OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

MASTOIDECTOMY & EPITYMPANECTOMY Tashneem Harris & Thomas Linder

Chronic otitis media, with or without cho- to describe the different types of mastoid-
lesteatoma, is one of the more common ectomy as summarized in Table 1.
indications for performing a mastoidecto-
my. Mastoidectomy permits access to re- Table 1: Types of mastoidectomy
move cholesteatoma matrix or diseased air
cells in chronic otitis media. Mastoidec- Canal wall up Canal wall down
mastoidectomy mastoidectomy
tomy is one of the key steps in placing a
cochlear implant. Here a mastoidectomy Combined approach Radical mastoidectomy

allows the surgeon access to the middle ear Intact canal wall Modified radical
mastoidectomy mastoidectomy
through the facial recess. A complete
Closed technique Open technique
mastoidectomy is not necessary; therefore,
the term anterior mastoidectomy is often Front-to-back mastoidectomy
used (anterior to the sigmoid sinus). A Atticoantrostomy
mastoidectomy is often an initial step in Open mastoidoepitympanec-
lateral skull base surgery for tumours tomy
involving the lateral skull base, including
vestibular schwannomas, meningiomas, One of the problems is that the termino-
temporal bone paragangliomas (glomus logy does not in fact entail specific infor-
tumours), and epidermoids or repair of mation about what was done either to the
CSF leaks arising from the temporal bone. middle ear or the mastoid. It is the authors’
preference to use the terms open/closed
Definition of Cholesteatoma mastoidoepitympanectomy and to state
separately whether a tympanoplasty or
Cholesteatoma is a chronic middle ear in- ossiculoplasty was done e.g. left open
fection with squamous epithelium and mastoidoepitympanectomy and tympano-
retention of keratin in the middle ear and/ plasty type III.
or temporal bone with progressive bone
erosion. A middle ear atelectasis does not The most commonly used terms for canal
retain keratin, although it also reveals skin wall down mastoidectomy are radical or
in the middle ear space due to the retrac- modified radical mastoidectomy. The clas-
tion pocket. sical radical mastoidectomy is not fav-
oured by the authors as it results in a large
Aims of Cholesteatoma Surgery cavity which frequently discharges and
therefore does not satisfy the ultimate goal
• Eradication of disease and preventing of mastoid surgery which includes having
residual disease a “trouble free” cavity.
• Improving middle ear ventilation and
preventing recurrent disease The method of open and closed mastoido-
• Creating a dry, self-cleansing cavity epitympanectomy as described in this text
is standard. Common to both open and
• Reconstitution of the hearing mecha-
closed mastoidoepitympanectomy is the
nism
bony work involving the mastoid cavity. It
involves first identifying the important
Types of Mastoidectomy
landmarks (= skeletonization = leaving a
thin shelf of bone covering the important
The terminology around mastoid surgery is
structure) before removing the disease and
not uniform. In fact, several terms are used
maximum exposure for complete Epitympanotomy: Partial removal of the
exenteration of the disease. lateral wall of the attic to expose the head
of the malleus and incus in order to remove
A closed technique, keeping the posterior soft tissue pathology in the epitympanum;
canal wall in place and working transcanal the ossicles are left in place
(following a proper canalplasty) and trans-
mastoid (with or without posterior tympan- Epitympanectomy: Removal of the lateral
otomy) is suggested in moderately pneum- wall of the attic, with removal of the incus
atized and ventilated ears with sufficient and head of malleus and with exenteration
exposure to remove the disease. and exteriorisation of supralabyrinthine
cells
Open mastoidoepitympanectomy involves
complete exenteration of the mastoid air Cortical mastoidectomy: Also referred to
cell system (e.g. retrosigmoid, retrofacial, as simple mastoidectomy, it entails exen-
perilabyrinthine) and the epitympanum teration of the mastoid air cells and is
(removal of incus and malleus head, performed most commonly for acute mas-
exenteration of the supralabyrinthine and toiditis
supratubal cells) and is indicated in poorly
pneumatized and ventilated ears with Posterior tympanotomy: Drilling away of
limited access and exposure. It requires the bone between the pyramidal (mastoid)
skeletonization of the facial nerve along segment of the facial nerve, and the lateral
the mastoid segment to lower the posterior bony canal and chorda tympani resulting in
canal wall to the facial nerve (still covered access to the middle ear from the mastoid.
by bone). The mastoid area behind the Posterior tympanotomy may be done for
facial nerve is later obliterated with a the following reasons:
muscle flap to keep the volume of the final • As part of a closed mastoidoepitympa-
cavity low and avoid discharging ears. nectomy (combined approach) when
removing cholesteatoma
The other method of “canal wall down” • To remove pus from the region of the
mastoidectomy is front-to-back mastoidec- round window in acute bacterial or
tomy. Surgeons may elect this approach viral otitis media with sensorineural
when it has been decided in advance that hearing loss
the canal wall will be taken down e.g. with • To provide access to the promontory or
a sclerotic mastoid. The principles of this round window in cochlear implant sur-
method are that one follows the disease, gery and access to incus or round
i.e. the mastoid is only opened as far as the window with insertion of the Vibrant
extent of the disease. The only problem Soundbridge
with this approach is that one must be
certain that there are no more mastoid cells Closed mastoidoepitympanectomy with
present as incomplete exenteration will tympanoplasty: This includes a canalplas-
cause a discharging cavity. ty, mastoidectomy, epitympanectomy,
(posterior tympanotomy) and tympano-
Surgical Terminology plasty. The external bony canal is pre-
served. The drawback of this approach is
Canalplasty: Enlargement of the external the limited view into the anterior epi-
ear canal while avoiding injury to the tem- tympanum and the sinus tympani in cases
poromandibular joint anteriorly and the of limited pneumatisation and cholestea-
mastoid air cells posteriorly (Video) toma formation

