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tomy is often used (anterior to the sigmoid Intact canal wall Modified radical
mastoidectomy mastoidectomy
sinus). A mastoidectomy is often an initial
Closed technique Open technique
step in lateral skull base surgery for
tumours involving the lateral skull base, Front-to-back mastoidectomy
including vestibular schwannomas, Atticoantrostomy
meningiomas, temporal bone paragang- Open mastoidoepitympanec-
liomas (glomus tumours), and epidermoids tomy
or repair of CSF leaks arising from the
temporal bone. One of the problems is that the
terminology does not in fact entail specific
Definition of Cholesteatoma information about what was done either to
the middle ear or the mastoid. It is the
Cholesteatoma is a chronic middle ear authors preference to use the terms
infection with squamous epithelium and open/closed mastoidoepitympanectomy
retention of keratin in the middle ear and to state separately whether a
and/or temporal bone with progressive tympanoplasty or ossiculoplasty was done
bone erosion. A middle ear atelectasis does e.g. left open mastoidoepitympanectomy
not retain keratin, although it also reveals and tympanoplasty type III.
skin in the middle ear space due to the
retraction pocket. The most commonly used terms for canal
wall down mastoidectomy are radical or
Aims of Cholesteatoma Surgery modified radical mastoidectomy. The
classical radical mastoidectomy is not
Eradication of disease and preventing favoured by the authors as it results in a
residual disease large cavity which frequently discharges
Improving middle ear ventilation and and therefore does not satisfy the ultimate
preventing recurrent disease goal of mastoid surgery which includes
Creating a dry, self-cleansing cavity having a trouble free cavity.
Reconstitution of the hearing mecha-
The method of open and closed mastoido-
nism
epitympanectomy as described in this text
is standard. Common to both open and
closed mastoidoepitympanectomy is the
bony work involving the mastoid cavity. It
involves first identifying the important Surgical Terminology
landmarks (= skeletonization = leaving a
thin shelf of bone covering the important Canalplasty: Enlargement of the external
structure) before removing the disease and ear canal while avoiding injury to the
maximum exposure for complete temporomandibular joint anteriorly and the
exenteration of the disease. mastoid air cells posteriorly (Video)
2
tomy, (posterior tympanotomy) and Table 2: Indications for closed vs. open
tympanoplasty. The external bony canal is cavity mastoidoepitympanectomy (MET)
preserved. The drawback of this approach
is the limited view into the anterior Factor Closed MET Open MET
epitympanum and the sinus tympani in Extent of Limited Large
cases of limited pneumatisation and disease cholesteatoma
cholesteatoma formation Primary surgery
with sufficient Labyrinthine
space fistula
Open mastoidoepitympanectomy (with
obliteration): This involves the radical Other
complications
exenteration of the tympanomastoid tracts
with exteriorisation of the surgical cavity, Recurrent
and lowering of the posterior bony canal cholesteatoma
after previous
wall to the level of the skeletonised facial closed MET
nerve. In order to reduce the size of the
cavity, especially with moderately-well
Pneumatisation Good Poor
pneumatised mastoids, the mastoid tip is pneumatisation pneumatisation
removed and a myosubcutaneous occipital
flap is created to reduce the size of the
cavity. Meatoplasty is routinely performed. Aeration Air in middle Glue in middle
ear and mastoid ear
air cells
Granulation tissue
Open/Closed Mastoidoepitympanectomy in mastoid air
cells
History
Applied Anatomy
Patients with chronic ear disease
Knowledge of middle ear and temporal frequently have a longstanding history of
bone anatomy is vital to understanding the hearing loss or chronic otorrhoea. It is
concepts of surgical management. It is important to establish whether there is a
imperative to practise the surgery and learn history of previous surgery. Foul smelling
the 3-dimensional temporal bone anatomy otorrhoea is a clear hint of cholesteatoma.
in a temporal bone laboratory. The
important landmarks and structures will be Otomicroscopy
highlighted with the surgical steps.
