Modified radical

Graft Materials
• Temporalis fascia
– Hermann (1960) and Storrs (1961)
– Large quantity
– No separate incision
– Sturdy
– Low metabolic rate
• Homograft TM
– Excellent success similar to fascia
– Theoretic risk of infectious disease transmission (prions,
HIV)
– Availability
 Cartilage Tympanoplasty
• 1958 – Jansen
– First used cartilage in the middle ear
• 1963 – Salen and Jansen
– First reported use of cartilage for reconstruction of the TM
• Excellent for prevention of recurrent retraction
pockets
– Most successful when placed posteriosuperiorly and pars
flaccida (Poe and Gadre, 1994)
• Recommended by Vrabec (2002) to be placed over
TORP or PORP to prevent extrusion
 Cartilage Tympanoplasty
• Results
– Gerber (2000) and Dornhoffer (1997)
• Hearing results comparable to temporalis fascia and
perichondrium even with complete TM reconstruction
with cartilage
Cartilage Tympanoplasty
Cartilage Tympanoplasty
Cartilage Tympanoplasty
Cartilage Tympanoplasty
 Tympanoplasty in Children
• Controversial
• Considered less successful than adults
– Higher incidence of ETD and otitis media
• Wide range of success rates
– 35% to 93%
• Tos and Lau (1989)
– Found comparable success rates compared to adults for all
ages in children (92%)
– Helps to lessen progression of ossicular pathology
 Results – overlay vs. underlay
• Doyle et al. (1972)
– Conclusions
• In experienced hands either technique can be equally
successful
• Residents and otolaryngologist of limited experience
– Medial grafting gives better healing and fewer complications
– All cases utilized endaural approach with is more
techniquely demanding
 Results – overlay vs. underlay
• Rizer (1997)
– Compared 551 underlay to 158 overlay
• Closure in 88.8% of underlay versus 95.6% of overlay
• Closure of ABG to 10 dB or less in 84.9% of underlay vs.
80.4% of overlay
• Similar complication rates
 Results – overlay vs. underlay
• Rizer (1997)
– Both groups – no relationship in re-perforation
with:
• Age of patient
• Perforation size or location
• Middle ear status
• Presence of cholesteatoma
 Conclusion
• Tympanoplasty has a high rate of success in closing tympanic
membrane perforations and improving hearing
• Patients should be chosen carefully based on the indications
discussed and attempts at attaining a dry ear prior to surgery
should be made
• Patients should be thoroughly counseled preoperatively about
the expectations and goals of the surgery
• Tympanoplasty in the pediatric age group is controversial
• Both underlay and overlay techniques for grafting are
effective, however, the surgeon should do what he/she is
most experienced and successful with
 Cartilage Tympanoplasty

K. Kevin Ho, MD
Tomoko Makishima, MD PhD
Univ. of Texas Medical Branch, Dept. of Otolaryngology
– Grand Rounds Presentation
March 19, 2008
 History of Tympanoplasty
• Banzer (1640): repair TM w/ pig’s bladder.
• Toynbee (1853): rubber disk.
• Blake (1877): paper patch.
• Zoellner and Wullstein in 1952, using STSG
• 1958 – Jansen
– First reported use of cartilage in OCR
• 1963 – Salen and Jansen
– First reported use of cartilage for reconstruction of the TM
 Indications for
Cartilage Tympanoplasty
• Atelectatic ear
• Retraction pocket/ Cholesteatoma
• High Risk Perforation
– Revision
– Anterior perforation
– > 50%
– Otorrhea at the time of surgery
– Bilateral
 Techniques
• Perichondrium/ Cartilage island flap
– Tragal cartilage

• Cartilage shield technique

– Conchal cartilage

• Palisade technique
– Tragal cartilage
– Concha cymba

• Inlay Butterfly graft

– Tragal cartilage
 Inlay Butterfly Graft
• Originally designed for small perforation
(< 1/3 TM diameter) myringoplasty without
cholesteatoma
• Inlay technique without elevation of
tympanomeatal flap
• Quick office procedure
• Expanded recently to repair larger perforations in
conjunction with mastoidectomy
• Split thickness skin graft over perichondrium for
large perforation
Inlay Butterfly Graft

