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DR. RAF Cooper Award Paper

A technique of Mastoidectomy, Cavity obliteration and Meatoplasty to minimize the problems of discharging Mastoid cavity

"Awarded Dr. RAF Cooper Award Paper in year 2000-2001"

Dr. Prahlada N.B

 

Abstract
Full Paper
Introduction
Methods
Surgical Technique
Results
Discussion
References

ABSTRACT


Objectives : To present and assess a surgical technique designed to minimize the known causes of a discharging mastoid cavity following canal wall down procedure for chronic suppurative otitis media with cholesteatoma.

Methods: In this prospective study of 68 patients in the age group of 15 to 63 years, with chronic suppurative otitis media with cholesteatoma and without complications were selected for this study. All patients underwent open mastoidectomy procedure, cavity obliteration and wide concho-meatoplasty described in detail. I have developed a new cavity obliteration and meatoplasty method using few modification of the various techniques described earlier. Various components of the three steps i.e., open mastoidectomy, meatoplasty and cavity obliteration are done with post-aural approach and are interrelated and intermingled. The advantage of this procedure are : it is easy to perform and easily reproducible and minimizes the complications of mastoidectomy, allows fast healing of the cavity, helps in improving the hearing, minimizes the postoperative cavity care.

Results: Our technique was successful in providing well epithelialized small cavity which was dry in 67 (98%) patients with dry tympanic membrane perforations in 2 (2.94%) patients. No patient required revision surgery.

Conclusions: The surgical technique presented here produces a small mastoid cavity which is well epithelialized and requiring minimal postoperative care.

FULL ARTICLE


Introduction:

Cholesteatoma remains a common otological problem. Otorrhoea following open mastoid cavity (Canal wall down) is surgeries common and is estimated to occur in 10 to 60% of patients (1-6). Various contributing factors for discharging cavity identified are inadequate surgery, residual or recurrent cholesteatoma, high facial ridge, kidney shape of a mastoid cavity, state of the tympanic membrane and the size of the meatus. Even in the ideal cavity, which is small with a low facial ridge and large meatus, 10% discharge recurrently (7). Various techniques designed to promote epithelialization have been proposed including cavity revision with or without a meatoplasty, cavity obliteration by different methods and partial or total reconstruction of the cavity. No single technique has proved superior. Considering patients preferences, financial limitations and cost effectiveness, the optimal treatment for cholesteatoma must be one operation, provided it achieves a dry safe ear. Canal wall down surgery with full cavity obliteration has become surgery of choice for all Chronic suppurative otitis media with cholesteatoma (8). Moreover, the altered acoustic behavior of the open cavity is known to cause partial extensive discrepancies of the resonance-caused sound-pressure augmentation in the frequencies of 3 and 4 kHz, which are important for speech perception. The average difference is reported to be more than 10 dB (SPL). Proved surgical techniques of cavity obliteration and meatoplasty can lead to a nearly normalized acoustic behavior of the outer ear in a statistic significant way (9). Swimming, diving, and free participation in all other aquatic sports are important additional benefits of cavity obliteration techniques (10). Even fitting a canal type hearing aid may pose difficulty in large cavities. The aim of the study was to design a technique of mastoidectomy, cavity obliteration and meatoplasty which is easy to perform, easily reproducible, provides easy access to harvest autologous cartilage graft and perform meatoplasty, associated with least number of complications, helps in early epithelialization of the cavity, reduces chances of the residual or recurrent disease and requires minimal follow-up and cavity care. This has more relevance in our Indian scenario, with majority of the patients being in low middle class or low class families, with financial constraints for revision surgeries and with poor turnout for the follow-ups.

Methods:

Patient selection Criteria: Sixty eight patients (N=68) who were screened and operated in a free treatment camp funded and organized by a non government organization, from 6th May 2000 to 20 July 2000 were included in this study in the setting of a peripheral Medical College Hospital. Only, patients aged above 15 years having chronic suppurative otitis media with cholesteatoma were included in this study. Children below 15 years were not included as the pediatric cholesteatoma is known to be more aggressive with high residual and recurrent rate requiring revision surgeries. Patients with disease extension beyond the confines of the mastoid, patients with complications of Chronic Suppurative Otitis Media and patients with threatened complication were not included in this study.