This is an important means to determine
the presence of cholesteatoma and it helps
to define the extent of disease. The ear
should be thoroughly cleaned of secretions
and debris. Findings may include a
3
retraction pocket with accumulation of Pneumatic otoscopy
keratin in the attic or in the posterosuperior
quadrant of the tympanic membrane, This should be routinely performed to
granulation tissue or a polyp (Figures 1 & determine the presence of a positive fistula
2). A polyp signals an underlying response. A negative response, however
cholesteatoma. does not exclude a fistula.
Audiology
4
Surgical planning with HRCT 4. Size and presence of emissary vein: A
large emissary vein can cause
HRCT of the temporal bone is the troublesome bleeding if not
otologists road map and one should have a anticipated!
systematic approach when evaluating the 5. Sigmoid sinus and its relation in the
CT scan. The decision whether to do an mastoid cavity: In children the sigmoid
open or closed cavity operation depends on may be very close to the lateral surface
the degree of pneumatisation and of the mastoid; in adults a sigmoid
ventilation of the temporal bone and extent sinus malformation may only be
of disease, all of which can be determined appreciated on preoperative CT scan.
on HRCT. Axial as well as coronal images When the sigmoid sinus lies very
are needed for preoperative evaluation and anteriorly in the mastoid cavity it may
should always be in the operating theatre be difficult to perform a posterior
and visible to the surgeon as intraoperative tympanotomy due to very limited
reference (and not in the patients chart!) exposure. In revision surgery, it is
important to assess whether the
CT scan checklist sigmoid sinus has been exposed or
whether it is still covered by bone. If
1. Pneumatisation: The temporal bone the sigmoid sinus has been exposed at
may be well-pneumatised, may have previous surgery, it will be covered
reduced pneumatisation, or be with scar tissue which becomes
sclerotic. This gives important difficult to elevate thus risking
information about what the eustachian breaching the sinus when elevating the
tube function during the first 4 years of periosteal flap
the patients life was like. It is 6. Jugular bulb: Is it high-riding (up to
important to assess the pneumatisation the level of annulus)? Is it dehiscent?
of the petrous apex as well. Poor 7. Carotid artery: Is there dehiscence,
ventilation favours an open cavity especially at the level of the eustachian
procedure tube?
2. Ventilation: This is assessed by the 8. Tegmen tympani: What is the shape of
aeration of the middle ear and mastoid the tegmen? Is it flat or does it slope
air cells. Opacification of the middle upwards with cells lying medial to it?
ear or mastoid cells suggests poor Is it low-lying? Is it dehiscent? A bony
ventilation of the middle ear cleft. This defect of the tympanic tegmen or
gives the best information about anterior wall of the epitympanum
eustachian function at the present time. should raise the suspicion of an
Poor ventilation of already-impaired encephalocoele or cholesteatoma
pneumatised cell tracts favours an extending into the middle cranial fossa.
open cavity procedure This requires further imaging in the
3. Ear canal: Evaluate the thickness of form of an MRI
the bone anteriorly and posteriorly. 9. Facial nerve: The tympanic segment
This is important when one needs to do may be dehiscent, especially in
a canalplasty as the anterior relation of children or in the presence of
the tympanic bone is the temporo- cholesteatoma. In cases of revision
mandibular joint and posteriorly are surgery, it is important to know
mastoid air cells. These should not be whether the facial nerve has been left
breached when doing a canalplasty exposed in an open cavity when
elevating the tympanomeatal flap
5
10. Is there a fistula of the lateral When approaching the mastoid tip the
semicircular canal? skin incision follows the skin tension
11. Extent of disease: Does it only involve lines which run directly inferiorly (not
the mesotympanum or does it extend curved) towards the neck
further into the mastoid cavity? Is the
petrous apex involved?
12. Status of ossicular chain: Are the
ossicles present or have they been
eroded?
