Mastoidectomy

MASTOIDECTOMY.
  • Mastoidectomy is defined as a surgical procedure which opens up the mastoid cavity, cleans up the infected air cells, improves middle ear ventilation by widening of the aditus Two types of mastoidectomy :
1.Canal wall up procedures (cortical mastoidectomy)
  • Here disease is removed by combined approach through the meatus and mastoid but retaining the posterior bony meatus wall, thereby avoiding an open mastoid cavity.
  • For reconstruction of hearing mechanism myringoplasty or tympanoplasty can be done at the time of primary surgery or as a second stage procedure.
2.Canal wall down procedures
  • These leave the mastoid cavity open into the external auditory canal so that the diseased area is fully exteriorized.
  • The commonly used procedures are atticotomy, modified radical mastoidectomy and rarely radical mastoidectomy.
  • Modified radical mastoidectomy is the procedure of choice.
  • The indications for a canal wall down procedure would be as follows:
  1. A large cholesteatonma involving the mastoid cavity.
  2. Extensive chronic otits media
  3. Patient with chronic otitis media who has already failed a canal wall up procedure -formation of a new attic retraction pocket with disease following a previously performed 
  4. canal wall up procedure
  5. Lateral semicircular canal fistula in the only hearing ear.
  6. Intracranial complications of chronic ottitis media, due to cholesteamoma like brain abscess ,meningitis or a sigmoid sinus thrombosis from ear disease .
  7. Canal wall down is usually done is cases of Attic cholesteotoma with complications.
CORTICAL MASTOIDECTOMY
  • Cortical mastoidectomy, is also known as simple or complete mastoidectomy or Schwartz operation, 
  • Complete exenteration of all accessible mastoid air cells and converting them into single cavity.
  • Posterior meatal wall is left intact.
  • Middle ear structures are not disturbed.
Indications:
  1. Acute coalescent mastoiditis
  2. Incompletely resolved acute otitis media with reservoir sign
  3. Masked mastoiditis
  4. As an initial step to perform Endolymphatic sac surgery,
  5. Decompression facial nerve,Translabyrinthine or retrolabyrinthine procedures for acoustic neuroma.
MODIFIED RADICAL MASTOIDECTOMY
  • Posterior meatal wall and lateral attic wall is removed along with cortical mastoidectomy.
  • Incus and head of Malleus may be needed to be removed in a case of cholesteatoma.
  • Modified radical mastoidectomy is indicated in Safe CSOM,Coalescent mastoiditis,Limited mastoid pathology.
  • Treatment of choice for Perforation in pars flaccida of the tympanic membrane with cholesteatoma is Modified Radical Mastoidectomy.
RADICAL MASTOIDECTOMY
  • Facial ridge is lowered.
  • The opening of Eustachian tube is closed by curetting its mucosa and plugging the opening with tensor tympani muscle or cartilage
  • Removal of middle ear ossicles and mucosa
  • Exteriorisation of mastoid
  • Indications for radical mastoidectomy:
  • When all Cholesteatoma(especially Attico-Antral type of Cholesteatoma) cannot be safely removed, e.g., that invading eustachian tube, round window niche, perilabyrinthine or hypotympanic cells.
  • If previous attempts to eradicate chronic inflammatory disease or cholesteatoma have failed.
  • As an approach to petrous apex
  • Removal of glomus tumor
  • Carcinoma middle ear.
COMPLICATIONS OF MASTOIDECTOMY
  • Infection
  • Labrynthitis ossificans
  • Mucosalization of the middle ear
  • Facial nerve injury
  • CSF leak
  • Encephalocele.
Iatrogenic facial nerve trauma most often occurs during mastoidectomy.
  1. When injury occur to more than 50% of the neural diameter either primary reanastomosis or reconstruction using a nerve graft is done. 
  2. Other Operations where Facial Nerve may be Damaged
  3. Stapedectomy
  4. Removal of acoustic neuroma
Exam Question
  • Operation of choice for a patient having Attic cholesteatoma of ear with lateral sinus thrombophlebitis is Canal Wall Down Mastoidectomy.
  • Iatrogenic traumatic facial nerve palsy is most commonly caused du­ring Mastoidectomy.
  • Schwartz operation is Cortical Mastoidectomy.
  • Radical mastoidectomy is done for Attico-Antral Cholesteatoma.
  • Coalescent Mastoiditis is an indication for cortical mastoidectomy.
  • Incus and head of malleus,lateral attic wall ,posterior meatal wall are removed in a Modified Radical Mastoidectomy in a patient with Cholesteatoma.
  • Cholesteatoma invading eustachian tube is an indication for Radical Mastoidectomy.
  • The treatment of choice for atticoantral variety of chronic suppurative otitis media is Modified radical Mastoidectomy.
  • Treatment of choice for Perforation in pars flaccida of the tympanic membrane with cholesteatoma is Modified Radical Mastoidectomy.
  • Treatment of cholesteatoma with facial paresis in child is Immediate Mastoidectomy
  • Communication between middle ear and Eustachian tube is obliterated in Radical mastoidectomy.
  • Treatment of middle ear malignancy includes Excision of petrous part of temporal bone and Modified radical mastoidectomy.
  • Treatment of middle ear papilloma is Tympanomastoidectomy.
  • Treatment for postauricular subperiosteal abscess is Antibiotics along with drainage of abscess and cortical mastoidectomy.

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