Eavey RD 1998
Placement of Butterfly graft

Eavey RD 1998
Postop Inlay Butterfly graft

Eavey RD 1998
Inlay graft for large perforation

Ghanem MA 2006
 Tragal Cartilage Harvest
• Cut on medial side of tragus
• Leave 2 mm tragal cartilage for
cosmesis
• Abundance: 15 x 10 mm
• Flat
• ~ 1 mm thickness
• Perichondrium from the side
away from the EAC is removed

Dornhoffer 2003
Perichondrium/ Cartilage Graft

Dornhoffer 2003
Medial Grafting

Dornhoffer 2003
Postop Perichondrium/ Cartilage Island
Graft

Dornhoffer 2003
Cartilage Shield

Aidonis I 2005
Cartilage Shield
 Palisade technique
• This technique is
favored when OCR is
performed in malleus-
present situation
• Cartilage from either
tragus or cymba
– Post-auricular: Cymba
– Transcanal: Tragus

Dornhoffer 2003
Conchal Cartilage Graft
Palisade techniques
Preparation of Cartilage Strips

Kazikdas KC 2007
Palisade technique

Anderson J et al. Otol Neurotol. 2004

Palisade Postop result
Modified Palisade technique

Murbe D 2002
 Postop care
• 2 weeks postop: Gelfoam completely suctioned
from EAC
• Start topical antibiotics x 2 weeks
• Adult: Start valsalva
• Children: Otovent TID
• 3-4 months: Audiogram
– Air bone gap
– Tympanogram no longer reliable. Type B tymp despite
normal hearing
 Criticisms of Cartilage T-plasty

• Time consuming to shape cartilage

• Opaque - Difficulty in surveillance
• Rigidity of cartilage raises concern about
audiologic outcome
 Effect of TM perforation on Hearing
• Diminished surface area on which sound pressure
can exert
– Decreased area effect of TM: stapes footplate (normally
17:1)
–  dampening of lever action of the ossicular chain
• Sound reaching round window at same intensity and
phase as oval window  cancelling fluid vibration in
cochlear
• Sound pressure entering the perforation acts on the
medial surface of the TM against that on the lateral
surface
 Hearing Results: Dornhoffer et al.
• 95 patients who failed at least 1 temporalis fascia graft
tympanoplasty
• 29 required OCR
• Avg f/u 12 months
• 90/95 (94.7%) with successful TM closure
• Pediatric group has similar success rate as adults
• PTA (p < 0.001)
– Preop: 24.6
– Postop: 12.2

EBM III
 Hearing Results: Gerber 2000
• 11 patients
• 2 groups: Cartilage vs. temporalis fascia
• Intact ossicular chain
• Size of graft: 1/3 – 2/3 of mesotympanum
• Tragal cartilage island graft (10), conchal (1)
• Primary indication: Retraction pocket
• Post-auricular or transcanal
• Average f/u: 12 months

EBM III
Hearing Results: Gerber 2000
Hearing Results: Gerber 2000
Thickness of Cartilage graft

Murbe D 2002
Acoustic Properties
Management of Middle ear effusion postop

• Appearance of TM
• Air-bone gap on audiogram
• CT temporal bone
• Initial treatment:
– Nasal steroids
– Valsalva
– 3 months
• Surgical treatment:
– Myringotomy (eg. CO2 laser)
– Tympanostomy tube (eg. soft Goode tube)
 High Risk perforation
• Account for 1/3 cases of cartilage
tympanoplasty
• > 95% successful closure of TM after cartilage
t-plasty
• 5 % requires postop MT
• Hearing results comparable to fascia graft
 Ossicular Chain Reconstruction
• Cartilage reinforces prosthesis to prevent
extrusion
• When malleus is present
– Palisade technique over island flap (obscure
malleus and reconstruction)
• When malleus is absent
– Tragal cartilage island flap
Cartilage T-plasty with TORP
 Cholesteatoma
• Palisade technique preferred
– Allow precise placement of prosthesis
against the malleus
• Leave anterior TM without cartilage
to allow surveillance and future
tube placement
• Consider 2nd look if sac disrupted
during initial cholesteatoma
excision
 Pervasive Eustachian Tube Dysfunction

• Criteria for intraoperative tube placement

– Craniofacial abnormalities
– Nasopharyngeal carcinoma
– Recurrent otitis media with ETD
• Round knife used to create a window in the
anterior graft
• Goode tube placed prior to insetting the graft
 Conclusions
• Cartilage tympanoplasty is a reliable
technique in reconstruction of TM
• Hearing results after cartilage tympanoplasty
is comparable to temporalis fascia graft
• Choice of techniques depend on surgeon’s
preference, status of ossicular chain,
Eutstachian tube, presence of cholesteatoma,
etc.
Thank You!
Mastoid Surgeries

