SURGERY OF THE MASTOID AND PETROSA

SURGICAL TECHNIQUE: MASTOIDECTOMY

Incisions

Postauricular Incisions
-Wilde
-afford best exposure
-generally made 8-10 mm behind postauricular crease
-in infants and children under 2 ya, inferior portion placed more posteriorly to prevent injury to facial nerve
-exposure of temporalis fascia; horizontal incision created along temporal line which is inferior margin of
temporalis muscle
-mastoid emissary vein may be encountered in making incision to mastoid cortex should be occluded d/t
possibility of introducing air embolism
-periosteum elevated off mastoid cortex, exposing posterior wall of external auditory canal

Endaural Incisions
-Lempert I: -canal incision medial to bony cartilaginous junction extending along entire posterior half
of canal
-Lempert II: -superior incision extending from Lempert I incision laterally between tragus and root of
helix at meatus of ear canal
-small relaxing incision made at inferior margin of Lempert I incision to allow mobilization of posterior
skin
-endaural incision for access to mastoid have become less commonly used d/t limitations of exposure

Surface Landmarks
-temporal line:
-indicates level of floor of middle cranial
fossa
-root of zygoma:
-extends anteriorly along temporal line
-spine of Henle:
-suprameatal spine
-eminence located near the posterosuperior
wall of the EAC
-Macewen Triangle (cribriform fossa):
-depression in area just posterosuperior to
suprameatal spine with an irregular bony
surface
-the apex, the most lateral extent of
petrosquamous suture line, signifies
location of underlying mastoid antrum
-tympanomastoid suture line:
-located posteriorly in EAC, reliable
landmark for the exit of the facial nerve
-tympanosquamous suture line:
embryonic fusion plane located posteriorly and inferiorly in the EAC, divides tympanic and mastoid
portions of the temporal bone
-vascular strip:
-thickened vascular skin of superior canal between tympanosquamous and tympanomastoid suture line

F.Ling - Surgery of the Mastoid and Petrosa (1)

Simple Mastoidectomy
-used for: CLINICAL INDICATORS FOR MASTOIDECTOMY
-drainage of coalescent mastoiditis
-exposure of antrum, attic, labyrinth Indicators (one of the following)
-persistent or recurrent otorrhea
and endolymphatic sac -persistent or recurrent ear pain
-mastoid antrum generally located beneath -conductive hearing loss
point at intersection between a horizontal and -tympanic membrane perforation and/or cholesteatoma
vertical line drawn tangential to superior and -acute mastoiditis with osteitis
-neoplasm of temporal bone
posterior margins of external auditory canal -fracture of temporal bone with CSF leak
-cortex removed -facial nerve paralysis requiring decompression of facial nerve
-superior limit of dissection: temporal
line/tegmen
-Korner septum:
-bony plate lateral to actual antrum and is remnant of petrosquamous suture line
-divides mastoid air cells into medial and lateral regions
-posterior limit: sigmoid sinus
-in anterior protympanum, a projection of bone extending inferiorly from tegmen tympani, the “cog” can
obscure occult disease in anterior epitympanum and supratubal recess

Facial Recess Approach

-facial recess is an aerated extension of posterior-superior middle ear medial to tympanic annulus and
lateral to fallopian canal that may allow access to middle ear through mastoid cavity

-boundaries of facial recess:

-facial nerve
-chorda tympani
-incus buttress (near tip of short process)

-exposure will aid in complete removal of cholesteatoma involving facial recess

-excessive thinning of posterior wall may result in delayed breakdown of canal wall and recurrent
cholesteatoma

-landmarks of the facial nerve:

-cochleariform process
-facial nerve directly medial to process
-to find cochleariform process, find Jacobson’s nerve and follow it superiorly until you
reach the process
-tip short process of incus
-facial nerve lies medial and inferior
-lateral semicircular canal
-posterior semicircular canal
-chorda tympani nerve
-digastric ridge

-inferiorly, facial nerve may be encountered lateral to tympanic annulus in 65% of cases
-dehiscence of facial nerve in 55-57%
-most common area of dehiscence:
-tympanic portion, superior to oval window
-accounting over 50% of dehiscent nerves
-other areas:
-geniculate ganglion
-facial recess

F.Ling - Surgery of the Mastoid and Petrosa (2)

 -tympanic sinus
-mastoid retrofacial air cell region
-most common site of injury to facial nerve: inferior to lateral semicircular canal after second genu
-other anomalies of the facial nerve:
-bifid nerve
-course inferior to oval window

-extended facial recess approach:

-chorda tympani removed
-bone between bony annulus and tympanic membrane and fallopian canal removed inferiorly
-exposes round window and hypotympanic area

