mastoidectomy
TRANSCRIPT
MASTOIDECTOMY
History
Infections of the ear were recorded as early as 380 sc in the Hippocratic canon, and surgery of the mastoid and petrosa developed as a treatment modality for suppurative ear disease.
Riolan the Younger described a procedure skin
to mastoidectomy in 1649, and John Luis Petit performed the first surgical
trephination /цлиндр хөрөөгөөр/ of the mastoid in 1774.
Petit exposed the mastoid cortex,. performed a trephination, and then enlarged the surgically created fistula.
procedure fell into disrepute after the sensational death of Danish physician Johanne Gust Von Berger in 1792.
He died of meningitis 12 days after a mastoidectomy performed by Koelpin and Callisen.
The first postauricular incision was introduced in 1853 by Sir Willium Wilde of Dublin.
Fortunately, Schwartze repopularized the operation in 1873.
Since then, technological advancements such as the operating microscope. the high-speed drill, and specialized microsurgical instruments have led to significant improvements in the treatment of mastoid disease.
CLASSIFICATIONS
Traditionally, classified as :1. Simple (cortical, complete) mastoidectomy 2. Modified radical mastoidectomy3. Radical mastoidectomy A fourth procedure, Tympanomastoidectomy ,
combines the simple mastoidectomy with a middle-ear procedure, maintaining the posterior and superior canal walls.
Depending on the fact whether postero-superior canal is removed or not,
1. Canal Wall Up mastoidectomy 2. Canal Wall Down mastoidectomy.
SUBCLASSIFICATION (M.Tos)
CANAL WALL UP (CWU) CANAL WALL DOWN (CWD)
1. Simple/ cortical/ complete/ Schwartze’s mastoidectomy
1. Atticotomy
2. Classic Intact Canal Wall Mastoidectomy/ Combined Approach Tympanoplasty (CAT)
2. Atticoantrotomy
3. Radical Mastoidectomy
4. Modified Radical Mastoidectomy/ bondy’s Procedure
5. Retrograde Mastoidectomy
Depending upon the mastoid cavity, 1. Open Technique 2. Closed Technique
ANATOMICAL CONSIDERATIONS
The temporal bone consists of four parts: squamous, tympanic, mastoid, and petrous (Figs.)
Important surface landmarks on the mastoid include the temporal line, which extends posteriorly from the zygomatic root and is the insertion site for the temporalis muscle.
Хөхөнцөрийн чухал таних тэмдгүүдийн нэг болох чамархайн шугам нь шанаа ясны угнаас арагш байх бөгөөд чамархайн булчинд руу орсон байж болно.
The suprameatal spine of Henle is a small bony protuberance extending superficially from the posterior and superior bony EAC.
Posterior to the suprameatal spine, a group of small holes is seen, described as the cribriform area. /suprameatal spine-н ард жижиг нүхнүүдийн бүрдэл байна
This cribriform area lies within Macewen’s triangle, an imaginary triangle defined by three lines-
1. Temporal line 2. Line formed by the superior and posterior
margins of the external bony meatus /сонсголын
гадна сувгийн ар дээд ирмэг / 3. Line drawn perpendicular to the first line
and tangential to the second. /эхний шугаманд перпендикуляр татаад хоёр дахь шугамруу шүргэх төдий
Mastoid antrum lies around 1.25 cm to 1.5 cm deep from the surface of Macewen’s triangle. / Macewen’s гурвалжингаас 1,25-1,5 см гүнд хөхөнцөрийн хөндий оршино
Cymba concha is the soft tissue anatomical landmark for the mastoid antrum.
Citelli’s angle (Sinodural angle)- is an angle between the sigmoid sinus and middle fossa dural plate. /сигмойд синус , гавлын дунд хотгорын хооронд /
Solid angle is an area where three bony semicircular canals meet. / 3 тал цагирган сувгийн уулзах цэгт/
Trautmann’s triangle is bounded by bony labyrinth (solid angle) anteriorly, sigmoid sinus posteriorly and dura superiorly. Дотор чихний урд ясан хана , синус сигмойдын хойд тал хатуу хальсаар хязгаарлагдана
Donaldson’s line is a line passing through the horizontal semicircular canal and bisects the posterior semicircular canal. Тал цагирган суьгийн хөндлөн зүслэгийг 2 хувааж түүний арийн сувгийг дайруулан татсан шугам
This line is a landmark for the endolymphatic sac.
APPROACHES And ROUTES
The term ‘Approach’ means the method of access to the middle ear through the soft tissues.
eg. Endaural approach, Retroauricular /post/ approach.
The term ‘Route’ means the method of access to the middle ear through the bone.
eg. Transcortical route, Transmeatal Route.
CORTICAL MASTOIDECTOMY
CORTICAL MASTOIDECTOMY (Schwartze 1873) is a transcortical opening of the mastoid cells and the antrum.
It is the initial stage of any transmastoid surgery of the
1)middle ear 2)inner ear, 3) facial nerve, 4)endolymphatic sac, 5) labyrinth, 6) I.A.C and 7) skull base.
SIMPLE MASTOIDECTOMY – This term is usually used when mastoidectomy is done for drainage of a mastoid abscess.
COMBINED APPROACH TYMPANOPLASTY
(CAT)/ CLASSIC INTACT CANAL WALL MASTOIDECTOMY
CAT consists of a large mastoidectomy with an intact but thin bony ear canal wall and a posterior atticotympanotomy.
