You are on page 1of 19

Otolaryngol Clin N Am

39 (2006) 1095–1113

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 first 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 reflect on the current status and indications of the
procedure as well as common complications.

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 first trephination procedure of
the mastoid. The subsequent 200 years did not produce many significant 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 effective for draining acute
infections; however, it did little to treat chronic infections of the ear. In
1890, Zaufal [2] described the first 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: (M. Bennett).

0030-6665/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
1096 BENNETT et al

The introduction of the Zeiss otologic operating scope in 1953 made precise
dissection possible. Soon thereafter, Wullstein described the first 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.

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’s and patient’s 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]:
 History of profuse otorrhea
 Previous tympanoplasty failure
 Secondary acquired cholesteatoma
 Tympanic 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

Simple mastoidectomy
A simple or cortical mastoidectomy involves removing the mastoid cortex
and some of the underlying air cells. Dissection may be superficial 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 affords
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

with canal wall down procedures. This approach can be combined with a fa-
cial recess dissection for:
 Removal of disease in the recess
 Better exposure of the posterior mesotympanum around the oval and
round windows
 Better visualization of the tympanic segment of the facial nerve
 Better 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.

Modified radical mastoidectomy

Although the classic description of a modified 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 modified 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
fistula 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
1098 BENNETT et al

pate, vascularized flaps, or abdominal fat. It is used in advanced cases in

which the ear continues to drain despite multiple prior attempts at canal
wall down surgery. Obliteration may also be indicated in cases of chronic
suppurative otitis media in which there is extensive dural dehiscence with
or without cerebrospinal fluid leakage.

Canal wall up versus down

The controversy over canal wall up versus down surgery has been on-
going for nearly half a century. Although there are multiple indications
to remove the canal wall, the decision is usually individualized. Most sur-
geons prefer to avoid a cavity if possible. The primary advantage of a ca-
nal wall down procedure is increased visibility and access to the
mesotympanum and epitympanum, which allows disease resection and re-
construction to be accomplished in a single stage. This increased exposure
accounts for reduced rates of recurrences versus intact canal wall proce-
dures [9]. However, postoperative care is more intense in the canal wall
down surgery both in the immediate postoperative period and long-
term. Serial debridements of the cavity and frequently antibiotic drop
irrigation are often required. In contrast, the intact canal wall mastoidec-
tomy maintains the natural anatomy and heals more quickly than the
modified radical mastoidectomy. Canal wall intact procedures do not re-
quire regular debridements, and hearing outcomes tend to be slightly im-
proved over canal wall down procedures [10]. However, poorer
intraoperative exposure and the recreation of a middle ear space increase
the potential for recurrent or residual disease after intact canal wall

Preoperative evaluation
Preoperative planning includes a comprehensive head and neck exami-
nation with an otomicroscopic examination. Active infections are treated
aggressively with topical antibiotic drops before surgery. Bilateral full au-
diometric evaluation is performed in all cases. Although computed tomog-
raphy scans can help delineate the bony anatomy of the temporal bone,
this evaluation is not necessary in most patients. They are especially useful
in revision surgery and in patients with symptoms consistent with a labyrin-
thine fistula. All patients should be encouraged to stop smoking because it
increases recurrence rates over nonsmokers [9]. Sinonasal disease is treated
aggressively. Adult patients with significant symptoms are tested and
treated for seasonal allergies. In children, preoperative adenoid assessment
may be necessary and when appropriate, adenoidectomy should be per-
formed 1 month before ear surgery.

Anesthesia is given without paralytic agents. Facial nerve bipolar elec-
trodes are placed into the orbicularis oculi and oris muscles for monitoring
of the facial nerve throughout the case. The tragus and the area just behind
the postauricular sulcus are injected with 2% lidocaine with 1:100,000 epi-
nephrine about 10 minutes before the start of the case to allow proper he-
mostasis. The periauricular hair is cleansed with a hibiclens shampoo and
the patient’s ear is prepped and draped in the usual sterile fashion. Antibi-
otics are routinely given preoperatively to reduce infection risks [11]. Ste-
roids are also often used to reduce postoperative nausea.