DR HARVINDER KUMAR
PROF & HEAD
ENT,PIMS
 Cortical Mastoidectomy
• Removal of disease mucosa and bone along
with incision and drainage
• This is a transcortical opening of the mastoid
air cell and the antrum.
• It is the initial stage of any transmastoid
surgery of the middle ear, inner ear, facial
nerve, endolymphatic sac, labyrinth, internal
auditory canal and various procedures on the
skull base for removing skull base tumors.
 Cortical Mastoidectomy
Other terminologies:
1. Simple mastoidectomy:
2. Schwartz mastoidectomy
3. Conservative mastoidectomy
4. Complete mastoidectomy
 Cortical Mastoidectomy
Incision :
• 1. Postauricular incision of Wilde
• 2. End aural incision of Lempert)

Post auricular incision:

• Most widely used
• Gives best exposure
• Used in well pneumatized mastoids
• 1 to 1 ½ cms behind postauricular crease
• Useful for Palva method of creating subcutaneous flap for mastoid obliteration.
• Heal rapidly, flap infection rare
• cosmetically acceptable.
• Preservation of the size and anatomy of external auditory meatus.
• When placed more posteriorly provides wider exposure necessary for translabyrinthine, retro
labyrinthine, retrosigmoid approaches to CP angle.
• Should not be placed directly on postauricular crease because cleaning becomes difficult.

Under 2 years of age, incision should be horizontal

End-Aural Incision:
• For temporal bones with restricted pneumatization.
 Cortical Mastoidectomy
Indications:
• 1. ASOM not responding to antibiotic therapy and proceeding to coalescent mastoiditis.
• 2. Acute mastoiditis with impending or coexisting complications [subperiosteal abscess,
zygomatic, Bezold’s, Citelli’s, meatal abscess (Luc’s abscess), sagging of posterosuperior canal
wall, positive reservoir sign,
• 3. Masked or latent mastoiditis
• 4. Prior to tympanoplasty
• 5. CSOM with mastoiditis where non-surgical management fails.
• 6. Refractory secretory otitis media.
• 7. Persistent profuse otorrhea
• 8. cochlear implantation.
• 9. Exposure of mastoid segment of facial nerve.
• 10. Exposure of mastoid region in CAT to delinate vertical portion of facial nerve and to
provide access for opening the posterior tympanotomy into middle ear.
• 11. Saccus decompression surgery
• 12. Trans-labyrinthine operations to allow access to the internal auditory meatus.
• 13. Retro-labyrinthine approach to the vestibular nerve.
 Cortical Mastoidectomy
Contraindication:
• No absolute contraindications
• Uncontrolled systemic diseases.
Instruments:
Periosteum elevator,
Mollison self retaining retractor,
Mastoid gauge and Hammers
Aural forceps, Artery forceps
Burr machine with burrs
Cell seeker with blunt probe,
10 ml syringe- for pouring water, Suture material,
Needle holder,
 Cortical Mastoidectomy
Anesthesia:
General Anesthesia
Position:
Supine with ring below the head
Head slightly turned towards opposite side
Macewans’s triangle:
Surface marking of mastoid antrum –
Anteriorly : by the posterior sup. Meatal wall
Superiorly : by supramastoid crest
Posteriorly : a vertical tangential line drawn
through the post wall of Ext. Audiyory canal