2
Open mastoidoepitympanectomy (with Applied Anatomy
obliteration): This involves the radical
exenteration of the tympanomastoid tracts Knowledge of middle ear and temporal
with exteriorisation of the surgical cavity bone anatomy is vital to understanding the
and lowering of the posterior bony canal concepts of surgical management. It is
wall to the level of the skeletonised facial imperative to practise the surgery and learn
nerve. In order to reduce the size of the the 3-dimensional temporal bone anatomy
cavity, especially with moderately-well in a temporal bone laboratory. The impor-
pneumatised mastoids, the mastoid tip is tant landmarks and structures will be high-
removed and a myosubcutaneous occipital lighted with the surgical steps.
flap is created to reduce the size of the
cavity. Meatoplasty is routinely performed. Preoperative assessment

Open/Closed Mastoidoepitympanectomy History

Age is not a limiting factor as children Patients with chronic ear disease frequen-
behave equally well with open MET’s as tly have a longstanding history of hearing
do adult patients! loss or chronic otorrhoea. It is important to
establish whether there is a history of
Deciding whether to do open or closed previous surgery. Foul smelling otorrhoea
cavity mastoidoepitym-panectomy may is a clear hint of cholesteatoma.
depend on the factors listed in Table 2.
Otomicroscopy
Factor Closed MET Open MET
Extent of Limited Large cholestea-
disease toma
This is an important means to determine
Primary surgery the presence of cholesteatoma and it helps
with sufficient Labyrinthine to define the extent of disease. The ear
space fistula
should be thoroughly cleaned of secretions
Other complica- and debris. Findings may include a retrac-
tions tion pocket with accumulation of keratin in
Recurrent
the attic or in the posterosuperior quadrant
cholesteatoma of the tympanic membrane, granulation
after previous tissue or a polyp (Figures 1 & 2). A polyp
closed MET
Pneumatisation Good Poor
“signals” an underlying cholesteatoma.
pneumatisation pneumatisation
Aeration Air in middle Glue in middle Pneumatic otoscopy
ear and mastoid ear
air cells
Granulation tissue This should be routinely performed to
in mastoid air determine the presence of a positive fistula
cells response. A negative response however
Bleeding does not exclude a fistula.
Follow-up Good 5-year Poor 5-year
follow-up follow-up Audiology
anticipated anticipated

Table 2: Indications for closed vs. open Pure tone audiometry should be obtained
cavity mastoidoepitympanectomy (MET) with air and bone conduction, and also
speech reception thresholds should be

3
determined. These should be done within 3 HRCT (0,5mm cuts) is invaluable for both
months of surgery. for diagnosis and surgical planning. Pre-
operative counselling is mandatory with
any surgical procedure. Information gained
from the CT scan enables the surgeon to
discuss in detail with the patient what the
surgical goals and risks of the surgery are,
as well as the possibility of a staged proce-
dure and follow-up routine.