Surgical incisions
Canal incisions
Each case starts with a detailed examination of the tympanic membrane.
With the exception of cochlear implantation, temporal bone resection, and
skull base procedures, transcanal injection of the posterior ear canal with
2% lidocaine and 1:50,000 epinephrine is performed. The ear is copiously
irrigated with saline solution impregnated with antibiotic and desquamated
debris in the external auditory canal is removed. Fig. 1 shows the vascular
strip incisions. A radial incision is made in the tympanomastoid and then
tympanosquamous suture lines. The dependent or inferior cut is always per-
formed first to avoid blood obscuring future incisions. These incisions are
then connected by a medial incision approximately 1 to 2 mm lateral to
the annulus. Just medial to the bony-cartilaginous junction, a radial incision
is made from the tympanomastoid suture line to the inferior aspect of the
external auditory canal.

Fig. 1. Vascular strip incisions. (A) tympanomastoid suture line, (B) tympanosquamous suture
line, (C) medial incision, (D) radial incision.
1100 BENNETT et al

Mastoid incisions
The standard postauricular incision and the endaural incision are the two
basic incisions for access to the mastoid.

Postauricular incision
A postauricular incision as shown in Fig. 2 is the method most widely used
to gain access to the mastoid. The incision spans from the helical rim to the
mastoid tip and is well hidden in the postauricular region. It rarely causes any
visible scarring. The incision should be about 1 cm behind the postauricular
crease to avoid unsightly deepening of the sulcus, which can occur when in-
cisions are placed directly in the crease. The incision is more posterior in
young children to avoid a superficial facial nerve near the mastoid tip.
The incision is made through the skin with a scalpel. An avascular plane
is elevated anteriorly toward the external auditory canal just below the sub-
dermal fat, leaving a layer of loose areolar tissue on the temporalis fascia.
This plane is developed down to the mastoid tip. The attachments of the
sternocleidomastoid muscle can be separated from the mastoid tip for in-
creased exposure during skull base cases, but usually these attachments
are left intact to reduce postoperative discomfort.
A self retaining retractor is spread over the temporalis muscle. As shown in
Fig. 3, a large graft is harvested with a scalpel and scissors. This tissue often is
scarce in revision surgery and if not present, a true temporalis fascial graft can
be harvested. For proper healing, this graft must be thinned of all muscle and
fat attachments. If the temporalis fascia is unavailable, tragal perichondrium
or periosteum medial to the temporalis muscle may be harvested for grafting.
Autologous veins or alloderm may also be used for grafting in rare cases [12].
As shown by the dashed lines in Fig. 3, ‘‘T’’ shaped incisions are then
made through the mastoid periosteum with electrocautery. The horizontal
incision is made just below the temporalis muscle in the linea temporalis.
A second incision is made perpendicular to the first in the middle of the

Fig. 2. Postauricular incision.


Fig. 3. Fascial graft harvest and periosteal incisions.

mastoid extending from the temporalis muscle to the mastoid tip. A Lem-
pert elevator is then used to elevate the periosteum posteriorly over the sig-
moid sinus, superiorly over the tegmen, and anteriorly to the suprameatal
spine of Henle where the vascular strip is identified and reflected laterally.
Two self retaining retractors are then placed in orthogonal directions as
shown in Fig. 4. In revision surgery, careful palpation of the underlying
bone will often identify a potentially unprotected sigmoid sinus or dura.
The incision is also modified to a ‘‘C’’ shaped incision at the posterior aspect
of the previously dissected mastoid cavity. In younger children, elevation in-
ferior to the external auditory canal can potentially injure a lateralized facial
nerve near the stylomastoid foramen.

Lempert incision
Endaural incisions have been used for more than 100 years. Lempert pop-
ularized this approach in the mid 1930s. An incision is made down to the

Fig. 4. Mastoid surface anatomy.