Mastoid antrum lies 1.5 cms deep

 Cortical Mastoidectomy
Steps of Operation:
• The area to be operated upon is clean and drapped
• Postauricular incision is given about ½ “ from the
retroauricular sulcus
Under 2 yrs of age : incision is given more
horizontal as Facial nerve is more superficial & mastoid is not
fully developed
• Periosteum incised and elevated with mastoid periosteal
elevator.
• Mollison’s self-retaining retractor is inserted to hold the
soft tissues away from the underlying exposed bone.
• Spine of Henle, MacEwen’s triangle and the posterior bony
margin of the meatus visualized.
• Bone of mastoid cortex is removed over MacEwen’s triangle
with gauge and hammer or using a drill fitted with burr till
all reached the mastoid antrum
 Cortical Mastoidectomy
• Exenteration of all the mastoid air cells is done with
• Superiorly : up to tegmen plate,
• posteriorly up to sinus plate,
• inferiorly upto mastoid tip
• anteriorly upto EAC
• medially upto lateral semi circular canal cover
• Opening of the antrum is enlarged
• From the antrum various cells tract are followed
• A drain is kept in the mastoid cavity and wound is closed in
• With antibiotic coverage, the wound may be sutured without any
drainage.
• A mastoid dressing is applied.
 Cortical Mastoidectomy
The landmarks seen after cortical mastoidectomy
include:
• Dural (Middle Cranial fossa) plate.
• Sigmoid sinus plate.
• Sinodural angle plate.
• Thinned bony posterior canal wall.
• Bony lateral semicircular canal at the floor of
antrum.
• Mastoid tip air cells.
• External genu of facial nerve.
• Fossa incudis.
Cortical Mastoidectomy
 Cortical Mastoidectomy
Post Operative care:
Antibiotics, anti-inflammatory, analgesic,
decongestant are given
Keep the operated ear up.
Drain can be removed after 48 hrs
Mastoid dressing can be removed on 7th or 10th
day along with sutures.
 Cortical Mastoidectomy
• Facial nerve injury:
Heat generated by diamond burr can cause nerve
injury.
Facial nerve can be traumatized during surgery.
By instrumentation during surgery
• Sigmoid sinus injury: Injury to the sigmoid sinus, the superior
petrosal sinus, jugular bulb, mastoid emissary vein result in profuse
bleeding which can be controlled by occlusion by packing with gel
foam
• Injury to the tegman plate with CSF leak- gel foam packing
• Dislocation or removal of the incus: Dislocation or removal of the
incus results in severe conductive hearing loss. This can be
managed by tympanoplasty operation.
• Injury to Labyrinth may cause giddiness
• Persistence of discharge from the ear
• Meatal stenosis
 MODIFIED RADICAL MASTOIDECTOMY
• Modified radical mastoidectomy (MRM) is a surgical
procedure where the disease process is eradicated from
the middle ear cleft; followed by converting the mastoid
cavity, middle ear and external auditory canal into a single,
smooth, self cleansing cavity exteriorized through external
auditory canal (EAC) leaving behind healthy tissues
whenever possible for the future reconstruction of sound
conducting mechanism.
Objectives of MRM
• Safe ear
• Dry ear
• Preservation and reconstruction of sound conducting
mechanism
 MODIFIED RADICAL MASTOIDECTOMY
• Indications for MRM
• 1. Cholesteatoma with recurrent ear
• 2. In atticoantral disease (AAD), where combined
approach tympanoplasty :
• (a) Is difficult - small sclerotic mastoids.
• (b) Cannot be done due to inexperience of the surgeon.
• (c) Should not be done in patient not willing to come for
regular follow-up.
• 3. Disease in the only hearing ear.
• 4. Unconstructable posterior canal wall.
• 5. Labyrinthine fistula.
• 6. CSOM associated with severe complications.
 MODIFIED RADICAL MASTOIDECTOMY

• Contraindications
• 1. Benign chronic otorrhea without cholesteatoma.
• 2. Acute otitis media with coalescent mastoiditis.
• 3. Persistent secretary otitis media or chronic allergic
otitis media.
• 4. Tubercular otitis media

• Approaches
• Endaural Approach
• Postaural Approach
 MODIFIED RADICAL MASTOIDECTOMY
Advantages of Canal Wall Down Mastoidectomy include:
• 1. Residual cholesteatoma is visible on follow up.
• 2. Recurrent cholesteatoma is rare.
• 3. Complete exteriorization of facial recess.
• 4. Second stage is rarely required.

Disadvantages include:
• 1. Mastoid cavity problems.
• 2. Shallow middle ear, which is difficult to reconstruct.
• 3. Position of pinna may be altered.
• 4. Postoperative vertigo due to caloric stimulation of
lateral semicircular canal.
 MODIFIED RADICAL MASTOIDECTOMY

• Same as in cortical mastoidectomy

• Preservation of Posterior canal skin is done by
elevating the posterior and superior canal wall skin
along with posterior annulus and reflecting it
anteriorly.
 MODIFIED RADICAL MASTOIDECTOMY