-transmission of high-frequency sound from vibration of drill bit through incus and stapes could result in
SNHL d/t transmitted acoustic energy
-regions at risk for residual disease:
-most lateral part of facial recess approach at medial part of posterior ear canal wall
-sinus tympani:
-medial and anterior to mastoid portion of fallopian canal

Open Versus Closed Techniques

Advantages Disadvantages

Canal-wall-up -physiologic tympanic membrane position -residual cholesteatoma may be occult

-deep middle ear -recurrent cholesteatoma may occur in attic
-no mastoid bowl -delayed canal breakdown
-incomplete exteriorization of facial recess
-second stage often required

Canal-wall-down -residual cholesteatoma visible on follow-up -mastoid bowl maintenance can be a lifelong problem
-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 sometimes required

Canal-Wall-Up (CWU):
-allows excellent view of facial recess and incus region while maintaining intact posterior ear canal
-may allow more physiologic ossicular reconstruction techniques with a deeper an better aerated middle ear
-increased risk of residual (20-35%) and recurrent disease (5-20%)
-most common site: mesotympanum
-increased likelihood of leaving cholesteatoma in lateral portion of facial recess
-“second-look” operation recommended at 6-12 months to reassess ear for residual disease and perform
planned reconstruction of sound-conducting system

Canal-Wall-Down (CWD):
-decreased risk of residual (2-17%) and recurrent disease (0-10%) cf CWU procedures
-equal or better hearing results reported
-lack of need for two surgeries
-indicated for advanced disease, noncompliant patients, only hearing ear

Radical mastoidectomy
-classic radical mastoidectomy:
-CWD mastoidectomy
-complete removal of TM, annulus, malleus, incus and middle ear mucosa
-eustachian tube plugged with fascia plug

F.Ling - Surgery of the Mastoid and Petrosa (3)

 -goal: establish dry open cavity devoid of secretory epithelium
-precludes reconstruction of middle ear
-rarely performed today
-indications:
-unresectable cholesteatoma secondary to extension down ET, into cochlea, or into
perilabyrinthine region
-multiple failed prior modified radical mastoidectomies

Modified Radical Mastoidectomy

-modification of radical surgery to construct a TM and ossicular chain +/- mastoid obliteration
-removal of posterior and superior external auditory canal wall
-scutum (medial portion of superior ear canal) is removed flush with anterior canal wall
-facial ridge:
-posterior and inferior portions of remaining ear canal wall
-must be removed down to level of fallopian canal to have a well-aerated dry mastoid cavity
-cortex completely surrounding mastoid should be well saucerized to a smooth contour
-mastoid tip must be removed if aerated or filled with diseased tissue
-failure to remove mastoid tip may lead to dependent pocket within mastoid defect which will
accumulate debris and harbor infection
-air cells over sigmoid sinus should be removed completely
-extensive saucerization of mastoid and removal of mastoid tip may lead to alteration in position of pinna
after closure
-lower floor of ear canal to same level as digastric ridge to create a smooth easily cleansed mastoid bowl
-most important factors in avoiding a chronic draining cavity and recurrent mastoid bowl infections are size
and shape of meatus and mastoid cavity

Mastoid Obliteration
-mastoid bowl generally needs to be cleansed q6-12 months
-*techniques to minimize potential complications after CWD:
-wide saucerization
-avoidance of dependent pocket in mastoid tip lower floor of ear canal to same level as digastric
ridge
-lowering facial ridge
-generous meatoplasty
-exteriorize sinodural angle
-further modifications:
-Palva flap:
-postauricular musculoperiosteal flap
-temporalis muscle pedicled anteriorly or temporalis fascia pedicled on superficial
temporal artery
-using bone paté and bone chips placed deep to postauricular musculoperiosteal flap

Meatoplasty
-large meatus necessary for effective postoperative care and subsequent cleansing of mastoid bowl
-facilitate epithelialization and reduction of size of mastoid bowl
-crescent of conchal cartilage removed
-most important aspects of meatoplasty are adequate resection of cartilage and positioning of posterior
canal after cartilage removal

F.Ling - Surgery of the Mastoid and Petrosa (4)

Bondy Procedure
-variation of modified radical mastoidectomy performed through either endaural or postauricular incisions
-used in cases of large attic cholesteatomas in which middle ear is functioning well
-ossicular chain and middle ear are free of disease
-posterior ear canal wall removed down to annulus superiorly and facial ridge inferiorly
-scutum removed exposing epitympanum
-cholesteatoma marsupialized and keratin content debrided
-medial wall of cholesteatoma matrix left in place over body of incus and malleus and seals middle ear
space
-if cholesteatoma seen extending around ossicles standard MRM performed
-same principles as outlined apply to mastoid saucerization and reconstruction except middle ear is not
entered