1102 BENNETT et al

mastoid bone in the lateral external auditory canal between the tragus and
the helical crus. Because exposure can only be obtained of the anterior su-
perior part of the mastoid, these incisions have fallen out of favor for mas-
toidectomies; however, some surgeons continue to use these incisions to
facilitate exposure of the middle ear in transcanal surgery.

All drilling is done under the microscope with binocular vision. Constant
irrigation is critical to prevent thermal damage from the drill bits. A variety
of surgical drills exist for mastoidectomy, but a high-speed, comfortable,
and reliable drill system is crucial. In the past, air-powered systems were
the norm, but recently the development of high-speed electrical systems offer
easier setup, efficiency, and less noise than the air powered systems.
A variety of burs exist, ranging from those that aggressively remove bone
to those used for fine polishing of structures like the facial nerve. Larger bits
are always preferred as they offer better control and easier removal of bone;
however, drill bits should not be so large as to obstruct visualization during
the dissection. Initially, cutting burs are used to removed bone and identify
important landmarks. Diamond burrs are then used for more delicate pro-
cedures like removing the last layer of bone over sigmoid sinus or facial
nerve. As dissection continues, smaller burrs will be required as space
becomes limited. Periodic irrigation of the surgical field with saline solution
reduces bleeding and washes squamous debris from wound.

Surface anatomy
An understanding of the temporal bone anatomy is important to avoid
injuring vital structures. The surface landmarks of the mastoid bone shown
in Fig. 4 not only define the boundaries of the mastoid bone, but approxi-
mate important deep structures. The spine of Henle is the anterior extent
of dissection. This protuberance extends superficially from the posterior su-
perior bony ear canal and approximates the location of the underlying mas-
toid antrum. Superiorly, the linea temporalis, the inferior border of the
temporalis muscle, approximates the lowest level of the tegmen or floor of
the middle fossa. The mastoid tip is the inferior limit of dissection.

Complete mastoidectomy
The key to a safe dissection is identifying key structures. Identifying the
tegmen, external auditory canal, sigmoid sinus, middle ear ossicles, and
facial nerve is the easiest and safest way to ensure their preservation.
As indicated by Fig. 5, dissection starts high in the mastoid cortex, re-
moving bone along the linea temporalis until a thin layer of tegmen bone

Fig. 5. Drill cuts used in start of mastoidectomy. (A) Thin layer of tegmen bone is left over the
middle fossa dura, remembering that tegmen height is variable depending on mastoid pneuma-
tization. Cut (B) perpendicular to the first and tangential to the external auditory canal is made
from the zygomatic root to the mastoid tip. Cut (C) is made from the mastoid tip to the
sinodural angle.

is left over the middle fossa dura, remembering that tegmen height is vari-
able depending on mastoid pneumatization. Next, a cut perpendicular to
the first and tangential to the external auditory canal is made from the zy-
gomatic root to the mastoid tip. Finally, a cut is made from the mastoid tip
to the sinodural angle. Dissection is continued along these three planes, sau-
cerizing the lateral surface of the temporal bone from the middle fossa teg-
men to the mastoid tip and from the ear canal to the sigmoid, keeping the
deepest part of the dissection in the anterior superior mastoid directly
over the mastoid antrum. There is no attempt to keep the mastoid small.
The next structure visualized deep in the mastoid cavity is Körner’s septum,
the remnant of the petrosquamous suture line. Once through Körner’s sep-
tum, the lateral semicircular canal is visible on the medial side of the antrum
as shown in Fig. 6. The otic capsule bone is easily distinguished from the
mastoid air cells by its smooth glistening appearance.
For proper exposure, it is critical at this point to thin the posterior exter-
nal auditory canal. The lateral external auditory canal is thinned from be-
hind to the base of the spine of Henle. This thickness is carried medially
to the level of the mastoid antrum. The superior external auditory canal is
thinned similarly, and the bone between the middle fossa tegmen and supe-
rior ear canal is removed to open the zygomatic root. As dissection is con-
tinued medially, the epitympanum is opened widely and both the incus and
malleus are visualized. Air cells lateral to the labyrinth are exenterated down
the mastoid tip where the digastric ridge is identified. At the completion of
the procedure, the middle and posterior fossa plates, sigmoid sinus, poste-
rior external auditory canal, and bony labyrinth are all skeletonized.
For endolymphatic sac procedures, the sigmoid sinus is decompressed
and the jugular bulb identified. The labyrinth is skeletonized, and the
1104 BENNETT et al