All patients underwent routine clinical examination, otomicroscopy, haematological and radiological investigations. Modified radical mastoidectomy, cavity obliteration and wide concho-meatoplasty by the technique described in detail below was done in all patients. Either general anaesthesia or local anaesthesia was used depending on the patients choice, compliance and cooperation. However, it is my routine practice to give local anaesthesia infiltration even to the patients who are undergoing surgery under general anaesthesia for personal reasons.

 

Surgical Technique :



Step I : Endaural incisions and elevation of Modified Korner's flap:


First endaural incision is made starting from at 12 'o' clock position on the superior meatal wall, 5 mm away from the annulus, extending in the same horizontal plane over the posterior meatal wall and then to inferior meatal wall up to 6 'o' clock position (Fig. 1) (Fig. 2) . Second endaural vertical incision is made beginning again at the 12 'o' clock position on the superior meatal wall where the first incision began. The second incision extends to the point between the root of the helix and the upper border of the tragus (Fig. 2) (Fig. 3) . No third incision is made. The incisions are deepened to the periosteum and posterior canal wall flap or Conchal flap (0r Modified Palva's flap) is raised outwards using a canal knife (Fig. 4) . The inner flap (endomeatal flap) is not disturbed at this moment.

pic1

Fig. 1: (R) Ear for Orientation. Note 12 o Clock and 6 o clock positions.

pic2

Fig. 2: Showing end-aural incisions. A: Lempert's end-aural incisions Part II, B: Lempert's end-aural incsion Part I, Postero-superior retraction pocket with cholesteatoma, D: Handle of the Malleus and E: Tympanic membrane.

pic3

Fig. 3: Endaural incisions: Lempert's end-aural incisions. A: Part II Incision and B: Part I incsion.

pic4

Fig. 4: Showing elevation of Posterior canal wall flap or Conchal flap (or Modified Palva's flap).

 

Step II : Post-aural sulcus incision and harvesting of temporalis fascia graft:


A post-auricular sulcus incision with 1 centimeter superior extension is made (Fig. 5) (Fig. 6) . The ear is elevated forward, exposing the areolar tissue superficial to temporalis fascia, temporalis muscle and post-auricular muscles. The post-aural skin is undermined using a sharp tissue dissecting scissors (Fig. 7) . Temporalis fascia graft of 1 x 1.5 inches measurement is harvested, allowed for drying (Fig. 8) .

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Fig. 5: Post-auricular sulcus incision with 1 centimeter superior extension is being made.

pic6

Fig. 6: Axial Section: Post-auricular sulcus incision with 1 centimeter superior extension is being made. A: Mastoid air cells, C: Pinna Cartilage, D: Incision site in Post aural groove, E: Perichondrium (Blue color), F: Facial nerve, F: Handle of the Malleus, and H: Tragus.

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Fig. 7: Post-aural skin is being undermined using a sharp dissection scissors.

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Fig. 8: Large temporalis fascia graft being harvested.

 

Step III : C onchal perichondrial incision and elevation of the post-aural perichondrial flap:


Soft tissue and Perichondrium over the conchal cartilage is incised close to the earlier skin incision all along (Fig. 9) (Fig.10) . The conchal perichondrium is elevated using a periosteal elevator. Once the medial edge of the conchal cartilage is reached, a No.15 knife or sharp tissue dissecting scissors is used to elevate the soft tissue flap over skin of the external auditory canal as a continuity to the conchal perichondrium, until the bony meatal wall is reached (Fig. 11) (Fig. 12) . Care is taken not to injure the skin of the meatal wall.

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Fig.9: Conchal Perichondriumon on the posterior surface of the pinna is being incised along the anti-helical line.

pic10

Fig.10: Axial section of the pinna showing: Conchal Perichondriumon on the posterior surface of the pinna being incised.

pic11

Fig. 11: The conchal perichondrium on the posterior surface of the pinna is being elevated using a periosteal elevator.

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Fig.12: Axial section of the pinna showing: Conchal Perichondriumon on the posterior surface of the pinna being elevated.