Diagnostic value of HRCT

• Specificity is poor with mass lesions

which may include granulation tissue,
secretions, cholesterol granuloma or a
neoplasm
• It therefore cannot be used to definiti-
Figure 1: Right ear: Granulation tissue in
vely diagnose cholesteatoma, which
the attic and a retracted tympanic mem-
remains a clinical diagnosis based on
brane; bony erosion of the superior canal
otoscopic findings
wall; lenticular and long process of the
incus is present with retraction of postero- • Findings highly suggestive of choles-
superior quadrant of tympanic membrane; teatoma include the presence of an ex-
tympanic membrane is in direct contact pansile soft tissue mass; retraction of
with the stapes superstructure (myringo- the tympanic membrane; erosion of the
stapediopexy) scutum; erosion of the ossicles; sharp
erosion of bone; extension of the les-
ion medial to the otic capsule; and
erosion of the tegmen tympani

Surgical planning with HRCT

HRCT of the temporal bone is the otolo-

gist’s road map and one should have a
systematic approach when evaluating the
CT scan. The decision whether to do an
open or closed cavity operation depends on
the degree of pneumatisation and ventila-
tion of the temporal bone and extent of
disease, all of which can be determined on
HRCT. Axial as well as coronal images are
needed for preoperative evaluation and
should always be in the operating theatre
Figure 2. Right ear: Polyp obscuring pos- and visible to the surgeon as intraoperative
terosuperior retraction pocket reference (and not in the patient’s chart!)
High resolution CT (HRCT) scan

All patients undergoing surgery should

ideally have preoperative imaging as
4
CT scan checklist covered with scar tissue which becom-
es difficult to elevate thus risking
1. Pneumatisation: The temporal bone breaching the sinus when elevating the
may be well pneumatised, may have periosteal flap
reduced pneumatisation, or be sclero- 6. Jugular bulb: Is it high-riding (up to
tic. This gives important information the level of annulus)? Is it dehiscent?
about what the eustachian tube func- 7. Carotid artery: Is there dehiscence, es-
tion during the first 4 years of the pecially at the level of the eustachian
patient’s life was like. It is important to tube?
assess the pneumatisation of the pe- 8. Tegmen tympani: What is the shape of
trous apex as well. Poor ventilation the tegmen? Is it flat or does it slope
favours an open cavity procedure upwards with cells lying medial to it?
2. Ventilation: This is assessed by the Is it low-lying? Is it dehiscent? A bony
aeration of the middle ear and mastoid defect of the tympanic tegmen or
air cells. Opacification of the middle anterior wall of the epitympanum
ear or mastoid cells suggests poor should raise the suspicion of an en-
ventilation of the middle ear cleft. This cephalocoele or cholesteatoma extend-
gives the best information about eusta- ing into the middle cranial fossa. This
chian function at the present time. Poor requires further imaging in the form of
ventilation of already-impaired pneum- an MRI
atised cell tracts favours an open 9. Facial nerve: The tympanic segment
cavity procedure may be dehiscent, especially in chil-
3. Ear canal: Evaluate the thickness of dren or in the presence of cholestea-
the bone anteriorly and posteriorly. toma. In cases of revision surgery, it is
This is important when one needs to do important to know whether the facial
a canalplasty as the anterior relation of nerve has been left exposed in an open
the tympanic bone is the temporo- cavity when elevating the tympano-
mandibular joint and posteriorly are meatal flap
mastoid air cells. These should not be 10. Is there a fistula of the lateral semi-
breached when doing a canalplasty circular canal?
4. Size and presence of emissary vein: A 11. Extent of disease: Does it only involve
large emissary vein can cause trouble- the mesotympanum or does it extend
some bleeding if not anticipated! further into the mastoid cavity? Is the
5. Sigmoid sinus and its relation in the petrous apex involved?
mastoid cavity: In children the sigmoid 12. Status of ossicular chain: Are the
may be very close to the lateral surface ossicles present or have they been
of the mastoid; in adults a sigmoid eroded?
sinus malformation may only be appre-
ciated on preoperative CT scan. When Preoperative preparation
the sigmoid sinus lies very anteriorly in
the mastoid cavity it may be difficult to Drugs: A single intravenous dose of
perform a posterior tympanotomy due amoxicillin with clavulanic acid and an
to very limited exposure. In revision antiemetic is given preoperatively. How-
surgery, it is important to assess whe- ever, antibiotics are unnecessary with a dry
ther the sigmoid sinus has been expo- ear, even in presence of a cholesteatoma.
sed or whether it is still covered by Low dose subcutaneous heparin is
bone. If the sigmoid sinus has been recommended to prevent deep vein throm-
exposed at previous surgery, it will be bosis with prolonged surgery.

5
Positioning: The patient lies supine with tract the pinna forward (Figure 4)
the head rotated away from the surgeon. • For adequate exposure the superior
Avoid overextension in children; Down’s incision must be made at the 12 o’clock
syndrome is associated with atlantoaxial position relative to the bony ear canal
subluxation. (Figure 4)

Facial nerve monitoring: Avoid long-

acting muscle relaxants so that the facial
nerve can be monitored.

