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PRESENTED BY Maj Avinash Sitaraman

INTRODUCTION
Keratin producing squamous epithelium in the middle ear,

mastoid or petrous apex Exhibits independent growth, replaces mucosa, resorbs bone Histologically :

INTRODUCTION
Classification  Congenital

 Acquired

Primary acquired  Metaplasia Basal layer proliferation  Eustachian tube dysfunction Retraction pockets  Secondary acquired  Migration through perforation  Repeated infections through perforation Metaplasia  Iatrogenic implantation  Penetrating or blast injuries

first trephination procedure of the mastoid 1873 .Schwartze and Eysell – Cortical mastoidectomy 1890 – Zaufal – First radical mastoidectomy Bondy – Revised the technique – leave uninvolved middle ear alone and exteriorise the epitympanum .HISTORY 17th century – Riolan the younger.

intact canal wall mastoidectomy .William House.HISTORY Wullstein – described tympanoplasty 1958 .

during aural toilet  Tinnitus – indication of a possible sensorineural component  Bleeding – from granulations or aural polyps while cleaning .‘cholesteatoma hearer’  Giddiness.CLINICAL FEATURES History of  Otorrhoea. foul smelling  Hearing loss – increases in ossicular discontinuity .scanty.possibility of labyrinthine fistula .

CLINICAL FEATURES History of Frequent ear infections as a child  Previous ear surgeries Grommet insertion  Tympanoplasty or mastoid surgery   Nasal symptoms  Suggestive of complications Headache  Swelling behind the ear  Facial weakness  Seizures  .

culture and ABST  Retraction pocket  TM Perforation  Attic erosion Otomicroscopy  Confirm otoscopy findings  Identify sac of retraction pocket .EXAMINATION Tuning fork tests  Conductive hearing loss  Mixed hearing loss Otoscopy  Swab of discharge.

EXAMINATION Functional hearing status  Conversational voice  Forced whisper Pneumatic otoscopy  Fistula test Otoneurological examination  Spontaneous or gaze evoked nystagmus  Facial nerve weakness Head and neck examination  Post auricular swelling  Neck swelling Examination of nose .

ray mastoid Schuller’s view .INVESTIGATIONS Pure tone audiometry  Degree and type of hearing loss  Preoperative record Tympanometry  Ossicular discontinuity X.

vestibular symptoms. or other complication evidence exists .INVESTIGATIONS High resolution CT Temporal bone  CT is not essential for preoperative evaluation  Should be obtained for:  Revision cases due to altered landmarks from previous surgery  Previous history of recurrent Chronic suppurative otitis media  Suspected congenital abnormalities  Cases of cholesteatoma in which sensorineural hearing loss.

INVESTIGATIONS High resolution CT Temporal bone  Erosion of scutum  Destruction of ossicular chain  Erosion of the labyrinth (fistula)  Low tegmen / tegmen defect  Facial nerve dehiscence  Petrous Apex Involvement .

INVESTIGATIONS Role of MRI  Determine between recurrence or persistent cholesteatoma vs. scar tissue or granulation tissue  Dural involvement or invasion  Subdural or epidural abscess  Facial nerve involvement  Tegmen defect / brain herniation  Sigmoid sinus thrombosis T1 weighted  Homogenous lesion hypointense to brain T2 weighted. similar to CSF .non enhancing.

INVESTIGATIONS Routine hematological and biochemistry  As a part of preoperative evaluation .

TREATMENT MEDICAL  Treat the infection  Regular aural toilet  Topical ear drops Antibiotic drops .culture and sensitivity specific  Steroid drops – to reduce inflammation   Systemic antibiotics Constitutional symptoms  In presence of complications  .

and cholesteatoma  Preserving as much normal anatomy as possible   Improvement of hearing is a secondary goal .PATIENT EVALUATION  Preoperative counseling is an absolute necessity prior to surgery  Primary objective of surgery is a safe dry ear which is accomplished by: Treating all supervening complications  Removing diseased bone. mucosa.TREATMENT SURGICAL. granulation polyps.