Preoperative preparation
Closed Mastoidoepitympanectomy
6
Periosteal flap Canalplasty
7
reflect periosteum posteriorly where
you may encounter an emissary vein,
and inferiorly to the mastoid tip
1
6
Figure 8: Tympanomeatal flap and
annulus have been elevated and middle 7
ear is entered below the pathological Figure 9: Surface markings of left ear:
area Temporomandibular joint (1); root of
zygoma (2); external ear canal (3);
Inspection of middle ear suprameatal spine (4); mastoid tip (5);
Macewens triangle (6); opening of
The middle ear in Figure 8 has been emissary vein (7)
entered at 6 oclock after excluding a
dehiscent jugular bulb on CT scan
Define the extent of the disease in the
middle ear and around the ossicular
chain
8
The tegmen tympani marks the superior to avoid touching the ossicles which
limit of the dissection would induce sensorineural hearing
Start drilling above linea temporalis loss
Figures 11, 12)
LSSC
Dural plate
9
Drilling tips Mastoidectomy
Avoid keyhole surgery; work through a Follow the sinodural plate posteriorly
wide space up to the sinodural angle, which is the
The tip of the drill should always be area between the sigmoid sinus and
visible dura
Never drill behind edges of bone Like the dural plate, the sinus plate is
Drilling should always be parallel to identified by the change in colour of
any structure you are trying to the bone and a change in the pitch of
preserve e.g. facial nerve, sigmoid the burr
sinus Skeletonise the sigmoid sinus; do not
When drilling deeper in the mastoid expose the sigmoid sinus, but leave a
cavity the burr needs to be lengthened covering of bone over the sinus.
One cannot lengthen a cutting burr as (Figure 17)
this will cause the drill to jump with
the risk of injuring structures (Figure
15)
Dural plate
Sinodural
angle
Sigmoid
sinus
10
Incus VII the sensory branch of facial nerve
Dura
n (which innervates the posterior wall of
the external auditory canal and a
portion of the tympanic membrane)
SCC just above the stylomastoid foramen.
LSC
Skeletonise the nerve by drilling in a
wide plane between the lateral
semicircular canal proximally and the
PSC stylomastoid foramen distally, working
Sigmoid sinus C from anteriorly to posteriorly (Figure
19)
Figure 18: Relations of VIIn to short
process of incus; superior semicircular
canal (SCC); lateral semicircular
canal (LSC); posterior semicircular
canal (PSC); dura; and sigmoid sinus
11
between the pyramidal segment of the
facial nerve posteriorly, the chorda
tympani, and the fossa incudis
superiorly (Figure 20)
Incus
Chorda
P
Tympanotomy
Epitympanectomy
Figure 20: Landmarks for posterior
tympanotomy are VIIn, chorda tympani This is indicated when cholesteatoma
and short process of incus extends medial to the ossicles or
overlies the lateral semicircular canal;
In the absence of disease in the facial in cases of bony erosion of the ossicles
recess, the stapes superstructure is due to cholesteatoma, the ossicles need
visible through the tympanotomy to be removed
For removal of cholesteatoma in facial Only recently, KTP laser evaporation
recess one has to work from both sides of cholesteatoma matrix has been
of the intact posterior external auditory discussed
canal wall The incus is removed by mobilising it
with a 2,5mm. 45 hook and rotating it
Epitympanotomy laterally, taking care not to injure the
underlying facial nerve
If the cholesteatoma does not extend The malleus head is severed with a
significantly into the epitympanum, an malleus nipper applied across its neck.