Closed Mastoidoepitympanectomy

Skin Incision and flap

• Infiltrate the area of the postauricular

skin incision as with local anaesthetic
(lidocaine 1% and adrenaline diluted to
1:200 000)
Figure 4: Flap elevated in plane just
• Make a curved skin incision about
superficial to temporalis fascia
1,5cm behind the postauricular sulcus
with a #10 blade extending from just
Periosteal flap
above linea temporalis to the mastoid
tip. Do not place the incision in the
• An anteriorly based periosteal flap is
postauricular sulcus (Figure 3)
developed, about 1,5cm in length
• When approaching the mastoid tip, the
(Figure 5)
skin incision follows the skin tension
lines which run directly inferiorly (not
curved) towards the neck

Figure 5: Periosteal flap

• A periosteal raspatory is used to eleva-

Figure 3. Postauricular skin incision te the flap from the bone until the spine
(left ear) of Henlé and the entrance to bony
canal come into view (Figure 6)
• Elevate the skin flap towards the ex- • A sharp towel clip can be placed on the
ternal ear canal. Cut through the post- periosteal flap at the level of the ear
auricular muscle to reach the correct canal to retract the pinna forward
plane just superficial to temporalis
fascia. A large rake can be used to re-

6
 Figure 6: Raspatory used to elevate
flap until spine of Henlé and the
entrance to bony canal come into view Figure 7: Completed canalplasty with
entire annulus visible
• In an adult two self-retaining retractors
are placed between the skin edges and • Elevate the annulus from its sulcus
soft tissue for exposure; one self- away from the pathological area e.g. a
retaining retractor is usually sufficient posterior retraction pocket would pre-
in a child clude entering the middle ear at the
level of the posterior tympanic spine as
Canalplasty this would breach the cholesteatoma
sac (Figure 8)
• If there are any bony overhangs a
canalplasty is performed
• A canalplasty should always be done
first as it defines the anterior limit of
your mastoidectomy
• For a detailed description of the sur-
gical technique readers are referred to
the canalplasty chapter or canalplasty
video
• The entire annulus should be visible
with one view of the microscope
following canalplasty (Figure 7)
Figure 8: Tympanomeatal flap and
Elevation of tympanomeatal flap
annulus have been elevated and middle
ear is entered below the pathological
• The posterior meatal skin flap is
area
elevated towards the annulus using a
microraspatory in one hand and a piece
Inspection of middle ear
of ribbon gauze which has been soaked
in adrenaline
• The middle ear in Figure 8 has been
• The microsuction is never placed
entered at 6 o’clock after excluding a
directly onto the meatal skin for risk of
dehiscent jugular bulb on CT scan
injury of the skin flap
• Define the extent of disease in the mid-
dle ear and around the ossicular chain

7
Division of incudostapedial joint

• To avoid causing a sensorineural hear-

ing loss when working in the epitym-
panum, the incudostapedial joint is
divided using a small joint knife

Antrotomy and Mastoidectomy

Note: Always perform antrotomy and/or

mastoidectomy after the canalplasty has
been done Figure 10: Completed bony exposure

• The principal surgical landmarks are Antrotomy

linea temporalis superiorly, the bony
ear canal and spine of Henlé anteriorly • A common mistake is to search for the
and the mastoid tip inferiorly antrum very low, thus endangering the
• Identify and expose the surgical land- facial nerve
marks (Figures 9, 10) • The safest way to finding the antrum is
• Using the mastoid raspatory, reflect the to follow dura
periosteal tissue superiorly in order to • The tegmen tympani marks the superior
expose the linea temporalis; then re- limit of the dissection
flect periosteum posteriorly where you • Start drilling above linea temporalis
may encounter an emissary vein, and Figures 11, 12)
inferiorly to the mastoid tip
• Identify Macewen’s triangle which is
situated posterosuperiorly to the exter-
nal auditory canal. It is bounded ante-
riorly by the Spine of Henlé and
approximates the position of the
antrum medially (Figure 10, 11)
1

3
Figure 11: Yellow lines indicate where
4 to drill; red star indicates where to
commence drilling
5

6 • Expose tegmen tympani (middle cran-

ial fossa dural plate); it is identified by
7
a change in colour of the bone and
Figure 9: Surface markings of left ear: change in pitch of the burr (Figure 13)
Temporomandibular joint (1); root of zyg- • Always skeletonize the dura of the
oma (2); external ear canal (3); supra- middle cranial fossa (dura seen shining
meatal spine (4); mastoid tip (5); Mace- through thin layer of bone) and follow
wen’s triangle (6); opening of emissary the dural plate of the middle cranial
vein (7) fossa in an anteromedial direction