TREATMENT Possible adverse outcomes must be discussed  Facial paralysis  Vertigo  Further hearing loss  Tinnitus Patient should understand that long-term follow-up will be necessary and that they may need additional surgeries A written Informed consent must be obtained once preoperative counselling is done .

no ossicular or mastoid involvement ~ 14%  Stage III – ossicular involvement. no ossicular or mastoid involvement ~ 40%  Stage II – multiple quadrants.CONGENITAL CHOLESTEATOMA Potsic staging  Stage I – single quadrant. no mastoid involvement ~ 23 %  Stage IV – mastoid extension ~ 23% .

no incus or stapes erosion ~ 15%  Type 2 – mesotympanum or attic. no mastoid extension ~ 59%  Type 3 – mesotympanum. mastoid extension ~ 26% Recurrence rates  Type 1 – nil  Type 2 – 34%  Type 3 – 55% . ossicular erosion.CONGENITAL CHOLESTEATOMA Nelson staging  Type 1 – mesotympanum.

but occasionally need a canal wall down tympanomastoidectomy . .CONGENITAL CHOLESTEATOMA SURGICAL MANAGEMENT  Type 1 – Controlled by extended tympanotomy.Possible ossicular reconstruction. . .  Type 2 – Extended tympanotomy.No second-look re-operation.  Type 3 – Similar to type 2.Possibly atticotomy and canal wall up tympanomastoidectomy with or without opening of the facial recess.

Laryngoscope 1985.43 . 95 : 1037.CONGENITAL CHOLESTEATOMA SURGICAL MANAGEMENT  INDICATIONS OF CANAL WALL DOWN MASTOIDECTOMY * Unreconstuctible EAC defects  Labyrinthine fistula  Poor health  Poor compliance  * Jackson CG. Glasscock ME. Open mastoid procedures : contemporary indications and surgical technique. Nissen AJ.

attic or middle ear  Increases air containing space – better accomodation to pressure changes without TM retraction .SURGICAL MANAGEMENT Type of mastoidectomy based on :  Extent of disease  Preoperative health of the patient  Status of the opposite ear  Surgeon’s and the patient’s preference Mastiodectomy  To help eradicate disease  Gain access to antrum.

SURGICAL MANAGEMENT Mastiodectomy  INDICATIONS* Absolute  Cholesteatomas  Tumours with extension into mastoid  Relative  History of profuse otorrhoea  Previous tympanoplasty failure  Secondary acquired cholesteatoma  Tympanic membrane perforations not correctable without further exposure  * Haynes DS.11 . Surgery for chronic ear disease. Ear Nose Throat J 2001 . 80 : 8 .

SURGICAL MANAGEMENT Cortical Mastoidectomy  Removal of mastoid cortex and air cells  To unroof the mastoid cortex  To drain a coalescent mastoiditis or subperiosteal abscess .

SURGICAL MANAGEMENT Intact canal wall or Complete Mastoidectomy  Removing mastoid air cells lateral to facial nerve while preserving the posterior and superior EAC walls  Gives access to epitympanum  Maintains natural barrier between EAC and mastoid  Can be combined with facial recess dissection for : Removal of disease from facial recess  Better exposure of posterior mesotympanum around oval and round windows  Better visualisation of tympanic segment of facial nerve  Better middle ear aeration postoperatively  .

In: Otologic surgery. Mastoidectomy: the intact canal wall procedure. 78 : 460. Chapter 18. Report of 50 cases . Arch Otol 1963 .Modified Radical Mastoidectomy  A canal wall down mastoidectomy with TM grafting  Preoperative Indications* Disease in an only hearing ear  Patients with poor general health  Patients in whom follow up is problematic  After failed attempt at intact canal wall mastoidectomy  SURGICAL MANAGEMENT  Intraoperative Indications#  Unreconstructible posterior EAC defect  Labyrinthine fistula  Obstructing low lying dura limiting epitympanic access * House WF.9 # Sheehy JL.24 . Middle cranial fossa approach to petrous pyramid. 212.

SURGICAL MANAGEMENT Radical Mastoidectomy  Leaves the middle ear and mastoid air cells exteriorized as a single cavity with no attempt at reconstruction  The Eustachian tube is occluded  Malleus and Incus are removed  Indications Severe eustachian tube dysfunction  Irreversible middle ear disease  Unresectable cholesteatoma  .

Otol Neurotol 2004.SURGICAL MANAGEMENT CANAL WALL UP MASTOIDECTOMY CANAL WALL DOWN MASTOIDECTOMY Maintains natural anatomy Heals quicker Do not require regular debridements Hearing outcome better # * Dornhoffer Increased visibility and access to meso.60 # Dodson EE. Lambert PR. Retrograde mastoidectomy with canal wall reconstruction : a follow up report. 108(7): 977. 25: 653.83 .and epitympanum Reduced rate of recurrences * Serial debridements of the cavity Intense postoperative care J. Intact canal wall mastoidectomy with tympanoplasty for cholesteatoma in children. Laryngoscope 1998.