 


Step IV : Post-aural soft tissue and periosteal incision and elevation of posteriorly based flap:


The post-aural soft tissue and the periosteum over the mastoid cortex is incised around the bony meatal wall from 12 'o' clock position to the 6 'o' clock position in a semicircular fashion (Fig. 13) (Fig. 14) . The conchal perichondrial flap raised earlier is left attached to the post-aural soft tissue and periosteum and not to the skin of the external auditory canal. Care is taken not to injure the skin of the meatal wall. Next, 3/4 to to 1 inche long horizontal incision parallel to linea temporalis is made into the post-auricular soft tissue and periosteum over the mastoid cortex beginning from the 12 'O' clock position of the earlier incision. Another parallel horizontal incisions is made beginning from the 6 'O' clock position of the first incision (Fig. 15) . Now, a posteriorly based flap is elevated off the mastoid cortex which now includes the conchal perichondrium, post-aural soft tissue and periosteum (Fig. 16) (Fig. 17) .

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Fig. 13: The post-aural soft tissue and the periosteum over the mastoid cortex is being incised around the bony meatal wall from 12 'o' clock position to the 6 'o' clock position in a semicircular fashion.

pic14

Fig. 14: Axial Section showing: the post-aural soft tissue and the periosteum over the mastoid cortex is being incised around the bony meatal wall from 12 'o' clock position to the 6 'o' clock position in a semicircular fashion.

pic15

Fig. 15: A 3/4 to to 1 inche long horizontal incision parallel to linea temporalis is made into the post-auricular soft tissue and periosteum over the mastoid cortex beginning from the 12 'O' clock position of the earlier incision. Another parallel horizontal incisions is made beginning from the 6 'O' clock position of the first incision.

pic16

Fig. 16: Posteriorly based flap is being elevated off the mastoid cortex which now includes the conchal perichondrium, post-aural soft tissue and periosteum.

pic17

Fig. 17: Posteriorly based flap is being elevated off the mastoid cortex which now includes the conchal perichondrium, post-aural soft tissue and periosteum.

 


StepVI: Isolation of the Retraction pocket or freshening the margins of the tympanic membrane :


A self retaining mastoid retractor is applied and the pinna is retracted forwards. Another retractor is used to retract the temporalis muscle and soft tissue over the mastoid tip (Fig. 18) , in order to view the tympanic membrane. (A) If there is a retraction pocket, the tympanic membrane and the meatal wall skin, 2-3 mm away and around the retraction pocket is incised and retraction pocket island is created (Fig. 19) . (B) If there is a perforation, the margins of the perforation are trimmed and freshened. (C) If complete pars tensa is retracted and plastered over the promontary, the drum is incised all around immediately medial to the annulus.

pic18

Fig. 18: A self retaining mastoid retractor is applied and the pinna is retracted forwards. Another retractor is used to retract the temporalis muscle and soft tissue over the mastoid tip.

 


Step V: Tympanomeatal incision and elevation of endomeatal flaps:


Now two oblique endomeatal incisons are made over the remaining skin of the external auditory canal. First incision, starting from the 12 'o' clock position to 2 'o'clock position, 3 mm away from the annulus. Second, starting from the 6 'o' clock postion to 4 'o' clock position, 3 mm away from the annulus (Fig. 20) . The meatal flaps are elvated and fibrous annulus is detached from the inferior, posterior and superior meatal walls. The elevated flap is cut lateral to medial at 11 'o' clock position in cases of retracton pocket or at 9 'o' clock position in other cases. Now, the two limbs of endomeatal flaps are retracted anteriorly and preserved to avoid injury from further instrumentation in the middle ear (Fig. 21) .

pic19

Fig. 20: Tympanomeatal incisions and elevation of tympanomeatal flaps. First incision, starting from the 12 'o' clock position to 2 'o'clock position, 3 mm away from the annulus. Second, starting from the 6 'o' clock postion to 4 'o' clock position, 3 mm away from the annulus

pic21

Fig. 21: Tympanomeatal flaps have been elevated and retracted forwards.

 


Step VII : Identification of the Chorda tympani and dislocation of the incudostapedial joint:


Chorda tympani is identified and preserved at this moment. The incudostapedial jont is identified and disarticulated using a joint knife (Fig. 22) . If the IS join is not visible due to bony overhang, a curette is used to remove the overhang and care is taken not to injure the chorda tympani and the ossicles. The chorda tympani forms main landmark for further steps of the surgery, particularly atticotomy done using a drill.

pic22

Fig. 22: Chorda tympani is identified and preserved at this moment. The incudostapedial jont is identified and dislocated using a Sickle knife.

