approach’ means the method of access
to the middle ear through the soft tissues.
eg. Endauralapproach, Retroauricular/post/
approach.
The term ‘Route’ means the method of access to
the middle ear through the bone.
eg. Transcorticalroute, TransmeatalRoute.

29. CORTICAL MASTOIDECTOMY
CORTICAL MASTOIDECTOMY ( Schwartze1873) is
a transcorticalopening of the mastoid cells and the
antrum.
It is the initial stage of any transmastoidsurgery of
the
1)middle ear 2)inner ear, 3) facial nerve,
4)endolymphaticsac, 5) labyrinth, 6) I.A.C and 7)
skull base.

32. SIMPLE MASTOIDECTOMY –This term is usually
used when mastoidectomyis done for drainage of a
mastoid abscess.

33. COMBINED APPROACH TYMPANOPLASTY (CAT)/
CLASSIC INTACT CANAL WALL MASTOIDECTOMY
CAT consists of a large mastoidectomywith an
intact but thin bony ear canal wall and a posterior
atticotympanotomy.
The intact canal wall technique is performed in two
stages.
The first operation is performed to remove all
cholesteatomaand repair the tympanic membrane.
Өргөн хэмжээний хагалгаа боловч Сувгийн ханыг гэмтээлгүй арын аттиктимпанотому хийгддэг.
Сувгийн ханийг гэмтээхгүй хийх техник нь үе шаттай явагдана. 1. бүх холестетомыг цэвэрлэн хэнгэрэг нөхнө.
2. 6 сарын дараа дахин холестетома үүссэн эсэх мөн сонсгол сайжирсан эсэхийг шалгаад сонсголын ясны нөхөн сэргээлтийг хийнэ.

34. Six months later, the second operation is performed
to inspect the mastoid and middle ear for residual or
recurrent cholesteatomaand to improve hearing by
ossicularreconstruction.

35. ATTICOANTROTOMY -is an extension of the
atticotomyin a posterior direction through the
transmeatalroute, in which lateral attic and aditus
walls are removed, and the antrumis entered.
It can be performed through the transcorticalroute,
but is usually performed through a transmeatalroute.

37. BONDY’S OPERATION –An atticoantrotomyis
called as Bondy’soperation if the tympanic cavity is
not entered.
If the tympanic cavity is entered, it is NOT described
as BONDY’S operation but as an atticoantrotomyor
conservative radical operation.

38. MODIFIED RADICAL
MASTOIDECTOMY
Classically, modified radical mastoidectomyrefers to
the Bondyprocedure, in which disease limited to the
epitympanumis simply exteriorized by removing
portions of the adjacent superior or posterior canal
wall.
Эпитимпанум шууд харагдаж байхаар Сувгийн ар болон дээд ханыг авах
A primary feature of the modified radical procedure
is complete removal of the posterior canal wall, the
major reason for failure of the Bondyprocedure.Сувгийн
ар ханыг бүрэн авах нь Bondyprocedure-г бүтэлгүй болгох гол шалтгаан болно

40. RADICAL MASTOIDECTOMY
Radical mastoidectomyis a canal wall down
mastoidectomyperformed to eradicate disease from
middle ear cleft in which mastoid cavity, tympanum
and EAC are converted into a common cavity
exteriorisedthrough the EAC, wherein the structures
of tympanic cavity (remnants of the incusand
malleus, and the drum remnant) are removed.дунд чихний
хөндийгөөс мастойд хөндий , сонсголын дотор суваг хүртэл цэвэрлэж сонсголын алх дөрөө яснуудыг авна

42. INDICATIONS

43. INDICATIONS OF CORTICAL
MASTOIDECTOMY
1)Coalescent Mastoiditisand Masked Mastoiditis.
2)Active Refractory to antibiotics.
3)Secretoryotitismedia Refractory to antibiotics.
4)Approach to:
-Endolymphaticsac surgery.
-Facial nerve decompression.
-Vestibulocochlear nerve section.
-TranslabyrinthineApproach for CP angle.
-Cochlear implant surgery.
-Combined Approach Tympanoplasty.

44. Indications For MRM
Absolute Indications (Shambaugh):
1.Unresectabledisease
2.UnreconstructablePosterior canal wall
3.Failure of first stage CWU procedure because of
poor E T function.
4.Inadequate Patient Follow up.Хангалтгүй

45. Relative Indications (Shambaugh):
1.Disease in only hearing ear or in a dead ear.
2.Medical illness
3.Severe otologicor CNS complications
4.Neoplasms
5.Poor E T function.

46. CONTRAINDICATIONS
1.Chronic otitismedia without cholesteatoma
2.Acute otitismedia with coalescent mastoiditis,
3.persistent secretoryotitismedia, or
4.Chronic allergic otitismedia.
5.Tuberculousotitismedia.

47. Indications For Radical
Mastoidectomy(shambaugh)
1. Unresectablecholesteatomaextending down the
Eustachian tube or into the petrousapex
2. Promontory cochlear fistula caused by
cholesteatoma
3. Chronic perilabyrinthineosteitisor cholesteatoma
that cannot be removed and must be cleaned or
inspected periodically
4. Resection of temporal bone neoplasmswith
periodic monitoring

49. OPERATIVE TECHNIQUES(CWU)
Preparation-
General anesthesia without paralytic agents and
with continuous facial nerve Monitoring.
Tragus and postauricularskin are injected with 1%
lidocainewith epinephrine (1: 100,000) to provide
hemostasisand local anesthesia.
“Pre-scrub" the ear and the entire side of the head,
including hair, with betadine.

50. The surgical site is
then prepped and draped in sterile fashion.

51. INCISION
The postauricularincision is made from helical
rim to mastoid tip, approximately 1 cm
posterior to the sulcus.
Care is taken to avoid making the incision in
the sulcusas this can make closure more
difficult.

53. A T-shaped incision is made in the mastoid
periosteumto expose the mastoid cortex
An incision is made along the lineatemporalis, to the
level of the underlying bone.
A second periostealincision is made perpendicular
to the lineatemporalisand is carried down to the
mastoid tip.

54. .

55. Using the Lempertelevator, the
periosteumis elevated superiorly over
the tegmen, posteriorlyover the
sigmoid sinus, and anteriorlyto the
level of the EAC meatus.

57. Two self-retaining retractors
are used perpendicular to each other to expose the
entire
mastoid and EAC

58. COMPLICATIONS
Trauma to Dura
Horizontal Semicircular Fistula
Trauma to Facial Nerve
Sigmoid Sinus and Jugular Bulb Injury.
Post operation infection

60. Thank you
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