SURGICAL MANAGEMENT Postauricular incision  1 cm behind the postauricular crease Temporalis fascia graft harvested .

SURGICAL MANAGEMENT .

SURGICAL TECHNIQUE-CORTICAL MASTOIDECTOMY .

sinus plate. EAC is thinned Bone between tegmen and sup.Tegmen plate.CORTICAL MASTOIDECTOMY Keep drilling till antrum is reached Keep walls sloping Post. tip cells. EAC removed for zygomatic cells Epitympanum opened to view incus and malleus On completion. zygomatic cells. Posterior EAC. Lateral SCC .

CORTICAL MASTOIDECTOMY Remove cells between tegmen plate and sigmoid sinus to expose the sinodural angle .

CORTICAL MASTOIDECTOMY .

CORTICAL MASTOIDECTOMY .

CORTICAL MASTOIDECTOMY .

POSTERIOR TYMPANOTOMY Allows a view of middle ear from posterior aspect 2 mm wide strip drilled out between vertical part of facial nerve and bony EAC .

promontory and lateral SCC .POSTERIOR TYMPANOTOMY Facial nerve. stapes.

.  Once the bridge is breached use a curette to remove its anterior and posterior buttresses. the epitympanum and the EAC. To convert a cortical mastoidectomy to a modified radical the posterior and superior walls of the EAC have to be removed. The most medial 2-3mm of the posterosuperior EAC bridges over the incus. lateral semicircular canal and the second genu of the facial nerve. the antrum. The facial ridge is lowered medially to the level of the annulus and inferiorly to the level of the floor of the EAC.MODIFIED RADICAL MASTOIDECTOMY The aim of this procedure is to make a common cavity the mastoid air cells.

MODIFIED RADICAL MASTOIDECTOMY .

MODIFIED RADICAL MASTOIDECTOMY Amputate the head of the malleus by placing the House Dieter malleus nipper at the neck of the malleus immediately superior to the cochleariform process .

MODIFIED RADICAL MASTOIDECTOMY .

MODIFIED RADICAL MASTOIDECTOMY MEATOPLASTY .

self cleaning cavity with no corners. A Surgical solution for the difficult chronic ear. Touma B. edges or depressions in which debris can accumulate * Jackson CG. Am J Otol 1996 .14 .to create a smooth.MODIFIED RADICAL MASTOIDECTOMY Keys to the procedure *  Aggressive saucerization of mastoid  Eliminating irregularities or bony overhangs  Removing the posterior bony EAC down to the level of the facial nerve  Creating a large meatus GOAL. 17: 7.

malleus and incus Eustachian tube is occluded with a fascial plug Labyrinthine fistulas  Flattening of lateral SCC  Defects in the medial wall of cholesteatoma  Palpate suspected areas with blunt instruments  Leaving a small matrix on fistula Preserves function in 93% patients  Only in 80% patients if matrix is removed  .RADICAL MASTOIDECTOMY An operation performed to eliminate all middle ear and mastoid disease through complete removal of mucosa. TM. annulus.

POSTOPERATIVE CARE Check facial nerve function Pain relief Mastoid dressing removed after 24 hrs Follow up after 1 and 3 weeks Gentian violet may be used on granulation tissue in canal wall down cavities Water precautions maintained for 02 months or until the TM has fully healed .

Cable graft using great auricular or sural nerve  Immediate postop paralysis.No treatment  >50% nerve injured.If persists beyond 04 hrs.04 mm nerve must be exposed proximal and distal to injured area by diamond burr  < 40% nerve injured.Nerve grafting  Segment of nerve missing.1 mAmp stimulation.prompt exploration .COMPLICATIONS Facial nerve injury  In revision surgery.difficult landmarks  03. facial muscle contraction ellicired by <0.