Fig. 6. Complete mastoidectomy in cholesteatoma dissection. Asterisk indicates lateral semicir-

cular canal.

dura between Donaldson’s line, a line drawn as the posterior extension of

the lateral semicircular canal, and the jugular bulb is exposed. The endolym-
phatic sac and duct are identified and decompressed carefully or opened
over the underlying dura.
At the completion of the procedure, the mastoid periosteum is reapproxi-
mated with several interrupted 3-0 Vicryl sutures, and the skin is closed with
interrupted subcuticular 4-0 Vicryl sutures. The wound is then covered with
a piece of telfa, several 4  4s, and a Glasscock dressing. The mastoid defect
rarely causes any aesthetic concerns, but recently surgeons have attempted
to reconstruct the mastoid cortex with titanium mesh [13].

Facial recess or posterior tympanotomy

As seen in Fig. 7, the facial recess is an inverted triangle bounded poste-
riomedially by the facial nerve, anterolaterally by the chorda tympani nerve,
and superiorly by the incus buttress. The first step in safely performing a fa-
cial recess is to ensure that the posterior external auditory canal is thinned
appropriately at the end of a complete mastoidectomy. The next step is iden-
tification of the facial nerve using previously found landmarks including the
lateral semicircular canal, short process of the incus, and digastric ridge. The
facial nerve is always found inferomedial to the lateral semicircular canal.
As shown in Fig. 7, a line drawn as the extension of the short process of
the incus approximates the facial recess.
Using a large diamond burr and copious amounts of irrigation, the facial
nerve is identified throughout its entire mastoid course, from the second
genu just inferior to the lateral semicircular canal to the stylomastoid fora-
men. Using strokes parallel to the direction of the nerve, the nerve is traced
out, leaving a thin layer of the fallopian canal bone intact over the nerve.

Fig. 7. Facial recess. (dashed line) Short process of the incus helps identify the facial recess.

The surgeon must be wary of a lack of bony covering, or dehiscent, facial

nerve in the mastoid. Invariably, there are several small vessels around
the facial nerve that bleed during dissection near the nerve that usually
can be controlled by the diamond burr or bipolar cautery. Next, the chorda
tympani nerve is identified as the anterior branch of the facial nerve 4 to 5
mm proximal to the stylomastoid foramen. Dissection proceeds between the
medial facial nerve and lateral chorda tympani nerve superiorly where the
recess is the widest until the middle ear is entered. A short bridge of bone,
the incus buttress, is left in the superior part of the facial recess to protect
the incus from the drill and maintain the support for the incus.

Extended facial recess

The facial recess can be extended after a complete mastoidectomy with
a facial recess both inferiorly and superiorly. Superiorly, the incus buttress
can be removed with a small diamond burr. After removal of the incus
and head of the malleus, the entire epitympanum can be accessed. Dissection
can proceed anteriorly to the temporomandibular joint.
Inferiorly, an extended facial recess can expose the entire hypotympanum
as shown in Fig. 8. The chorda tympani nerve is skeletonized and sacrificed
sharply to avoid retrograde trauma to the facial nerve. As shown in Fig. 8,
dissection proceeds between the facial nerve and the tympanic membrane
annulus as far anteriorly as the parotid fascia. Identification of the jugular
bulb in this approach often helps avoid inadvertent injury.

