MASTOIDECTOMY

History

 Infections of the ear were recorded as early as 380

sc in the Hippocratic canon, and surgery of the
mastoid and petrosa developed as a treatment
modality for suppurative ear disease.
 Riolan the Younger described a procedure skin
 to mastoidectomy in 1649, and
 John Luis Petit performed the first surgical
trephination /цлиндр хөрөөгөөр/ of the mastoid in
1774.
 Petit exposed the mastoid cortex,. performed a
trephination, and then enlarged the surgically
created fistula.
 procedure fell into disrepute after the
sensational death of Danish physician
Johanne Gust Von Berger in 1792.
 He died of meningitis 12 days after a
mastoidectomy performed by Koelpin and
Callisen.
 The first postauricular incision was introduced
in 1853 by Sir Willium Wilde of Dublin.
 Fortunately, Schwartze repopularized the
operation in 1873.
 Since then, technological advancements
such as the operating microscope. the high-
speed drill, and specialized microsurgical
instruments have led to significant
improvements in the treatment of mastoid
disease.
 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.
 Depending on the fact whether postero-superior
canal is removed or not,
 1. Canal Wall Up mastoidectomy
 2. Canal Wall Down mastoidectomy.
 SUBCLASSIFICATION (M.Tos)
CANAL WALL UP (CWU) CANAL WALL DOWN (CWD)

1. Simple/ cortical/ complete/ 1. Atticotomy

Schwartze’s mastoidectomy
2. Classic Intact Canal Wall 2. Atticoantrotomy
Mastoidectomy/ Combined
Approach Tympanoplasty (CAT)
3. Radical Mastoidectomy

4. Modified Radical
Mastoidectomy/ bondy’s
Procedure
5. Retrograde Mastoidectomy
 Depending upon the mastoid cavity,
 1. Open Technique
 2. Closed Technique
ANATOMICAL
CONSIDERATIONS
 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.
 Хөхөнцөрийн чухал таних тэмдгүүдийн нэг болох чамархайн шугам нь шанаа
ясны угнаас арагш байх бөгөөд чамархайн булчинд руу орсон байж болно.
 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.
/suprameatal spine-н ард жижиг нүхнүүдийн бүрдэл байна

 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 /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
 Mastoid antrum lies around 1.25 cm to 1.5 cm deep
from the surface of Macewen’s triangle. / Macewen’s
гурвалжингаас 1,25-1,5 см гүнд хөхөнцөрийн хөндий оршино

 Cymba concha is the soft tissue anatomical

landmark for the mastoid antrum.
 Citelli’s angle (Sinodural angle)- is an angle
between the sigmoid sinus and middle fossa dural
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’s triangle is bounded by bony labyrinth
(solid angle) anteriorly, sigmoid sinus posteriorly and
dura superiorly. Дотор чихний урд ясан хана , синус сигмойдын хойд тал хатуу
хальсаар хязгаарлагдана
 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 endolymphatic sac.

 APPROACHES And ROUTES

 The term ‘Approach’ means the method of access

to the middle ear through the soft tissues.
 eg. Endaural approach, Retroauricular /post/
approach.
 The term ‘Route’ means the method of access to
the middle ear through the bone.
 eg. Transcortical route, Transmeatal Route.
 CORTICAL MASTOIDECTOMY

 CORTICAL MASTOIDECTOMY (Schwartze 1873) is

a transcortical opening of the mastoid cells and the
antrum.
 It is the initial stage of any transmastoid surgery of
the
1)middle ear 2)inner ear, 3) facial nerve,
4)endolymphatic sac, 5) labyrinth, 6) I.A.C and 7)
skull base.
 SIMPLE MASTOIDECTOMY – This term is usually
used when mastoidectomy is done for drainage of a
mastoid abscess.
 COMBINED APPROACH TYMPANOPLASTY (CAT)/
CLASSIC INTACT CANAL WALL MASTOIDECTOMY

 CAT consists of a large mastoidectomy with 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
cholesteatoma and 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.
 Six months later, the second operation is performed
to inspect the mastoid and middle ear for residual or
recurrent cholesteatoma and to improve hearing by
ossicular reconstruction.
 ATTICOANTROTOMY- is an extension of the
atticotomy in a posterior direction through the
transmeatal route, in which lateral attic and aditus
walls are removed, and the antrum is entered.
 It can be performed through the transcortical route,
but is usually performed through a transmeatal route.
 BONDY’S OPERATION – An atticoantrotomy is
called as Bondy’s operation if the tympanic cavity is
not entered.
 If the tympanic cavity is entered, it is NOT described
as BONDY’S operation but as an atticoantrotomy or
conservative radical operation.
 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.
 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 Bondy procedure. Сувгийн
ар ханыг бүрэн авах нь Bondy procedure-г бүтэлгүй болгох гол шалтгаан болно
 RADICAL MASTOIDECTOMY

 Radical mastoidectomy is a canal wall down

mastoidectomy performed to eradicate disease from
middle ear cleft in which mastoid cavity, tympanum
and EAC are converted into a common cavity
exteriorised through the EAC, wherein the structures
of tympanic cavity (remnants of the incus and
malleus, and the drum remnant) are removed. дунд чихний
хөндийгөөс мастойд хөндий , сонсголын дотор суваг хүртэл цэвэрлэж сонсголын алх дөрөө яснуудыг авна
INDICATIONS
 INDICATIONS OF CORTICAL
MASTOIDECTOMY
1) Coalescent Mastoiditis and Masked Mastoiditis.
2) Active Refractory to antibiotics.
3) Secretory otitis media Refractory to antibiotics.
4) Approach to:
-Endolymphatic sac surgery.
-Facial nerve decompression.
-Vestibulo cochlear nerve section.
-Translabyrinthine Approach for CP angle.
-Cochlear implant surgery.
-Combined Approach Tympanoplasty.
 Indications For MRM

 Absolute Indications (Shambaugh):

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. Хангалтгүй
 Relative Indications (Shambaugh):
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.
 CONTRAINDICATIONS

1. 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.
 Indications For Radical
Mastoidectomy (shambaugh)
 1. Unresectable cholesteatoma extending down the
Eustachian tube or into the petrous apex
 2. Promontory cochlear fistula caused by
cholesteatoma
 3. Chronic perilabyrinthine osteitis or cholesteatoma
that cannot be removed and must be cleaned or
inspected periodically
 4. Resection of temporal bone neoplasms with
periodic monitoring
 OPERATIVE TECHNIQUES(CWU)

Preparation-
 General anesthesia without paralytic agents and

with continuous facial nerve Monitoring.

 Tragus and postauricular skin are injected with 1%
lidocaine with epinephrine (1: 100,000) to provide
hemostasis and local anesthesia.
 “Pre-scrub" the ear and the entire side of the head,
including hair, with betadine.
The surgical site is
.
then prepped and draped in sterile fashion
INCISION
 The postauricular incision 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 sulcus as this can make closure more
difficult.
 A T-shaped incision is made in the mastoid
periosteum to expose the mastoid cortex
 An incision is made along the linea temporalis, to the
level of the underlying bone.
 A second periosteal incision is made perpendicular
to the linea temporalis and is carried down to the
mastoid tip.
 .
 Using the Lempert elevator, the
periosteum is elevated superiorly over
the tegmen, posteriorly over the
sigmoid sinus, and anteriorly to the
level of the EAC meatus.
Two self-retaining retractors
are used perpendicular to each other to expose the
entire
mastoid and EAC
 COMPLICATIONS

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