8
 Incus
Body
Short process

VIIn

Dural plate

LSCC

Figure 12: Drilling along linea tempo-

ralis
Figure 14. Postero-anterior view
through antrotomy and aditus ad
• The lateral semicircular canal is
antrum into epitympanum
encountered next (Figure 13)
• The direction of the drilling now must
Drilling tips
be changed to a medial-to-lateral action
to avoid touching the ossicles which
• Avoid keyhole surgery; work through a
would induce sensorineural hearing
wide space
loss
• The tip of the drill should always be
visible
• Never drill behind edges of bone
• Drilling should always be parallel to
any structure you are trying to preser-
ve e.g. facial nerve, sigmoid sinus
• When drilling deeper in the mastoid
LSSC cavity the burr needs to be lengthened
• One cannot lengthen a cutting burr as
Dural plate this will cause the drill to jump with
the risk of injuring structures (Figure
15)

Figure 13. Dural plate and lateral

semicircular canal

• The body and short process of incus

are the next landmarks one encounters;
the incus is often first identified by its
refraction in the irrigation fluid (Figure
14)
• Medial to the incus the tympanic seg-
ment of the facial nerve (VIIn) is iden- Figure 15: Correct length of a cutting
tified (Figure 14) burr in the drill

9
• Therefore, if it is necessary to lengthen • Next identify the facial nerve
the burr, then change to a rough dia- • The superior landmarks for the mastoid
mond or diamond burr (Figure 16) segment of the facial nerve are the
lateral semicircular canal, to which the
facial nerve runs anteroinferiorly, and
the posterior semicircular canal, to
which the nerve runs 2,5mm anterior
to. The figure below is a cadaver dis-
section which demonstrates the rela-
tionship between the lateral semicir-
cular canal, posterior semicircular
canal and facial nerve (Figure 18)

Incus VII
Figure 16: A diamond burr can be Dura
lengthened to safely drill deeper in the
mastoid
SCC
Mastoidectomy LSC

• Follow the sinodural plate posteriorly

up to the sinodural angle, which is the
area between the sigmoid sinus and PSC
C
dura Sigmoid sinus
• Like the dural plate, the sinus plate is Figure 18: Relations of VIIn to short
identified by the change in colour of process of incus; superior semicircular
the bone and a change in the pitch of canal (SCC); lateral semicircular
the burr canal (LSC); posterior semicircular
• Skeletonise the sigmoid sinus; do not canal (PSC); dura; and sigmoid sinus
expose the sigmoid sinus but leave a
covering of bone over the sinus (Figure • Finding the facial nerve along digastric
17) ridge and the stylomastoid fibers is a
very safe way of identifying the facial
nerve away from any mastoid patholo-
gy
• It requires proper drilling technique
Dural plate
and can easily be learned in the tem-
poral bone laboratory
Sinodural
angle
• When searching for the mastoid seg-
ment of facial the nerve, a large (4-
Sigmoid
sinus
5mm) diamond burr is used
• Use ample irrigation to prevent thermal
Figure 17: Sigmoid sinus, sinodural injury to the nerve
angle and dural plate • The digastric ridge is the distal land-
mark for the mastoid segment of the
• The lateral and posterior semicircular facial nerve. It is a smooth convex
canals are identified and the retro- bone found close to the mastoid tip.
labyrinthine air cells are exenterated The digastric ridge can be difficult to

10
 find in poorly pneumatised temporal • Once the facial nerve has been identi-
bones. Once the sigmoid sinus has fied, the retrofacial cells can be exen-
been skeletonised the digastric ridge is terated
found by drilling inferiorly to the sinus,
close to the mastoid tip, from laterally Posterior tympanotomy
to medially, in a horizontal direction.
• Periosteal fibres run anteriorly from the • The facial nerve is skeletonised leaving
digastric ridge in a plane perpendicular a thin shelf of bone covering the nerve
to the ridge. The facial nerve can be • It is followed proximally towards its
located proximal to the stylomastoid pyramidal segment, just inferior to the
foramen by drilling the last of these lateral semicircular canal
periosteal fibres. One often encounters • The facial recess is approached by dril-
the sensory branch of facial nerve ling away the bone situated between
(which innervates the posterior wall of the pyramidal segment of the facial
the external auditory canal and a por- nerve posteriorly, the chorda tympani,
tion of the tympanic membrane) just and the fossa incudis superiorly
above the stylomastoid foramen. (Figure 20)
• Skeletonise the nerve by drilling in a
wide plane between the lateral semicir-
cular canal proximally and the stylo-
mastoid foramen distally, working Incus