Modified radical mastoidectomy

The goal in creating a modified radical mastoidectomy is to create
a smooth, self-cleaning cavity with no corners, edges, or depressions in
1106 BENNETT et al

Fig. 8. Inferior extended facial recess. Asterisks indicate sacrificed chorda tympani nerves.

which debris can accumulate. As shown in Fig. 9, the keys to the procedure
include [7]:
 Aggressive saucerization of the mastoid
 Eliminating irregularities or overhangs in the bone
 Removing the posterior bony external auditory canal down to the level
of the facial nerve
 Creating a large meatus
The modified radical mastoidectomy procedure starts after a complete
mastoidectomy and identification of the mastoid segment of the facial nerve.
The incudostapedial joint is separated, and both the incus and malleus are
removed. The external auditory canal is then removed completely to the
level of the fallopian canal, first with a large cutting burr and later with a di-
amond burr. If the air cells in the mastoid tip are diseased, they are com-
pletely exenterated to avoid dependent tip infections. If the mastoid is

Fig. 9. Modified radical mastoidectomy. Asterisk indicates low facial ridge. Arrowheads
indicate smooth junction of ear canal plus mastoid cavity.

well aerated, it is often helpful to reduce the size of the cavity by removing
the lateral aspect of the mastoid tip, allowing the soft tissue to ‘‘cave in’’ and
auto-obliterate some of the cavity. As shown by the arrowheads in Fig. 9,
both the floor and roof of the medial ear canal are then drilled flush to
the anterior ear canal. This creates a smooth transition between the ear ca-
nal and tegmen superiorly and mastoid tip inferiorly. Care must be used in-
feriorly to avoid injury to a high jugular bulb in the hypotympanum. The
ossicular chain may be reconstructed and a large fascial graft is used to rec-
reate the tympanic membrane.
A large meatoplasty is necessary for epithelialization of the cavity and
easier postoperative care. A postauricular approach is used to remove
nearly 30% to 40% of the conchal cartilage as shown by the trapezoidal
wedge of cartilage between lines A and B in Fig. 10. This allows posterior
reflection of the Körner’s flap without deforming the auricle. Electrocautery
is used to divide the subcutaneous tissues of the auricle in a half-moon
shape until the conchal cartilage is encountered. The cartilage is then ex-
posed medially to about the bony cartilaginous junction. A curvilinear in-
cision is made through the cartilage as shown in Fig. 11. Retrograde
elevation of the deep perichondrium with a freer elevator is then performed,
and a crescent-shaped wedge of cartilage is removed. A small portion of the

Fig. 10. Meatoplasty. (A) Superior canal cut. (B) Inferior canal cut. Dashed line indicates area
of cartilage removed. The lower image shows Koerner’s flap reflected posteriorly.
1108 BENNETT et al

Fig. 11. Conchal incisions.

cartilage is cut to the appropriate size and thinned for use in the ossicular
chain reconstruction.
A shown by the dashed lines in Fig. 10, meatal incisions A and B are
then made to enlarge the opening of the external auditory canal. A 15
blade is placed in the ear canal and under direct vision an incision is
made through skin and subcutaneous tissue at 12 o’clock in the external
auditory canal. As shown by line A, this incision is made from the bony
cartilaginous junction to the incisura notch. An incision is made in the in-
ferior aspect of the ear canal as depicted by line B. These incisions are
made through the skin and subcutaneous tissues in continuity with the
postauricular Koerner’s flap. As shown in Fig. 12, three subdermal sutures
are placed between the Koerner’s flap and periosteum to reflect the Koern-
er’s flap posteriorly. Tension in the sutures is adjusted to optimize the con-
figuration of the meatus. Generally, the meatus initially should be made
about the size of the mastoid cavity because it will undergo about 25%
contraction over time. A good approximation of this size is the surgeon’s
The postauricular skin is then closed using several interrupted subcuticu-
lar 4-0 Vicryl sutures. The mastoid and meatus are then filled with bactro-
ban ointment. The wound is then covered with a telfa, several 4  4s and
a Glasscock dressing or formal mastoid wrap.

Radical mastoidectomy
The radical mastoidectomy is an operation performed to eliminate all
middle ear and mastoid disease through complete removal of mucosa, tym-
panic membrane, annulus, malleus, and incus. Dissection is performed in
a fashion similar to the modified radical mastoidectomy, but there is no

Fig. 12. Koerner’s flap. Suture tension can be varied to optimize meatus.

attempt at reconstruction or tympanic membrane grafting. In addition, the

eustachian tube is occluded with a fascial plug.