 


Step VII : Removing and lowering the facial ridge:


The cholesteatoma sac is followed from front to back (inside out). The external auditory canal is drilled in a step-wise manner, while keeping the horizontal plane of drilling lateral to the chorda tympani (Fig. 23) (Fig. 24) . Initially a large cutting burr is used. When the ridge has been lowered to within 5 to 6 mm of the annulus, a large diamond burr is used. The ridge now lowered to the level where the chorda tympani is exposed as it exits the bone into the middle ear. This is a safe method and the risk of injury to the facial nerve is less as the facial nerve lies 2 mm medial to the chorda. Drilling is performed parallel to the chorda tympani nerve from superior to inferior and not across the direction of the direction. As the tegmen and the anterior butress drilled, the tympanic part of the facial nerve and ossicle will become visible bit by bit (Fig. 25) . All the visible mastoid air cells are removed.

pic23

Fig. 23: The cholesteatoma sac is followed from front to back (inside out). The external auditory canal is drilled in a step-wise manner, while keeping the horizontal plane of drilling lateral to the chorda tympani.

pic24

Fig. 24: The cholesteatoma sac is followed from front to back (inside out). The external auditory canal is drilled in a step-wise manner, while keeping the horizontal plane of drilling lateral to the chorda tympani.

pic25

Fig. 25: As the tegmen and the anterior butress drilled, the tympanic part of the facial nerve and ossicle will become visible bit by bit.

 


Step VIII: Removal of the ossicles:


At this stage, incus is extracted (Fig. 26) . The head of the malleus is nipped off (Fig. 27) . The fossa incudis and lateral semicircular canal are identified. The facial nerve is traced from its tympanic segment to where it can be seen entering the facial ridge (Fig. 28) . The bone of the facial ridge between the exposed chorda tympani and the second genu of the facial nerve is lowered to the same height as the lateral semicircular canal. The facial nerve lies medial to the lateral semicircular canal and this step avoids exposure of the facial nerve. Care must be taken if the lateral semicircular canal has been eroded by cholesteatoma. Facial ridge is lowered until the lowered ridge is level with the floor of the external auditory canal. The ridge is lowered below the level of the floor of the external canal, if there is a large mastoid tip.

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Fig. 26: The incus is being extracted.

pic27

Fig. 27: The head of the malleus is being nipped off.

pic28

Fig. 28: The facial nerve is traced from its tympanic segment to where it can be seen entering the facial ridge. A: Lateral semicircular canal, B: Stapes and C: Facial nerve (Green color).

 


Step IX: Complete excision of the Cholesteatoma:


Cholesteatoma is dissected out completely, giving special attention to sino-dural angle, zygomatic cells, tips cells, facial recess, sinus tympani, supra-tubal recess and hypotympanum, potential sites residual cholesteatoma (Fig. 29) . The endomeatal flap and under surface of the drum are examined for cholesteatoma and excised if any.

pic29

Fig. 29: Completing modified radical mastoidectomy and excising the cholesteatoama completely. A: Zygomatic root cells, B: Anterior epitympanum or supra-tubal recess, C: Sinodural angle, D: Tubal area, E: Sinus tympani area, F: Lateral sinus and perisinus cell area, G: Mesotympanum, H: Floor of the external auditory canal and I: Tip cell area.

 

Step X : Harvesting Conchal cartilage:


The exposed crescent shaped conchal cartilage is incised along the skin incision line with a downward extension to involve the cartilage of the floor and partially anterior wall of the external auditory canal, i.e., tragal cartilage. Cartilage is elevated off the pericondrium and skin using periosteal elevator or sharp dissecting scissors and care is taken not injure the skin which is usually very thin (Fig. 30) (Fig. 31) .

pic30

Fig. 30: The exposed crescent shaped conchal cartilage isbeing incised along the skin incision line with a downward extension to involve the cartilage of the floor and partially anterior wall of the external auditory canal, i.e., tragal cartilage.

pic31

Fig. 31: Picture shows the amount of the cartilage than can be excised. A: Conchal cartilage, B: Floor carilage and C: Tragal cartilage.

 


Step XI : Placing the temporalis fascia and Ossicular reconstruction:


The mastoid cavity and middle ear is thoroughly irrigated and cleaned of all the bone dust and blood clots. The temporal facia graft is placed to create middle ear cleft and to cover the facial ridge, attic region and the cavity (Fig. 32) . The facia is tucked beneath the margins of the remaining tympanic membrane or the fibrous annulus and fixed with gelfoam support. Ossicular reconstruction is done now using the conchal or tragal cartilage or autologous incus. The reconstructed ossicles are supported with the gelfoam pieces filled in the middle ear.