epitympanotomy (atticotomy) is The malleus nipper is held anteriorly
performed between the thumb and index finger to
This involves exposure of the head of stabilise it when the malleus head is
the malleus and the incus to remove divided
soft tissue from the epitympanum The head of the malleus is removed
The lateral wall of the epitympanum leaving the tensor tympani tendon
or attic is removed with a diamond intact
burr; drilling is commenced at 12 Clear cholesteatoma from the
oclock relative to the ear canal, taking epitympanum
care not to make drill contact with the Detailed knowledge of facial nerve
malleus or incus which is immediately anatomy is crucial to avoid injury to
medial to the outer attic wall, or to the nerve when drilling or removing
breach the dural plate above (Figure cholesteatoma in the epitympanum
21) The tympanic and labyrinthine
segments and geniculum all lie in this
12
very confined space and may be fenestrating the posterior wall of the
dehiscent external auditory canal
The tympanic segment lies in the floor Avoid fenestrating the posterosuperior
of the anterior epitympanic recess (Fig canal wall
22) Identifying the facial nerve along its
course in the mastoid is the best way of
avoiding injury to the nerve
TT Cog Most injuries occur when the facial
StR
nerve has not been adequately
visualised
TTymp ET
CP GSP
TeT
GG
VIIn Dura
VII.T
Figure 22: Anatomy of anterior VII.L
epitympanic recess: Facial nerve
(VIIn); Tegmen tympani (TT); Cog; LSC
SSC
Supratubal recess StR; Cochleariform
process (CP); Eustachian tube (ET)
Figure 23: View of epitympanum with
The cochleariform process is a fairly cog and cochleariform process drilled
consistent landmark and the nerve lies away: Tympanic (VII.T) and
directly superior to it; the semicanal of Labyrinthine (VII.L) segments of facial
the tensor tympani is sometimes nerve and Geniculate Ganglion (GG)
mistaken for the facial nerve; however and Greater Superficial Petrosal nerve
this canal ends at the cochleariform (GSP); Superior Semicircular Canal
process (Figure 22) (SSC); Lateral Semicircular Canal
The cog is a bony process in the (LSC); Dura; Tensor Tympani tendon
anterior epitympanum which extends (cut) (TeT)
from the tegmen tympani and points to
the facial nerve (Figure 22)
Figure 23 above shows the geniculate
ganglion and greater superficial
petrosal nerve once the Cog and
cochleariform process have been
drilled away
13
Ossiculoplasty The cartilage is cut into 2-3 thin pieces
(use a new 10 or 20 #blade)
Refer to the chapter on ossiculoplasty and These pieces are aligned so as to
incus interposition for detailed surgical slightly overlap each other
steps.
Tympanic membrane reconstruction
The following conditions should be present
in order to proceed to an incus Refer to chapter on Myringoplasty and
interposition at the time of the primary tympanoplasty for detailed surgical steps
surgery (Figure 25)
Temporalis fascia or cartilage is
Malleus handle present harvested
Stapes superstructure intact If there is diseased middle ear mucosa
Footplate mobile or retraction of the pars tensa, then
Choleasteatoma limited and could be silastic sheeting (1mm thickness) is
removed entirely introduced into the tympanic cavity
Incus free of cholesteatoma and protympanum to prevent adhesions
Anterior third or half of the eardrum is between the graft and the promontory
preserved and defines the proper plane The graft always lies medial to the
handle of malleus (if present);
Second-stage surgery is done at 6-12 therefore a slit has to be made to
months to ensure stabilisation of the graft accommodate the tensor tendon
in cases of perforation; to verify
eradication of cholesteatoma; and to assess Wound closure and packing
whether there is good middle ear
ventilation and whether eustachian tube The meatal skin flap is replaced and
dysfunction is present gelfoam pledgets are placed
strategically over the meatal skin flap
and fascia to secure it over the
tympanic sulcus
The external canal is packed with a
strip of gauze impregnated with
antibiotic ointment
An easyflow drain or tube of a suction
drain (without suction!) is placed in the
mastoid cavity through a separate skin
incision and the wound is closed in
layers
A mastoid pressure bandage is applied
for 1 day
Figure 25: Incus interposition
14
Open Mastoidoepitympanectomy (MET) fallopian canal, but lowering the bone
to the level of the facial nerve
Skin incision: As for Closed MET The course of the nerve can clearly be
identified inferior to the lateral