Alternative procedures
Recently, several alternative procedures to the standard mastoidectomy
have been described. Dornhoffer [9] has described an intact canal wall mas-
toidectomy in which removal of the posterior superior external auditory ca-
nal provides better epitympanic exposure. It also allows for dissection of
cholesteatoma sacs in continuity without the obstruction of the ear canal.
The canal defect is then reconstructed with conchal cartilage to maintain
the natural barrier between the external auditory canal and mastoid cavity.
The cartilage appears to remain stable over time, and there is a low rate of
postoperative complications or recurrences.
A recent variation of the modified radical mastoidectomy has been pro-
posed recently by Gantz and Hansen [14] in which the posterior ear canal is
removed en bloc. This creates exposure for cholesteatoma dissection similar
to a canal wall down mastoidectomy. Once dissection is complete, the poste-
rior external auditory canal is replaced, and several large bone chips are used
to seal off the epitympanum. The mastoid cavity is then obliterated with bone
pate, obviating the need for serial mastoid cavity care. Patients require hospi-
talization for at least 2 days of intravenous antibiotics postoperatively [14].

Cholesteatoma dissection
For the sake of simplicity, this article will not address cholesteatoma dis-
section in the middle ear. However, cholesteatoma sacs often extend into the
1110 BENNETT et al

mastoid air cells. Before dissection, bone is removed circumferentially

around the cholesteatoma sac avoiding direct contact with the sac. Once
fully exposed, the cholesteatoma sac is opened and the squamous debris re-
moved to facilitate dissection.
Because labyrinthine fistulas are difficult to assess preoperatively, careful
examination of medial surface of the cholesteatoma sac is performed, look-
ing for flattening of the lateral semicircular canal or defects in the medial
wall of the cholesteatoma, which may indicate an underlying fistula. Areas
of suspected fistula can also be palpated carefully with blunt instruments.
Leaving a small matrix on the fistula preserves labyrinthine function in
93% of patients as opposed to only 80% if the matrix is removed [15]. If
less than 2 mm of matrix is left, a canal wall intact procedure can be per-
formed if a second stage is planned. A canal wall down procedure should
be performed if a large cholesteatoma matrix is left in the mastoid [16].

Postoperative care
Both immediate and long-term care are important in the mastoidectomy
patient. Both nausea and pain are treated aggressively to make the patient
comfortable. Facial nerve function is tested and recorded. Patients are dis-
charged with their dressings in place and are allowed to remove the dressing
after 24 hours. Patients are instructed to change cotton balls in their ear and
keep the postauricular incision clean. Follow-up is scheduled for 3 weeks at
which time their ears are lightly debrided and the patient is started on anti-
biotic drops. Gentian violet is often used on granulation tissue in liberal
fashion in canal wall down cavities. Water precautions are maintained for
2 months or until the ear drum is noted to be fully healed.

Facial nerve injury
Other than death, facial nerve injury is the most disturbing complication
of ear surgery. We monitor all otologic cases to aid in preservation of the
facial nerve; however, monitoring is not a substitute for the thorough
knowledge of the anatomy of the nerve. In primary surgery, surgical land-
marks are usually present and identification of the nerve is easier. In revision
surgery and congenital ears, normal landmarks may be absent, making iden-
tification of the nerve more difficult.
If nerve injury is suspected intraoperatively, identification of the nerve is
performed. It is important to remember that the injury often extends beyond
the visible injury several millimeters in both directions, and 3 to 4 mm of nerve
should be exposed both proximal and distal to the suspected site of injury us-
ing a diamond burr. Injury to the epineurium or nerve sheath usually has no