As such incus was removed and head of the malleus nipped off routinely, the types of ossiculoplasty done was one of the below depending on the pathology:

Type I: When head of the stapes present and malleus hand intact:
A remodelled autologous ossicle or cartilage piece is placed between the head of the stapes and handle of malleus.

Type II: When head of the stapes absent and malleus hand intact:
A remodelled autologous ossicle or cartilage piece is placed between the stapes foot plate and handle of malleus.

Type IV: When head of the stapes present but handle of malleus absent: A remodelled autologous ossicle or cartilage piece is placed between the stapes head and the temporalis fascia graft.

Type V: When head of the stapes and handle of malleus are absent: A remodelled autologous ossicle or cartilage piece is placed between the stapes foot plate and temporalis fascia graft.

pic32

Fig. 32: The temporal facia graft is placed to create middle ear cleft and to cover the facial ridge, attic region and the cavity. A: Temporal fascia graft.

 


Step XII: Obliteration of the attic and mastoid cavity:

A properly shaped and cut conchal cartilage is used to obliterated the attic pit above the tympanic segment of the facial canal and is covered with temporalis facia graft completely (Fig. 33) . The cartilage should not be bare and exposed. Remaining conchal and tragal cartilage is used to obliterate the tip area, sino-dural angle and remaining cavity, under the cover of the temporalis fascia (Fig. 34) . The posteriorly based post auricular flap (Karnataka flap) is turned into the mastoid cavity, placed below the temporalis fascia, such as that, the periosteum will be in contact with and covering the cartilage pieces used to obliterate the cavity (Fig. 35) . The conchal pericondrium will be facing the temporalis fascia and the post aural soft tissue lying in between periosteum and perichondrium. As such this flap consists of post-aural soft tissue and periosteum over the mastoid cortex, they sort of fall in or cave in into the mastoid, which is now devoid of cortex, the chances of flap retraction is less.

Now, Care is taken to drape the temporalis fascia completely over the cavity filled with cartilage pieces and post-aural flaps. This avoids raw area, the chances of cartilage exposure and extrusion.

Next, the superior tympanomeatal skin flap is reposited in such a way that, the upper flap lies in the attic region covering the cartilage piece and the temporalis fascia (Fig. 36) . The inferior endomeatal skin flaps reposited over the part of the facial ridge close to it, covering the temporalis fascia graft. These flaps are very important and they stabilize the temporalis fascia graft, nourish the fascia the help in early epithelialization.

pic33

Fig. 33: A properly shaped and cut conchal cartilage is used to obliterated the attic pit above the tympanic segment of the facial canal and is covered with temporalis facia graft completely. A: Dural plate, B: Piece of conchal cartilage used to obliterate the attic, C: Fascial covering SD angle, D: Lateral sinus and E: Anterior wall of the EAC.

pic34

Fig. 34: More conchal and tragal cartilagepieces are used to obliterate the tip area, sino-dural angle and remaining cavity, under the cover of the temporalis fascia. A: Attic area, B: SD angle area and C: Tip area.

pic35

Fig. 35: The posteriorly based post auricular flap (Karnataka flap) is turned into the mastoid cavity, placed below the temporalis fascia, such as that, the periosteum will be in contact with and covering the cartilage pieces used to obliterate the cavity. A: Karnataka Flap and B: Temporalis fascia graft.

pic36

Fig. 36: Superior tympanomeatal skin flap is reposited in such a way that, the upper flap lies in the attic region covering the cartilage piece and the temporalis fascia. The inferior endomeatal skin flap is reposited over the part of the facial ridge close to it, covering the temporalis fascia graft. A: Superior tympanomeatal flap. B: Karnataka Flap, C: Temporalis fascia covering conchal cartilage in SD angle area and D: Inferior tympanometal flap.

 

Step XIII: Meatoplasty: Now, the modified Korner's skin flap of posterior meatal wall is fixed with catgut sutures to the temporal muscle superiorly and to the soft tissues over the mastoid tip area, to ensure that the flap is over the facial ridge, covering the temporalis fascia and post-auricular flaps (Fig. 37) . When this is done, one should be able to pass index finger though the entrance of the meatus. Care is taken to not to pull out the post-auricular flap inadvertently.