from anteriorly to posteriorly (Figure

19) Chorda

P
Tympanotomy

VIIn

Figure 20: Landmarks for posterior

tympanotomy are VIIn, chorda tympani
and short process of incus

• In the absence of disease in the facial

Figure 19: Distal portion of mastoid recess, the stapes superstructure is
segment of facial nerve (arrow) is visible through the tympanotomy
identified close to digastric ridge • For removal of cholesteatoma in facial
recess one must work from both sides
• Always drill parallel to the course of of the intact posterior external auditory
the facial nerve and use lots of water canal wall
for irrigation. Drill along the lateral
aspect of the nerve; do not drill behind Epitympanotomy
and medial to the fallopian canal
• Watch out for an early take-off of the • If the cholesteatoma does not extend
chorda tympani close to the stylo- significantly into the epitympanum, an
mastoid foramen epitympanotomy (atticotomy) is per-
formed

11
• 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 in-
or attic is removed with a diamond tact
burr; drilling is commenced at 12 • Clear cholesteatoma from the epitym-
o’clock relative to the ear canal, taking panum
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 seg-
ments and geniculum all lie in this very
confined space and may be dehiscent
• The tympanic segment lies in the floor
of the anterior epitympanic recess (Fig
22)

TT Cog
StR

TTymp ET
CP

Figure 21: Direction of drilling with

epitympanotomy or epitympanectomy VIIn

Epitympanectomy
Figure 22: Anatomy of anterior epi-
tympanic recess: Facial nerve (VIIn);
• This is indicated when cholesteatoma Tegmen tympani (TT); Cog; Supratu-
extends medial to the ossicles or over- bal recess StR; Cochleariform process
lies the lateral semicircular canal; in (CP); Eustachian tube (ET)
cases of bony erosion of the ossicles
due to cholesteatoma, the ossicles need
• The cochleariform process is a fairly
to be removed
consistent landmark and the nerve lies
• Only recently, KTP laser evaporation directly superior to it; the semicanal of
of cholesteatoma matrix has been dis- the tensor tympani is sometimes mis-
cussed taken for the facial nerve; however,
• The incus is removed by mobilising it this canal ends at the cochleariform
with a 2,5mm. 45° hook and rotating it process (Figure 22)
laterally, taking care not to injure the • The cog is a bony process in the ante-
underlying facial nerve rior epitympanum which extends from
• The malleus head is severed with a the tegmen tympani and points to the
malleus nipper applied across its neck. facial nerve (Figure 22)
The malleus nipper is held anteriorly • Figure 23 above shows the geniculate
between the thumb and index finger to ganglion and greater superficial petro-

12
 sal nerve once the Cog and coch-
leariform process have been drilled
away

Key points: Completed closed mastoido-

epitympanectomy (Figure 24)

• The posterior canal wall should not be

too thin
• Avoid drilling too far anteriorly while
exposing the facial nerve and fenestra-
ting the posterior wall of the external Figure 24: Completed closed mas-
auditory canal toidoepitympanectomy
• Avoid fenestrating the posterosuperior
canal wall Ossiculoplasty
• Identifying the facial nerve along its
course in the mastoid is the best way of Refer to the chapter on ossiculoplasty and
avoiding injury to the nerve incus interposition for detailed surgical
• Most injuries occur when the facial steps.
nerve has not been adequately visua-
lised The following conditions should be present
in order to proceed to an incus inter-
position at the time of the primary surgery
GSP
(Figure 25)
TeT
GG
Dura • Malleus handle present
• Stapes superstructure intact
VII.T
• Footplate mobile
VII.L • Choleasteatoma limited and could be
removed entirely
SSC
LSC • Incus free of cholesteatoma
• Anterior third or half of the eardrum is
preserved and defines the proper plane
Figure 23: View of epitympanum with
cog and cochleariform process drilled
away: Tympanic (VII.T) and Labyrin-
thine (VII.L) segments of facial nerve
and Geniculate Ganglion (GG) and
Greater Superficial Petrosal nerve
(GSP); Superior Semicircular Canal
(SSC); Lateral Semicircular Canal
(LSC); Dura; Tensor Tympani tendon
(cut) (TeT)