long-term consequences [17]. If less than 40% of the nerve is injured and facial
muscle contraction can be elicited with small milliamp (!0.1) stimulation of
the proximal segment of the nerve, no further treatment is necessary other
than the decompression already performed, postoperative steroids and close
follow-up. If more than 50% of the nerve is injured, superior results may be
achieved through nerve grafting [18]. This is often a difficult decision, and
a consultation from a colleague is useful in prompt evaluation of the nerve.
Primary reanastamosis through simple reapproximation in the fallopian ca-
nal or several 9-0 sutures through the epineurium should be performed if there
is enough length of nerve present. If there is a segment of nerve missing, mo-
bilization of the nerve may obtain the extra length needed for anastomosis. If
more length is still needed, a cable graft using the great auricular or sural nerve
may be used.
Immediate facial paralysis in the postoperative period also requires
prompt evaluation. Several hours may pass to ensure paresis is not the result
of overzealous use of local anesthetic at the beginning of the case. If paral-
ysis persists beyond 4 hours, prompt operative exploration of the nerve is
warranted. Postoperative care depends on intraoperative circumstances
and common sense; if the nerve was already decompressed in the operating
room, observation may be appropriate. If the operative team has gone home
and an inexperienced team is present, it may be advisable to observe the pa-
tient until the regular team is back in the morning. Referral may also be the
best option in these difficult cases depending on the experience and expertise
of the surgeon. Conservative management with steroids, antibiotics, and
antivirals is warranted in all cases of delayed facial paralysis [19].

Hearing loss
Iatrogenic hearing loss may occur after mastoid surgery. Sensorineural
hearing loss (SNHL) may be the result of removal of cholesteatoma over
labyrinthine fistulas or inadvertent contact between the drill and ossicular
chain during dissection. Labyrinthitis may also lead to SNHL as inflamma-
tory cells enter the inner ear via the round or oval windows. Drill injuries
usually result in a high-frequency sensorineural hearing loss. Conductive
hearing losses are usually observed. They can be owing to multiple etiologies
including middle ear adhesions, tympanic membrane perforation, middle
ear effusions, ossicular fixation, or failed ossicular chain reconstruction.

Postoperative infections occur in 2% to 5% of mastoidectomies. Infec-
tion may be the result of wound infection or continued chronic ear disease.
Routine prophylaxis may not necessarily reduce postoperative infection
rates [20]. Perichondritis occurs in approximately 1% of canal wall down
procedures; therefore, perioperative antibiotics are used routinely in these
procedures. Aggressive intervention with debridement and topical
1112 BENNETT et al

antibiotics will limit overall disfigurement. Infections in a mastoid with

exposed dura may predispose the patient to meningitis and brain abscesses.

Labyrinthine fistulas and injuries during mastoid surgery may alter the
vestibular responses of an ear. Chronic infection may also be a source of re-
duced vestibular function. Although unilateral loss of vestibular function
may occur, chronic disequilibrium is rare.

Intracranial injury
Exposure of dura generally is avoided but is not of consequence unless
large defects in the tegmen, dural abrasions, or cerebrospinal fluid are en-
countered. Repair is generally through layered closure with soft tissue sup-
port including muscle and fascia grafts with fibrin glue. Emergence from
anesthesia must be controlled without bucking or rises in intracranial

Like any surgery, bleeding is a potential postoperative risk. In modified
radical and radical mastoidectomies, postoperative bleeding is greater owing
to more soft tissue dissection; however, blood drains through the meatus
and there is little risk for hematoma formation. Injury to large vascular
structures like the sigmoid sinus, jugular bulb, or large emissary veins man-
dates immediate assessment. Bleeding often is controlled easily with gelfoam
and gentle pressure. Hematomas may form from uncontrolled bleeding or
more often from vessels in vasospasm during the procedure, which start
bleeding with coughing or straining in the postoperative period.

Canal defects
Small defects in the external auditory canal usually require no interven-
tion. Defects greater than 0.5 cm may be fixed with bone pate or cartilage
grafting often with overlying fascial grafts to prevent canal cholesteatoma

Further readings
Cass S. Mastoid surgery. In: Operative Otolaryngology Head and Neck Surgery. 1997.
p. 1280–98.
Glasscock ME. Surgical technique for open mastoid procedures. Laryngoscope 1982;92:1440–2.
Glasscock ME III, Haynes DS, Storper IS, et al. Surgery for chronic ear disease. In: Hughes GB,
Pensak ML, editors. Clinical otology. New York: Thieme Medical Publishers; 1996.
p. 215–32.
Haynes DS, Harley DH. Surgical management of chronic otitis media: beyond tympanostomy
tubes. Otolaryngol Clin N Am 2002;35:827–39.