Through thse steps of surgery, the cavity is obliterated with autologous cartilage pieces which were harvested from the vicinity, and covered by three fibrous tissue layers, i.e., periosteum and conchal perichondrium which get rich blood supply from the branches of the occipital artery and the temporalis fascia whose nutritional needs are minimal, and helps in the reconstruction of the middle ear space as well as hearing mechanism. These are further reinforced by the endomeatal skin flaps and the Korner's flap which would help in epithelization.

pic37

Fig. 37: The modified Korner's skin flap of posterior meatal wall is fixed with catgut sutures to the temporal muscle superiorly and to the soft tissues over the mastoid tip area, to ensure that the flap is over the facial ridge, covering the temporalis fascia and post-auricular flaps. A: Karnataka flap, B: Temporalis fascia graft and C: Koerner's flap.

 


Step XII: Packing the Cavity:

The exposed temporalis fascia is covered with gelfoam pieces and the external auditory canal is filled with Oxytetracycline skin ointment soaked packing to make sure that the various flaps are in close approximation and there is no dead space or hematoma between them (Fig. 38) (Fig. 39) . Skin incision is closed in one layer and mastoid dressing done.

pic38

Fig. 38: The exposed temporalis fascia is covered with gelfoam pieces and the external auditory canal is filled with Oxytetracycline skin ointment soaked packing to make sure that the various flaps are in close approximation and there is no dead space or hematoma between them.

pic39

Fig. 39: The exposed temporalis fascia is covered with gelfoam pieces and the external auditory canal is filled with Oxytetracycline skin ointment soaked packing to make sure that the various flaps are in close approximation and there is no dead space or hematoma between them.

 



Post-op care:


A broad spectrum antibiotic and antihistamines are given for 2 weeks.
2nd day post-op: First dressing change is done. Conventional mastoid dressing stays for a week.
1 week post-op: Sutures are removed and a small dressing is kept to protect the pack. Secretions are sucked out during this time. If there is profuse or foul smelling secretions, antibiotic is changed and patient is called for suction cleaning on alternated days. Suction is done over the pack without loosening or disturbing it.
2 weeks post-op: Pack is removed and cavity is filled with an antibiotic and steroid cream. Cavity is not cleaned. If cavity suction is required, done so carefully without disturbing the Korner's flap or temporalis fascia graft. Antibiotics are continued if foul smelling or profuse secretions are present. Patient is adviced to keep the ear dry for 3 months.
1 month post-op: Antiobiotic and steroid cream, debris, heamatoma, secretions in the cavity are cleaned with suction. Anitiobiotic with steroid drops are adviced only if there are signs of infeciton.
2 months post-op: Cavity is inspected and cleaning done only if required.
3 months post-op: Cavity inspection and patient undergoes Heairng assessment.
Later patient reviews after 6 months or if any problem persists.

 

Results:


Sixty eight patients (N = 68) with chronic suppurative otitis media and cholesteatoma who had undergone surgery by this technique presented here were included in this study. Age range of the patients was 15 to 63 years, with an average of 32.5 years. The male to female ratio was 2.23 : 1 (47 : 21). The main presenting complaints was foul smelling otorrhoea (87%), followed by hard of hearing (81%), and earache (31%). On clinical examination, retraction pocket with cholesteatoma was found in 49 (72.02%) patients, pars tensa perforation with cholesteatoma in 11 (16.17%) patients and completely retracted drum with cholesteatoma in 6 (8.82%) patients . Large attic defect with cholesteatoma was found in 2 (2.94%) patients. Some form of ossiculoplasty was done 62 (19.17%) patients. Type I ossiculoplasty was done in 41 (66.12%) patients, Type II ossiculoplasty in 8 (12.90%) patients, Type IV ossiculoplasty in 10 (16.12%) patients and Type V ossiculoplsty in 3 (4.83%) patients.

Follow-up ranged from 14 months to 8 months with an average of 10 months. Number of follow-up visits ranged from 7 to 16 with an average of 11.

In 2 (2.94%) patients, the Korner's flap was avulsed and displaced during pack removal which had to be replaced back and supported with a new pack under microscope. Subsequently these patients did well. 1(1.14%) patient developed a granuloma after 2 months at the entrance of the meatus which had to be debrided. 4 (5.58%) patients had dermatitis between 2 to 4 months following surgery, which was treated with antibiotics and steroid creams. 7 (10.94%) patients had otomycosis requiring cleaning of the meatus and antifungal ear drops. One (1.14%) patient developed narrowing of the meatoplasty which had to be revised. 2 patients have perforation of the tympanic membrane (2.94%), however they are not discharging. Only one patient (1.14%) has persistent ear discharge with myringitis who is not responding to conservative line of treatment. At the end of one year, overall, this technique was successful in providing well epithelialized small cavity which was dry in 67 (98%) patients with dry tympanic membrane perforations in 2 (2.94%) patients.

