C.S.O.M.: Mastoidectomy

Dr. Vishal Sharma

Schwartze’s Cortical Mastoidectomy

Middle ear cleft (Right)

Cortical Mastoidectomy

Boundaries of cavity

• Superior: Dural or Tegmen plate

• Anterior: Posterior wall of external auditory canal

• Inferior: Digastric ridge

• Posterior: Sigmoid sinus plate

• Medially: Lateral semicircular canal

Normal temporal bone (right)

Cortical Mastoidectomy

Indications

1. Coalescent mastoiditis & Masked mastoiditis2. CSOM T.T.D. active refractory to antibiotics3. Secretory otitis media refractory to antibiotics4. Approach to:

Endolymphatic sac surgery Facial nerve decompression Vestibulo-cochlear nerve section Translabyrinthine approach for C.P. angle Cochlear implant surgery Combined approach tympanoplasty

Antiseptic dressing

Draping

Infiltration with Lignocaine

Marking of incision

Wilde’s post-aural incision

Incision deepened till periosteum

Musculo-periosteal flap elevated

Bezold’s abscess

Aspiration of pus

Drainage of abscess

Drainage of abscess

Corical mastoidectomy begun

Exposure of mastoid antrum

Widening of aditus

Aditus widened

Final Cavity (right)

Final Cavity (left)

Drain put in mastoid cavity

Mastoid dressing

Healed post-aural scar

Treatment for Attico-antral disease

Topical ear drops + frequent suction clearance

Indications:

1. Early disease with shallow retraction pocket

2. Only hearing ear with cholesteatoma

3. Elderly patients

4. Pts who are not fit for surgery under G.A.

5. Pts who can regularly come for follow up

Medical Treatment

Canal Wall down:

• Attico-antrostomy

• Modified Radical Mastoidectomy (MRM)

• Radical Mastoidectomy

Canal Wall up:

• Combined Approach Tympanoplasty (CAT)

Surgical Treatment

Mac Ewan’s triangle

Canal Wall Up Mastoidectomy

Canal Wall Down Mastoidectomy

Middle ear cleft

Attico-antrostomy

Modified Radical Mastoidectomy

Pre-operative Anatomy

Cortical Mastoidectomy done

Modified Radical Mastoidectomy

Surgical Steps

• Perform cortical mastoidectomy

• Lower facial ridge & break facial bridge

• Remove cholesteatoma & granulations from

mastoid air cells & middle ear cavity

• Preserve healthy mucosa, T.M. remnant & ossicles

• Mastoid cavity & E.A.C. become a single cavity

seperated by middle ear cavity

• Perform tympanoplasty. Do concho-meatoplasty.

Antiseptic dressing

Draping

Infiltration

Infiltration

Marking of incision

Wilde’s post-aural incision

Wilde’s post-aural incision

End-aural incision

Incision deepened till periosteum

Incision deepened till periosteum

Temporalis fascia graft

Periosteum incised

Periosteal flap elevated

Mastoid cortex exposed

Posterior canal wall incision

Posterior canal wall vascular strip

Vascular strip retracted laterally

Drill cuts on mastoid cortex

Corical mastoidectomy begun

Cholesteatoma in mastoid cavity

Exposure of mastoid antrum

Widening of aditus

Aditus widened

Cortical mastoidectomy cavity

Facial ridge lowering started

Breaking of facial bridge

Elevation of tympanomeatal flap

Elevation of tympanomeatal flap

Removal of cholesteatoma over lateral SCC

Retrofacial & labyrinthine cells removed

Incudo-stapedial joint separated

Malleus head nipped off

Tensor tympani tendon cut

Cholesteatoma removal from attic

Exposure of sinus tympani

ET orifice plugged with malleus head

MRM cavity

MRM cavity (ossicles preserved)

Sites of facial nerve injury

Korner’s meatoplasty incision

Flap elevated

Conchal cartilage cut

Flap sutured posteriorly

Healed Concho-meatoplasty

Post-aural incision closed

Radical Mastoidectomy

Radical Mastoidectomy

Surgical Steps

• Perform cortical mastoidectomy. Lower facial ridge

& break facial bridge. Remove cholesteatoma &

granulations from mastoid air cells & middle ear.

• Remove normal middle ear mucosa, T.M. remnant &

ossicles (except stapes footplate).

• Close Eustachian tube opening. No tympanoplasty

done. Concho-meatoplasty performed.

• Mastoid, E.A.C. & middle ear become single cavity.

Indications1. CSOM attico-antral disease with

Intra-cranial complication

Recurrence after modified radical mastoidectomy

Profound sensori-neural hearing loss (?)

2. Limited malignancy of middle ear

3. Glomus jugulare

4. Osteomyelitis of temporal bone

Causes of discharging mastoid

cavity

1. Inadequate concho-meatoplasty2. Recurrence of cholesteatoma 3. Residual cholesteatoma: facial ridge, facial

bridge, anterior + posterior buttress, mastoid tip, sinus tympani, anterior epitympanum

4. Persistent infection: petrositis, T.B., sinusitis

5. Persistent allergy6. Retained foreign body: cotton ball

7. Persistent extra-dural abscess8. Wrong indication

Combined Approach Tympanoplasty

Surgical Steps

1. Cortical Mastoidectomy

2. Anterior tympanotomy: via tympano-meatal

flap

3. Posterior tympanotomy: via facial recess

4. Tympanoplasty

Cortical Mastoidectomy

Anterior Tympanotomy

Posterior Tympanotomy

Tympanoplasty

Thank You