Figure 25: Incus interposition

13
Second-stage surgery is done at 6-12 mastoid cavity through a separate skin
months to ensure stabilisation of the graft incision and the wound is closed in
in cases of perforation; to verify eradica- layers
tion of cholesteatoma; and to assess whe- • A mastoid pressure bandage is applied
ther there is good middle ear ventilation for 1 day
and whether eustachian tube dysfunction is
present Open Mastoidoepitympanectomy (MET)

Posterior canal wall reconstruction Skin incision: As for Closed MET

• Conchal or tragal cartilage is used to Periosteal flap: A small periosteal flap is

reconstruct the posterosuperior canal made in order to preserve the soft tissue for
wall myosubcutaneous occipital flap
• The cartilage is cut into 2-3 thin pieces
(use a new 10 or 20 #blade) Canalplasty: As for Closed MET
• These pieces are aligned to slightly
overlap each other Inspection of middle ear and division of
incudostapedial joint: As for Closed MET
Tympanic membrane reconstruction
Antrotomy
Refer to chapter on Myringoplasty and
tympanoplasty for detailed surgical steps • As for Closed MET
• With Open MET you may already have
• Temporalis fascia or cartilage is har- lowered the posterosuperior canal wall
vested
• If there is diseased middle ear mucosa Mastoidectomy and epitympanectomy
or retraction of the pars tensa, then
silastic sheeting (1mm thickness) is in- • Radical exenteration and exteriorisa-
troduced into the tympanic cavity and tion of all cell tracts, including retro-
protympanum to prevent adhesions facial, retrolabyrinthine, supra-labyrin-
between the graft and the promontory thine, and supratubal cell tracts
• The graft always lies medial to the • A common error is not to saucerise the
handle of malleus (if present); there- cavity; this limits exposure and creates
fore, a slit must be made to accommo- a larger cavity
date the tensor tendon • The more bone one removes, the small-
ler the cavity
Wound closure and packing • Incomplete exenteration will result in a
discharging cavity
• The meatal skin flap is replaced and • Never leave bony overhangs
gelfoam pledgets are placed strategi-
cally over the meatal skin flap and Lower the facial ridge over the mastoid
fascia to secure it over the tympanic segment of facial nerve
sulcus
• The external canal is packed with a • A high facial ridge may cause a dis-
strip of gauze impregnated with anti- charging mastoid cavity
biotic ointment • Therefore, it is important to skeletonise
• An easyflow drain or tube of a suction the facial nerve in order to lower the
drain (without suction!) is placed in the facial ridge sufficiently

14
• Lower the facial ridge with a large Obliteration of mastoid cavity
diamond burr and continuous suction
irrigation The mastoid cavity is small after exterio-
• Skeletonize the facial nerve, keeping risation of a poorly pneumatised mastoid
the nerve intact within the bony fallo- and does not require obliteration. However
pian canal, but lowering the bone to the following exenteration of all tracts in a
level of the facial nerve highly pneumatised mastoid, one may be
• The course of the nerve can clearly be left with a large cavity; in such cases
identified inferior to the lateral semi- obliteration is necessary to create a dry
circular canal, anterior to the posterior cavity
canal, and along the stylomastoid
periosteal fibres at the level of the Mastoid obliteration with myosubcuta-
digastric ridge neous occipital flap

Removal of mastoid tip • This is an inferiorly-based flap based

on the occipital artery which is rotated
• Removal of the mastoid tip will help into the mastoid cavity (Figure 26)
reduce the size of the cavity by allow-
ing soft tissue to collapse into the cavi-
ty
• The stylomastoid foramen is medial to
the digastric ridge
• Anteriorly where it extends into the
external ear canal, the drill therefore
remains lateral to the digastric ridge
• The mastoid tip is weakened when one
drills with a diamond drill lateral to the
digastric ridge to expose the muscle at
its attachment along the mastoid tip
and will develop a fracture line
• A rongeur is used to remove the mobi-
lised mastoid tip by rotating it out-
Figure 26: Inferiorly-based myosub-
wards
cutaneous occipital flap
• The remaining soft tissue attachment
can be cut with scissors pointing to the
• The flap comprises subcutaneous fascia
bone
and muscle
Tympanoplasty • It extends superiorly behind the mas-
toidectomy cavity from the mastoid tip
See chapter on Myringoplasty and tym- where it is pedicled; the pedicle has to
panoplasty for detailed technique. Note be kept wide (3.5cm) enough so that
that if the tympanic membrane and annulus blood supply is adequate
are deficient then a tympanic sulcus is • The tip of the flap is just below the
drilled out with a small diamond burr in level of the temporalis muscle; the
order to support the fascial graft length is approximately 7.5cm
• Elevate the retroauricular skin from the
subcutaneous fascia using electro-
cautery

