12. 12.

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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

HISTORY
17th century Riolan the younger- 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
Wullstein described tympanoplasty

1958 - William House- intact canal wall

mastoidectomy

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

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

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

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

INVESTIGATIONS
Pure tone audiometry Degree and type of hearing loss Preoperative record Tympanometry Ossicular discontinuity X- ray mastoid Schullers view

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, vestibular symptoms, or other complication evidence exists

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- non enhancing, similar to CSF

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

TREATMENT
SURGICAL- 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, granulation polyps, and cholesteatoma Preserving as much normal anatomy as possible

Improvement of hearing is a secondary goal

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

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

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

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

CONGENITAL CHOLESTEATOMA
SURGICAL MANAGEMENT INDICATIONS OF CANAL WALL DOWN MASTOIDECTOMY *
Unreconstuctible EAC defects Labyrinthine fistula Poor health Poor compliance

* Jackson CG, Glasscock ME, Nissen AJ. Open mastoid procedures : contemporary indications and
surgical technique. Laryngoscope 1985; 95 : 1037- 43

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

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. Surgery for chronic ear disease. Ear Nose Throat J 2001 ; 80 : 8 - 11

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

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. Middle cranial fossa approach to petrous pyramid. Report of 50 cases . Arch Otol 1963 ; 78 : 460- 9 # Sheehy JL. Mastoidectomy: the intact canal wall procedure. In: Otologic surgery. Chapter 18. 212- 24

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

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- and epitympanum Reduced rate of recurrences *
Serial debridements of the cavity Intense postoperative care

J. Retrograde mastoidectomy with canal wall reconstruction : a follow up report. Otol Neurotol 2004; 25: 653- 60 # Dodson EE, Lambert PR. Intact canal wall mastoidectomy with tympanoplasty for cholesteatoma in children. Laryngoscope 1998; 108(7): 977- 83

SURGICAL MANAGEMENT
Postauricular incision 1 cm behind the postauricular crease

Temporalis fascia graft harvested

SURGICAL MANAGEMENT

SURGICAL TECHNIQUE-CORTICAL MASTOIDECTOMY

CORTICAL MASTOIDECTOMY
Keep drilling till

antrum is reached Keep walls sloping Post. EAC is thinned Bone between tegmen and sup. EAC removed for zygomatic cells Epitympanum opened to view incus and malleus On completion- Tegmen plate, sinus plate, tip cells, 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

POSTERIOR TYMPANOTOMY
Facial nerve, stapes, promontory and lateral SCC

MODIFIED RADICAL MASTOIDECTOMY

The aim of this procedure is to make a common cavity the

mastoid air cells, the antrum, 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. Once the bridge is breached use a curette to remove its anterior and posterior buttresses. 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

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

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- to create a smooth, self cleaning cavity with no

corners, edges or depressions in which debris can accumulate

* Jackson CG, Touma B. A Surgical solution for the difficult chronic ear. Am J Otol 1996 ; 17:

7- 14

RADICAL MASTOIDECTOMY
An operation performed to eliminate all middle ear and

mastoid disease through complete removal of mucosa, TM, annulus, 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

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

COMPLICATIONS
Facial nerve injury In revision surgery- difficult landmarks 03- 04 mm nerve must be exposed proximal and distal to injured area by diamond burr < 40% nerve injured, facial muscle contraction ellicired by <0.1 mAmp stimulation- No treatment >50% nerve injured- Nerve grafting Segment of nerve missing- Cable graft using great auricular or sural nerve Immediate postop paralysis- If persists beyond 04 hrs- prompt exploration

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, 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 > 0.5 cm- fixed with bone patte or cartilage grafting

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)

OSSICULOPLASTY
The incudostapedial joint and the lenticular process of the

incus are the most common sites of ossicular discontinuity. This defect can lead to an air-bone gap of up to 60 dB. Interposition of incus body as a bridge between the stapes and the mallues was the original ossicular reconstruction surgery. 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

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)

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, gold cup, and titanium clips was also developed In 1993,the total (Arial) prosthesis and the partial (Bell) prosthesis were made of Titanium In 1996, Spiggle and Theis introduced a new titanium prostheses that can be trimmed intraoperatively to the appropriate length

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

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

Reported to be up to 67% in the pediatric population

REFERENCES
Scott-Browns Otorhinolaryngology, Head and Neck Surgery.7th

ed. Ballengers Otorhinolaryngology ,Head and Neck Surgery. 17th ed. The otolaryngologic clinics of north america. Vol 22/ No 5; October 1989 The otolaryngologic clinics of north america. 39 (2006) xi Internet References

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