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Indications and Technique

Indications and Technique

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Indications and Technique
in Mastoidectomy
Marc Bennett, MD*, Frank Warren, MD,
David Haynes, MD
The Otology Group, Otolaryngology Head & Neck Surgery, Vanderbilt University,
300 20th Avenue North, Suite 502, Nashville, TN 37203, USA

Approximately 350 years have passed since the \ufb01rst published report of a mastoidectomy by Riolan the Younger. Many changes have occurred over the subsequent years, especially since the advent of the operating microscope 50 years ago. This report focuses on mastoid surgery as it relates to chronic ear disease as well as providing access for a variety of other sur- gical procedures. We re\ufb02ect on the current status and indications of the procedure as well as common complications.

History

Chronic and suppurative infections of the mastoid have been described as long ago as ancient Greece. However, it was not until mid 17th century when Riolan the Younger described the \ufb01rst trephination procedure of the mastoid. The subsequent 200 years did not produce many signi\ufb01cant ad- vances until Fielitz and Petit reported multiple cases of mastoid trephina- tions for acute abscesses in the late 18th century. These procedures fell out of favor for more than 100 years until Schwartze and Eysell[1] popular- ized the cortical mastoidectomy in 1873. It was e\ufb00ective for draining acute infections; however, it did little to treat chronic infections of the ear. In 1890, Zaufal[2] described the \ufb01rst radical mastoidectomy removing the superior and posterior ear canal, tympanic membrane, and ossicles in an at- tempt to eliminate infection, externalize disease, and create a dry ear. Bondy revised the technique by leaving the uninvolved middle ear alone and exte- riorizing the epitympanum[3].

* Corresponding author.
E-mail address:Marc.Bennett@vanderbilt.edu(M. Bennett).
0030-6665/06/$ - see front matter\u00d3 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2006.08.012
oto.theclinics.com
Otolaryngol Clin N Am
39 (2006) 1095\u20131113

The introduction of the Zeiss otologic operating scope in 1953 made precise dissection possible. Soon thereafter, Wullstein described the \ufb01rst attempts at reconstruction of the tympanic membrane via tympanoplasty[4]. Five years later, William House introduced intact canal wall mastoidectomy[5]. Since then, there have been multiple variations of the mastoidectomy described.

Indications

The goals of any chronic ear surgery are to create a dry, safe ear and pre- serve or restore hearing as much as possible. Although there are some abso- lute and relative indications for a mastoidectomy, the type of mastoidectomy is based on the extent of disease, preoperative health of the patient, the status of the opposite ear, and both the surgeon\u2019s and patient\u2019s preference. For chronic ear surgery, a mastoidectomy is performed to help eradicate disease and gain access to the antrum, attic, or middle ear. It also increases the air- containing space in continuity with the middle ear, allowing the middle ear to better accommodate changes in pressure without tympanic membrane re- traction. Absolute indications include cholesteatomas or tumors with exten- sion into the mastoid bone. Relative indications include[6]:

\ue000History of profuse otorrhea
\ue000Previous tympanoplasty failure
\ue000Secondary acquired cholesteatoma
\ue000Tympanic membrane perforations no correctable without the further ex-

posure provided by a mastoidectomy

Although surgeons remain divided on the utility of the mastoidectomy in primary cholesteatoma surgery and tympanic membrane perforation re- pairs, most agree to its utility in revision cases after graft failure. Generally, imaging and cholesteatoma size are not a determinate of what procedure is performed.

Simple mastoidectomy

A simple or cortical mastoidectomy involves removing the mastoid cortex and some of the underlying air cells. Dissection may be super\ufb01cial or pro- ceed to the mastoid antrum. It is used to unroof the mastoid cortex and drain a coalescent mastoiditis with subperiosteal abscess.

Intact canal wall or complete mastoidectomy

The canal wall up mastoidectomy involves removing the mastoid air cells lateral to the facial nerve and otic capsule bone while preserving the poste- rior and superior external auditory canal walls. This technique a\ufb00ords access to the epitympanum while maintaining the natural barrier between the external auditory canal and mastoid cavity. In pediatric patients, this ap- proach is preferred generally to avoid the long-term problems associated

1096
BENNETTet al
with canal wall down procedures. This approach can be combined with a fa-
cial recess dissection for:
\ue000Removal of disease in the recess
\ue000Better exposure of the posterior mesotympanum around the oval and
round windows
\ue000Better visualization of the tympanic segment of the facial nerve
\ue000Better middle ear aeration postoperatively

For increased exposure, the facial recess can be extended inferiorly or su- periorly to gain complete access to the hypotympanum and epitympanum. If cholesteatoma or tumor cannot be resected via this approach, the surgery needs to be converted to a canal wall down procedure. Occasionally, a mas- toidectomy may be used to identify and repair an injured facial nerve.

Modi\ufb01ed radical mastoidectomy

Although the classic description of a modi\ufb01ed radical mastoidectomy is the atticotomy described by Bondy, most surgeons currently use the term to describe a canal wall down mastoidectomy with tympanic membrane grafting. There are both preoperative and intraoperative indications to re- move the auditory canal. Preoperative indications for a modi\ufb01ed radical mastoidectomy include[5] (1) disease in an only hearing ear, (2) patients with poor general health making them an anesthetic risk, and (3) patients in whom follow-up is problematic.

Some surgeons advocate a canal wall down after multiple failed attempts at canal wall intact surgery[7]. The decision to remove the canal wall is made intraoperatively when one of the following is encountered[8]: (1) un- reconstructible posterior external auditory canal defect, (2) labyrinthine \ufb01stula where the matrix cannot be resected primarily, and (3) obstructing low-lying middle fossa dura limiting epitympanic access. Again, cholestea- toma size is not a determining factor.

Radical mastoidectomy

A radical mastoidectomy is performed in patients with severe eustachian tube dysfunction, irreversible middle ear disease, or unresectable cholestea- toma or tumors. The procedure leaves middle ear and mastoid air cells ex- teriorized as a single cavity with no attempt at reconstruction. The eustachian tube is occluded and both the malleus and incus are removed. Be- cause the middle ear is not reconstructed, the expectation is that surround- ing squamous epithelium will overgrow the middle ear and mastoid cavity.

Mastoid obliteration
Mastoid obliteration involves overclosing the external auditory canal in
blind sac fashion and obliterating the cavity with autologous bone, bone
1097
MASTOIDECTOMY

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