• Facial bridge is that portion of posterosuperior

bony meatal wall that bridges over the notch of
Rivinus and overlies the ossicles.
This is removed with cutting burr working
outwards and away from fallopian canal
• Facial ridge is that part of posterior bony meatal
wall which houses the posterior bend and
vertical segment of facial nerve.
The bone is lowered up to the level of digastric
ridge so that it comes at the level of the flor of the
EAC
 MODIFIED RADICAL MASTOIDECTOMY

Meatoplasty :
A window is created by giving an incisionin the post
canal wall and reflecting the edges.
This should be wide enough
Advantage:
1. It allows better aeration of the mastoid cavity
2. Easy visualization of entire cavity
3. It facilitate post operative care and self cleaning
or suction of cavity
MODIFIED RADICAL MASTOIDECTOMY
 MODIFIED RADICAL MASTOIDECTOMY

Complications:
Intraoperative:
• Injury to :
Dura mater
Sigmoid sinus
Facial nerve
Labyrinth—Total hearing loss
2. Bleeding from the dura, sinodural angle, sigmoid
sinus, middle ear and facial nerve
 MODIFIED RADICAL MASTOIDECTOMY
• Postoperative
• 1. Recurrent and residual cholesteatoma.
• 2. Persistent otorrhea
• 3. Inadequate epithelization
• 4. Granulations in mastoid cavity- apply AgN03 cautery
• 5. Mucous cyst:
• 6. Perichondritis.
• Late
• 1. Stenosis of the mastoid cavity due to neo-osteogenesis
• 2. Meatal stenosis and closure.
• 3. Mastoidocutaneous fistula.
• 4. Postauricular depression.
• 5. Graft failure.
 MODIFIED RADICAL MASTOIDECTOMY
Causes of Discharging Mastoid Cavity
• 1. Inadequate meatoplasty(Most important reason)
• 2. Too large cavity
• 3. Residual disease in- a. Sinus tympani, b. Facial
recess ,c. Root of zygoma, d. Mastoid tip, e.
Retrofacial region, f. Sinodural angle
• g. Perisinus cells (Retrosigmoid cells), h. Retrolabyrinthine
and supralabyrinthine cells

• 4. Recurrent disease
• 5. Inadequate lowering of facial ridge
• 6. Inadequate removal of anterior and posterior buttresses
• 7. Nasal allergy
• 8 Brain abscess/extradural abscess draining in to mastoid cavity
• 9 CSF otorrhea.
 RADICAL MASTOIDECTOMY
• It is an operation performed to eradicate middle
ear and mastoid disease in which, mastoid
antrum, tympanum and external auditory canal
are converted into a common cavity exteriorized
through the external auditory meatus (removal of
all the structures excepting the footplate of
stapes).

• Is not very popular in modern days because of

the non-feasibility of future reconstruction of the
middle ear.
 RADICAL MASTOIDECTOMY
• Indication for Radical Mastoidectomy
• 1. Unresectable cholesteatoma extending to
eustachian tube.
• 2. Promontory cochlear fistula due to
cholesteatoma.
• 3. Chronic perilabyrinthine osteitis or
cholesteatoma
• 4. Carcinoma of external auditory meatus and
middle ear.
• 5. Childhood necrotizing acute otitis media
leading on to secondary acquired cholesteatoma.
 RADICAL MASTOIDECTOMY
Steps of Radical Mastoidectomy
• Exposure of the mastoid area.
• Cortical mastoidectomy
• Atticotomy
• Canal wall down
• Removal of middle ear contents
• Lowering of facial ridge
• Removing of Inf. Bony annulus
• Cleaning & correcting of the aperture of ET & then seal the
opening
• Polishing the cavity
• meatoplasty
RADICAL MASTOIDECTOMY
 Combined ApproachTympanoplasty
(Canal Up Mastoidectomy)
1. Post auricular incision
• 2. Exposure of Macewen triangle
• 3. Forward elevation of posterior superior meatal wall
• 4. Cortical mastoidectomy with extension into attic
• 5. Identification of chordofacial angle - Short process of incus
superiorly, medially vertical portion of facial nerve, laterally post-
superior meatal wall, inferiorly chorda tympani nerve.
• 6. Exposure of the chordofacial angle (Posterior tympanotomy)
with the help of fine diamond end cutting burr.
• 7. Extension of the lower border of the exposed chordofacial
angle to the hypotympanum.
• 8. Ossicles and ossicular defect can be visualized adequately
when various types of tympanoplasty as given below can be
performed
Thanx