 

References:



1. Males A, Grey R. Mastoid Misery : Quantifying the distress in a radical cavity.
Clin Otol 1991;16:12-14

2. Sade J. Weinberg J, Berco E, brown M, Halevy A.: The marsupilized (radical) mastoid.
L Laryngol Otol 1982;96:869-875

3. Males R. Surgical management of the discharging mastoid cavity.
L Laryngol Otol 1988;16(suppl):1-6

4. Wormald PJ, Nilssen E. The facial ridge and the dischrging mastoid cavity.
Laryngoscope 1998;108:92-96

5. Wormald PJ, Hasselt AV ; A technique of Mastoidectomy and Meatoplasty That Minimizes Factors Associated With a Discharging Mastoid Cavity
Laryngoscope 1999;109:478-482

6. Saunders JE, Shoemaker DL, McElveen JT Jr. : Reconstruction of the radical mastoid ;
Am J Otol 1992 Sep;13(5):465-469

7. Bowdler DA, Walsh RM. The use of Davis pinch grafts to promote epithelialization in a post- mastoidectomy cavity ; Rev Laryngol Otol Rhinol (Bord) 1995;116(1):65-8

8. Palva T. : Cholesteatoma surgery today;
Clin Otolaryngol 1993 Aug;18(4):245-252

9. Hartwein J.: The acous tics of the open mastoid cavity (so-called "radical cavity") and its modification by surgical measures. II. Clinical studies.
Laryngorhinootologie 1992 Sep;71(9):453-61

14. Peter J W, C. Andrew Van Hasselt : A technique of Mastoidectomy and Meatoplasty That Mini mizes Factors Associated With a Discharging Mastoid Cavity :
The Laryngoscope 109, No.3 : 478 - 482, 1999.

15. Portmann M. : Results of middle ear reconstruction surgery ;
Ann Acad Med Singapore 1991 Sep;20(5):610-613

16. Birzgalis AR, Farrington WT, O'Keefe L.: Reconstruction of discharging mastoid cavities using the temporalis myofascial flap.;
Clin Otolaryngol 1994 Feb;19(1):70-72

17. Mills RP.: Surgical management of the discharging mastoid cavity ;
J Laryngol Otol Suppl 1988;16:1-6

18. Charachon R, LeJeune JM, Bouchal H. :Reconstruction of radical mastoidectomy by obliteration technique. :
Ear Nose Throat J 1991 Dec;70(12):830-838

19. H.H Naumann : Surgical treatment of Chronic Otitis Media and its immediate consequences.
Head and Neck Surgery, Vol 3. W.B Philadelphia, WB Saunders, 1982, pp 171-265.

20. Cheney ML, Megerian CA, Brown MT, McKenna MJ., Mastoid obliteration and lining using the temporoparietal fascial flap ;
Laryngoscope 1995 Sep;105(9 Pt 1):1010-1013

21. Van Hasselt CA : Toynbee Memorial Lecture 1994: Mastoid surgery and the Hong Kong Flap:
J Laryngol Otol 1994 Oct;108(10):825-833

22. Farrior JB.: Postauricular myocutaneous flap in otologic surgery.;
Otolaryngol Head Neck Surg 1998 Jun;118(6):743-746

23. Birzgalis AR, Farrington WT, O'Keefe L.: Reconstruction of discharging mastoid cavities using the temporalis myofascial flap ;
Clin Otolaryngol 1994 Feb;19(1):70-72

24. Mercke U.: The cholesteatomatous ear one year after surgery with obliteration technique.;
Am J Otol 1987 Nov;8(6):534-536

25. Decher H. Reduction of radical cavities by homologous cartilage chips.
Laryngol Rhinol Otol (Stuttg) 1985 Aug;64(8):423-426

26.Michael McGee, MD and J.V.D Hough, MD : Ossiculoplasty
Otolaryngologic Clinics of North America ; Vol. 32. No.3, June 1999, pp471 - 488.

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