Jackson CG, Glasscock ME, Nissen AJ, et al. Open mastoid procedures: contemporary
indications and surgical technique. Laryngoscope 1985;95:1037–43.
Kaylie DM, Jackson CG. Revision Chronic Ear Surgery. Otol Head Neck Surg 2006;134:443–50.
McGrew BM, Glasscock ME. Impact of mastoidectomy on simple tympanic membrane
perforation repair. Laryngoscope 2004;114:506–11.
Pillsbury HC III, Carrasco VN. Revision mastoidectomy. Arch Otolaryngol Head Neck Surg
Smyth GD, Toner JG. Mastoidectomy: the canal wall down procedure. In: Otologic surgery.
p. 226–39.
Syms MJ, Luxford WM. Management of cholesteatoma: status of the canal wall. Laryngoscope

[1] Schwartze HH, Eysell CG. Ueber die Kunstliche eroffnung des warzenfortsatzes. Arch
Ohrenheilkd 1873;7:157.
[2] Zaufal E. Technik der Trepanationdes Proc. Mastoid. Nach Kuster‘‘schen Grundsatzen.
Arch Ohrenheilkd 1893;30:291.
[3] Shambaugh GE, Glasscck ME. Surgery of the ear. Philadelphia: WB Saunders; 1980.
[4] Wullstein HL. Tympanoplasty and its results. Arch Ohren Nasen Kehlkopfheilkd 1958;171:
[5] House WF. Middle cranial fossa approach to the petrous pyramid. Report of 50 cases. Arch
Otol 1963;78:460–9.
[6] Haynes DS. Surgery for chronic ear disease. Ear Nose Throat J 2001;80:8–11.
[7] Jackson CG, Touma B. A Surgical solution for the difficult chronic ear. Am J Otol 1996;17:
[8] Sheehy JL. Mastoidectomy: the intact canal wall procedure. In: Otologic surgery. Chapter
18. 212–24.
[9] Dornhoffer J. Retrograde mastoidectomy with canal wall reconstruction: a follow-up report.
Otol Neurotol 2004;25:653–60.
[10] Dodson EE, Lambert PR. Intact canal wall matoidectomy with tympanoplasty for choles-
teatoma in children. Laryngoscope 1998;108(7):977–83.
[11] Haynes DS. Perioperative antibiotics in chronic suppurative otitis media. Ear Nose Throat J
[12] Haynes DS, Vos JD, Labadie RF. Acellular allorgraft dermal matrix for tympanoplasty.
Curr Opin Otol Head Neck Surg 2005;13(5):283–6.
[13] Kim HH, Wilson DF. Titanium mesh for functional reconstruction of the mastoid cortex
after mastoidectomy. Otol Neurotol 2006;27(1):33–6.
[14] Gantz BJ, Hansen M. Canal wall reconstruction tympanomatoidectomy with mastoid oblit-
eration. Laryngoscope 2005;115:1734–40.
[15] Palva T, Ramsay H. Treatment of labyrinthine fistula. Arch Otolaryngol Head Neck Surg
[16] Glasscock ME, Poe D. Surgical management of cholesteatoma in an only hearing ear. Otol
Head Neck Surg 1990;102:246–50.
[17] Lambert P. Mastoidectomy. In: Cummings otolaryngology head and neck surgery. 4th edi-
tion. 2005. p. 3075–86.
[18] Brackman DE. Tympanoplasty with mastoidectomy: canal wall up procedures. Am J Otol
[19] Vrabec JT. Delayed facial palsy after tympanomastoid surgery. Am J Otol 1999;20(1):26–30.
[20] Jackson CG. Antimicrobial prophylaxis in ear surgery. Laryngoscope. 1988 Oct;98(10):