Periosteal flap: A small periosteal flap is semicircular canal, anterior to the
made in order to preserve the soft tissue for posterior canal, and along the
myosubcutaneous occipital flap stylomastoid periosteal fibres at the
level of the digastric ridge
Canalplasty: As for Closed MET
Removal of mastoid tip
Inspection of middle ear and division of
incudostapedial joint: As for Closed MET Removal of the mastoid tip will help
reduce the size of the cavity by
Antrotomy allowing soft tissue to collapse into the
cavity
As for Closed MET The stylomastoid foramen is medial to
With Open MET you may already have the digastric ridge
lowered the posterosuperior canal wall Anteriorly where it extends into the
external ear canal, the drill therefore
Mastoidectomy and epitympanectomy remains lateral to the digastric ridge
The mastoid tip is weakened when one
Radical exenteration and exteriorisa- drills with a diamond drill lateral to the
tion of all cell tracts, including digastric ridge to expose the muscle at
retrofacial, retrolabyrinthine, supra- its attachment along the mastoid tip
labyrinthine, and supratubal cell tracts and will develop a fracture line
A common error is not to saucerise the A rongeur is used to remove the
cavity; this limits exposure and creates mobilised mastoid tip by rotating it
a larger cavity outwards
The more bone one removes, the The remaining soft tissue attachment
smaller the cavity can be cut with scissors pointing to the
Incomplete exenteration will result in a bone
discharging cavity
Never leave bony overhangs Tympanoplasty
Lower the facial ridge over the mastoid See chapter on Myringoplasty and tym-
segment of facial nerve panoplasty for detailed technique. Note
that if the tympanic membrane and annulus
A high facial ridge may cause a are deficient then a tympanic sulcus is
discharging mastoid cavity drilled out with a small diamond burr in
Therefore it is important to skeletonise order to support the fascial graft
the facial nerve in order to lower the
facial ridge sufficiently Obliteration of mastoid cavity
Lower the facial ridge with a large
diamond burr and continuous suction The mastoid cavity is small after
irrigation exteriorisation of a poorly pneumatised
Skeletonize the facial nerve, keeping mastoid and does not require obliteration.
the nerve intact within the bony However following exenteration of all
tracts in a highly pneumatised mastoid, one
15
may be left with a large cavity; in such Vicryl 2/0 sutures are used to suture
cases obliteration is necessary to create a the flap to the exposed digastric muscle
dry cavity to hold the flap in place in the mastoid
cavity
Mastoid obliteration with myosubcuta-
neous occipital flap Meatoplasty
16
Gelfoam is placed medially in the ear
canal
Gauze impregnated with Terracortril
ointment is used to fill the lateral
portion of the mastoid cavity and ear
A mastoid pressure dressing is applied
Postoperative Imaging
Figure 29: Completed meatoplasty
CT cannot accurately define
It is important that there are no cholesteatoma postoperatively, because
exposed edges of the cartilage as this the CT attenuation of cholesteatoma is
can lead to perichondritis not specific enough to differentiate it
from granulation tissue or effusion
Wound closure and packing
Non-EPI MRI has better tissue
differentiation for cholesteatoma and
The retroauricular wound is closed in has a high sensitivity and specificity
two layers using 2/0 Vicryl for for cholesteatomas measuring >5mm
subcutaneous tissue and skin clips or
The senior author (T.L) recommends
3/0 Nylon for the skin. An easy-flow
routine imaging, ideally with non- EPI
drain may be inserted
diffusion weighted MRI, at 1 & 3 years
following closed mastoidoepitympa-
17
nectomy when there is concern about Lucerne Canton Hospital, Switzerland
recurrent or residual cholesteatoma thomas.linder@ksl.ch
Editor
References
Johan Fagan MBChB, FCORL, MMed
Fisch U, May J. Tympanoplasty, Mastoid- Professor and Chairman
ectomy, and Stapes Surgery. New York: Division of Otolaryngology
Thieme; 1994 University of Cape Town
Cape Town, South Africa
Jindal M, Riskalla A, Jiang D, Connor S, johannes.fagan@uct.ac.za
O'Connor AF. A systematic review of
diffusion-weighted magnetic resonance
imaging in the assessment of postoperative THE OPEN ACCESS ATLAS OF
cholesteatoma. Otol Neurotol 2011; 32(8): OTOLARYNGOLOGY, HEAD &
1243-9
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
Acknowledgements
Author
Senior Author
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