COMPLICATIONS
Hearing loss  Sensorineural
Cholesteatoma removal over labyrinthine fistulas  Inadvertent contact between drill and ossicular chain- high frequency SNHL  Labyrinthitis

 Conductive

Middle ear adhesions  Ossicular fixation  Failed ossicular chain reconstructions

COMPLICATIONS
 Infection  Occur in 2% to 5% of mastoidectomies  Wound infection  Continued chronic ear disease  Perichondritis occurs in 1% of canal wall down mastoidectomies Vertigo  Labyrinthine fistulas and injuries during mastoid surgery

COMPLICATIONS
Intracranial injury  Exposure of dura avoided generally  Not consequential unless
Large defects in tegmen  Dural abrasions  Cerebrospinal fluid leak

 Repair

Layered closure with soft tissue support  Muscle and fascia grafts with fibrin glue

COMPLICATIONS Bleeding  Controlled with gelfoam.5 cm.fixed with bone patte or cartilage grafting . soaked cotton balls and pressure  More in radical and modified radical mastoidectomy  Immediate assessment in case of injury to Sigmoid sinus  Jugular bulb  Large emissary veins  Canal defects  Small defects in EAC.no intervention  Defects > 0.

RETROGRADE MASTOIDECTOMY Temporary removal of the upper canal wall in association with a retrograde type mastoidectomy followed by reconstruction of canal defect using cymba cartilage Autologous  Bone  Cartilage Alloplastic  Hydroxyapatite cement  Titanium Posterior tympanic membrane reconstucted by cartilage pallisade technique in approximation with canal reconstruction .

RETROGRADE MASTOIDECTOMY Indication for staged surgery is involvement of sinus tympani with uncertain removal Primary reconstruction of ossicular chain done Represents a union of two divergent approaches  Osteoplastic flap of Wullstein  Small cavity technique of Smyth Extent of canal wall removal between  Anterior malleolar spine ( 1 ‘o’ clock in rt)  Exit of chorda tympani from the bone ( 9 ‘o’ clock in rt) If more than 30% canal wall is removed. reconstruction becomes difficult .

MASTOID CAVITY OBLITERATION Free grafts  Bone chips/ bone pate  Fat  Cartilage  Fascia  Hydroxyapatite Local flaps  Meatally based musculoperiosteal flap (Palva flap)  Inferiorly based periosteal.pericranial flap  Superiorly based musculoperiosteal flap  Temporalis muscle flap  Temporoparietal fascial flap (TPFF) .

This defect can lead to an air-bone gap of up to 60 dB. Disadvantages of autograft ossiculoplasty  prolonged operative time  possible displacement or resorption  possibility of the autograft harboring microscopic cholesteatoma  poor fit if the stapes superstructure is absent . Interposition of incus body as a bridge between the stapes and the mallues was the original ossicular reconstruction surgery.OSSICULOPLASTY The incudostapedial joint and the lenticular process of the incus are the most common sites of ossicular discontinuity.

OSSICULOPLASTY Advantages of autograft ossiculoplasty :  low extrusion rate  low cost  excellent biocompatibility Irradiated homograft ossicles and cartilage were first introduced in the 1960s in an attempt to overcome some of the disadvantages of autograft implants In the late 1970s. a high-density polyethylene sponge (HDPS) that had nonreactive properties was developed The original form was a machined-tooled prosthesis (PlastiPore) .

and titanium clips was also developed In 1993.OSSICULOPLASTY A more versatile manufactured thermal-fused HDPS (Polycel) arrived later Applebaum designed a hydroxyapatite prosthesis for defects of the incus long process Kurz angular prosthesis made of a gold shaft. Spiggle and Theis introduced a new titanium prostheses that can be trimmed intraoperatively to the appropriate length . gold cup.the total (Arial) prosthesis and the partial (Bell) prosthesis were made of Titanium In 1996.

OSSICULOPLASTY .

PETROUS APEX CHOLESTEATOMA Imaging Features of Petrous Apex lesions .

PETROUS APEX CHOLESTEATOMA Suboccipital Approach Transethmoid transphenoid  Lateral rhinotomy  Maintains labyrinthine function Transpalatal transclival Middle cranial fossa Approach  Good Exposure  Severe SNHL .

6%  Residual or recurrent cholesteatoma over 5 years – 15 to 40%  Reported to be up to 67% in the pediatric population .RECIDIVISM A tendency to relapse into former behaviour Recurrent cholesteatoma  Primarily in sinus tympani. anterior epitympanum  More following canal wall up procedure  CWU vs CWD .8% vs. oval window area.

 Ballenger’s Otorhinolaryngology . 17th ed. October 1989  The otolaryngologic clinics of north america.REFERENCES  Scott-Brown’s Otorhinolaryngology.Head and Neck Surgery. Head and Neck Surgery.7th ed.  The otolaryngologic clinics of north america. Vol 22/ No 5. 39 (2006) xi  Internet References .

T H A N K Y O U .