15
• Use a mastoid raspatory to elevate the results in 2 crescent-shaped pieces of
flap from the bone cartilage (Figure 28)
• Mastoid emissary veins may be en- • The opening is approximately the size
countered; bleeding is stopped with of the surgeon’s finger
bipolar coagulation and/or diamond
drilling of the bony foramen with a
large diamond burr without irrigation
• Vicryl 2/0 sutures are used to suture
the flap to the exposed digastric muscle
to hold the flap in place in the mastoid
cavity

Meatoplasty

Failure to do a meatoplasty with an open

cavity can lead to a chronic draining ear. A Figure 28: Exposing cartilage, and
meatoplasty is therefore routinely perfor- illustrating cartilage to be removed
med because for exteriorization and self-
cleansing • The conchal skin flaps are inverted by
• A # 11 blade is inserted into the exter- placing 2/0 Vicryl sutures through the
nal ear canal and is directed postero- skin flaps and suturing them to the
superiorly toward the sinodural angle; temporal muscle superiorly and to the
the concha is incised through both skin mastoid soft tissues inferiorly. It may
and cartilage (Figure 27) be necessary to place more sutures to
improve the shape of the meatal
opening (Figure 29)

Figure 27: Initial incision

• Hold the skin with forceps and using

curved scissors, separate the skin from
the conchal cartilage; it is important to Figure 29: Completed meatoplasty
direct the curvature of the scissors
towards the cartilage and not upwards • It is important that there are no
towards the skin as this may injure the exposed edges of the cartilage as this
skin can lead to perichondritis
• Once enough cartilage has been expo-
sed, excise cartilage circumferentially
with tympanoplasty scissors; this

16
Wound closure and packing • Non-EPI MRI has better tissue differ-
entiation for cholesteatoma and has a
• The retroauricular wound is closed in high sensitivity and specificity for
two layers using 2/0 Vicryl for sub- cholesteatomas measuring >5mm
cutaneous tissue and skin clips or 3/0 • The senior author (T.L) recommends
Nylon for the skin. An easy-flow drain routine imaging, ideally with non- EPI
may be inserted diffusion weighted MRI, at 1 & 3 years
• Gelfoam is placed medially in the ear following closed mastoidoepitympa-
canal nectomy when there is concern about
• Gauze impregnated with Terracortril recurrent or residual cholesteatoma
ointment is used to fill the lateral
portion of the mastoid cavity and ear References
• A mastoid pressure dressing is applied
Fisch U, May J. Tympanoplasty, Mastoid-
Postoperative care (Figure 30) ectomy, and Stapes Surgery. New York:
Thieme; 1994
• Mastoid drain removed after 24hours
• Mastoid pressure bandage removed Jindal M, Riskalla A, Jiang D, Connor S,
after 24hours O'Connor AF. A systematic review of
• Sutures/clips removed after 7-10 days diffusion-weighted magnetic resonance
• Ribbon gauze with Terracortil is imaging in the assessment of postoperative
changed every 2 weeks for 2 months cholesteatoma. Otol Neurotol 2011; 32(8):
1243-9
• After the ribbon gauze has been re-
moved, topical eardrops (e.g. Oto-
Acknowledgements
sporin) are applied for 2-4weeks
This guide is based on the text by Prof
Fisch (Tympanoplasty, Mastoidectomy,
and Stapes Surgery) and personal
experience of Prof Linder, as well as
course material for the temporal and
advanced temporal bone courses conducted
annually by Prof Fisch and Prof Linder at
the Department of Anatomy, University of
Zurich, Switzerland

Figure 30: Epithelialised mastoid cavi-

ty and meatoplasty 4 weeks after sur- Author
gery
Tashneem Harris MBChB, FCORL,
Postoperative Imaging MMED (Otol), Fisch Instrument
Microsurgical Fellow
• CT cannot accurately define cholestea- ENT Specialist
toma postoperatively, because the CT Division of Otolaryngology
attenuation of cholesteatoma is not spe- University of Cape Town
cific enough to differentiate it from Cape Town, South Africa
granulation tissue or effusion [email protected]

17
Senior Author

Thomas Linder MD
Professor, Chairman and Head of
Department of Otorhinolaryngology,
Head, Neck and Facial Plastic Surgery
Lucerne Canton Hospital, Switzerland
[email protected]

Editor

Johan Fagan MBChB, FCS(ORL), MMed

Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
[email protected]

THE OPEN ACCESS ATLAS OF

OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za

The Open Access Atlas of Otolaryngology, Head &

Neck Operative Surgery by Johan Fagan (Editor)
[email protected] is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
License

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