Endoscopy
-to provide visualization of facial recess and sinus tympani

ENDOLYMPHATIC SHUNT

-procedures designed to “shunt” endolymph from lumen of endolymphatic sac into extracellular space in
treatment of intractable Meniere disease
-shunts established with Silastic strips or specially manufactured valves
-exposure of endolymphatic sac attained through complete mastoidectomy
-Donaldson’s Line:
-imaginary line drawn from lateral SCC that bisects perpendicularly the posterior SCC
-region where line crosses the sigmoid sinus marks the superior edge of the
endolymphatic sac
-bone over sigmoid sinus thinned
-bone overlying dura between inferior portion of posterior SCC and sigmoid sinus removed
-endolymphatic sac located between inferior portion of posterior semicircular canal and sigmoid
sinus
-bone over this region of dura is thinned and removed, exposing endolymphatic sac
-appears as a thickened whiter area of dura
-incision made with microscalpel, exposing luminal endothelium
-shunt inserted

F.Ling - Surgery of the Mastoid and Petrosa (5)

PETROUS APICECTOMY
-suppurative processes of petrous apex cause chronic infection and sometimes deep pain, abducens
paralysis, and facial paralysis
-divided into anterior and posterior portion by a coronal plane through internal auditory canal
-anterior portion: pneumatized in 9% pts
-posterior portion: pneumatized in 30% pts
-infection or cholesteatoma spread only to pneumatized apices
-surgical approaches:
-via middle cranial fossa
-via mastoid and middle ear
-surgeon can usually follow infected tracts:
-tracts into posterior apex:
-retrofacial tract
-subarcuate tract
-tracts along sinodural angle (retrolabyrinthine approach)
-tracts into anterior apex:
-infralabyrinthine tract:
-below posterior SCC and posterior to fallopian canal
-high jugular bulb may block entry through this route
-infracochlear tract:
-below cochlea
-carotid artery identified in anterior protympanum
-tensor tympani muscle in superior protympanum removed
-triangle made up of: carotid artery, cochlea and tegmen tympani
-triangle forms a direct opening into anterior petrous apex
-glenoid fossa approach:
-glenoid fossa exposed and contents displaced anterior
-medial wall of glenoid fossa then dissected
-location of carotid artery monitored
-all bone removed between carotid artery and dura of middle cranial fossa
-complete exenteration of anterior petrous apex is impossible without labyrinthectomy, but in most cases,
drainage of infected cells is sufficient to reverse suppurative process

F.Ling - Surgery of the Mastoid and Petrosa (6)

F.Ling - Surgery of the Mastoid and Petrosa (7)
COMPLICATIONS AND EMERGENCIES
COMPLICATIONS

Facial Nerve Injury Perioperative complications

-heat generated by diamond burr may injure nerve -facial nerve injury
-SNHL
-revision surgery: sclerotic new bone can distort anatomy
-postoperative infection
-if trauma suspected: -dysgeusia
-stimulate (0.5 mA) nerve proximal and distal to site of -brain herniation
injury -CSF leakage
-if no contractions on proximal stimulation, then
Delayed complications
exposure of nerve over lateral 180 degrees performed -posterior canal breakdown
-repair: -perichondritis
-reanastomosis for severely injured or severed nerve -blue-domed cyst
-mucosalization of mastoid bowl
-cable grafting with greater auricular nerve
-stenosis of external canal
-paralysis in post-operative period
-observe for a few hours until effects of local
anaesthetic are gone
-if total paralysis persists early re-exploration indicated
-if facial palsy is delayed or paretic conservative management with steroids

Sensorineural Hearing Loss

-greatest risk to hearing is in treatment of chronic otitis media with cholesteatoma
-removal of cholesteatoma matrix from stapedial footplate or round window or over labyrinthine
fistula
-usually cholesteatoma in a vital area should be left for the second look procedure
-inadvertent contact of drill burr with ossicular chain hf SNHL

Vestibular Injury
-from trauma or subsequent infection
-results in acute vertigo with slow resolution over weeks to months
-chronic disequilibrium or vertigo may occur

Postoperative Infection
-perioperative oral antibiotics administered if infection occurs

Dysgeusia
-injury to chorda tympani

Brain Herniation
-if larger areas of dura are exposed, brain herniation into mastoid cavity and epitympanum can occur
-may result in cerebritis, meningitis and CSF leak

CSF Leak
-lacerated dura sutured and covered by fat, fascia or muscle graft to prevent CSF fistula

Bleeding
-laceration of sigmoid sinus or jugular bulb
-can be controlled by placing Gelfoam
-large lacerations secondary complications such as air embolism, sigmoid thrombosis
-early signs of air embolism:
-increases end-expiratory CO2, hypotension and abnormal cardiac sounds
-injury to carotid artery requires proximal and distal occlusion

F.Ling - Surgery of the Mastoid and Petrosa (8)