My MRM.pptx

Ent & head neck surgery

1. My MRM

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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.

9. 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

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

11. 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

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

13. ANATOMICAL CONSIDERATIONS

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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.

22. 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

23. 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).

24. 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

25. 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.

26. 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

27. 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.

28. 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

29. 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.

30. 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.

31. 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

32. TECHNIQUE OF MODIFIED RADICAL MASTOIDECTOMY(MRM) A lso known as complete mastoidectomy and tympanoplasty M ajor 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

33. Preoperative Assessment D ecision 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

34. 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

35. 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

36. 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

37. 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.

38. 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.

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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.

45. 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

46. 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.

47. 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.

48. 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

49. 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

50. 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

51. 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

52. 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

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

54. 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.

55. 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

56. 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

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

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

59. 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

60. 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

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

62. Facial nerve paralysis most common major complication

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

64. “ 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

65. 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

66. 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

67. 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

68. Bibliography

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