The intact canal wall technique is performed in two stages.
The first operation is performed to remove all cholesteatoma and repair the tympanic membrane.
Өргөн хэмжээний хагалгаа боловч Сувгийн ханыг гэмтээлгүй арын аттиктимпанотому хийгддэг.
Сувгийн ханийг гэмтээхгүй хийх техник нь үе шаттай явагдана. 1. бүх холестетомыг цэвэрлэн хэнгэрэг нөхнө.
2. 6 сарын дараа дахин холестетома үүссэн эсэх мөн сонсгол сайжирсан эсэхийг шалгаад сонсголын ясны нөхөн сэргээлтийг хийнэ.
Six months later, the second operation is performed to inspect the mastoid and middle ear for residual or recurrent cholesteatoma and to improve hearing by ossicular reconstruction.
ATTICOANTROTOMY- is an extension of the atticotomy in a posterior direction through the transmeatal route, in which lateral attic and aditus walls are removed, and the antrum is entered.
It can be performed through the transcortical route, but is usually performed through a transmeatal route.
BONDY’S OPERATION – An atticoantrotomy is called as Bondy’s operation if the tympanic cavity is not entered.
If the tympanic cavity is entered, it is NOT described as BONDY’S operation but as an atticoantrotomy or conservative radical operation.
MODIFIED RADICAL MASTOIDECTOMY
Classically, modified radical mastoidectomy refers to the Bondy procedure, in which disease limited to the epitympanum is simply exteriorized by removing portions of the adjacent superior or posterior canal wall.
Эпитимпанум шууд харагдаж байхаар Сувгийн ар болон дээд ханыг авах
A primary feature of the modified radical procedure is complete removal of the posterior canal wall, the major reason for failure of the Bondy procedure. Сувгийн ар ханыг бүрэн авах нь Bondy procedure-г бүтэлгүй болгох гол шалтгаан болно
RADICAL MASTOIDECTOMY
Radical mastoidectomy is a canal wall down mastoidectomy performed to eradicate disease from middle ear cleft in which mastoid cavity, tympanum and EAC are converted into a common cavity exteriorised through the EAC, wherein the structures of tympanic cavity (remnants of the incus and malleus, and the drum remnant) are removed. дунд чихний хөндийгөөс мастойд хөндий , сонсголын дотор суваг хүртэл цэвэрлэж сонсголын алх дөрөө яснуудыг авна
INDICATIONS
INDICATIONS OF CORTICAL MASTOIDECTOMY
1) Coalescent Mastoiditis and Masked Mastoiditis.2) Active Refractory to antibiotics.3) Secretory otitis media Refractory to antibiotics.4) Approach to:-Endolymphatic sac surgery.-Facial nerve decompression.-Vestibulo cochlear nerve section.-Translabyrinthine Approach for CP angle.-Cochlear implant surgery.-Combined Approach Tympanoplasty.
Indications For MRM
Absolute Indications (Shambaugh):1. Unresectable disease 2. Unreconstructable Posterior canal wall3. Failure of first stage CWU procedure because
of poor E T function.4. Inadequate Patient Follow up. Хангалтгүй
Relative Indications (Shambaugh):1. Disease in only hearing ear or in a dead ear.2. Medical illness3. Severe otologic or CNS complications4. Neoplasms5. Poor E T function.
CONTRAINDICATIONS
1. Chronic otitis media without cholesteatoma2. Acute otitis media with coalescent
mastoiditis,3. persistent secretory otitis media, or4. Chronic allergic otitis media.5. Tuberculous otitis media.
Indications For Radical Mastoidectomy (shambaugh)
1. Unresectable cholesteatoma extending down the Eustachian tube or into the petrous apex
2. Promontory cochlear fistula caused by cholesteatoma
3. Chronic perilabyrinthine osteitis or cholesteatoma that cannot be removed and must be cleaned or inspected periodically
4. Resection of temporal bone neoplasms with periodic monitoring
OPERATIVE TECHNIQUES(CWU)
Preparation- General anesthesia without paralytic agents
and with continuous facial nerve Monitoring. Tragus and postauricular skin are injected
with 1% lidocaine with epinephrine (1: 100,000) to provide hemostasis and local anesthesia.
“Pre-scrub" the ear and the entire side of the head, including hair, with betadine.
The surgical site is
then prepped and draped in sterile fashion.
INCISION
The postauricular incision is made from helical rim to mastoid tip, approximately 1 cm posterior to the sulcus.
Care is taken to avoid making the incision in the sulcus as this can make closure more difficult.
A T-shaped incision is made in the mastoid periosteum to expose the mastoid cortex
An incision is made along the linea temporalis, to the level of the underlying bone.
A second periosteal incision is made perpendicular to the linea temporalis and is carried down to the mastoid tip.
.
Using the Lempert elevator, the periosteum is elevated superiorly over the tegmen, posteriorly over the sigmoid sinus, and anteriorly to the level of the EAC meatus.
Two self-retaining retractorsare used perpendicular to each other to expose the entiremastoid and EAC
COMPLICATIONS
Trauma to Dura Horizontal Semicircular Fistula Trauma to Facial Nerve Sigmoid Sinus and Jugular Bulb Injury. Post operation infection
