Canal Wall-up Mastoidectomy Research Articles

Attic Reconstruction in Pediatric Canal Wall‐up Mastoidectomy

Objective: 1) To evaluate 3 methods: conchal cartilage, tragal cartilage, and bone pate, for primary attic reconstruction (scutumplasty) in pediatric canal wall-up mastoidectomies in terms of recurrence rates and formation of retraction pockets. Method: All patients undergoing attic reconstruction following a canal wall up mastoidectomy were evaluated from a single surgeon prospective pediatric otological database maintained over a 10-year period. The reconstruction of the scutum defects was done using bone pate, conchal and tragal cartilage. The outcome measures were postoperative retraction pocket formation and recurrence of cholesteatoma. Results: A total of 120 patients underwent primary attic reconstruction following canal wall-up mastoidectomy over a 10-year period. The overall recurrence rate was 9.83% (n = 12). Fifty-one patients underwent attic reconstruction with tragal cartilage, while 33 were reconstructed using conchal cartilage and 36 with bone pate. The recurrence rate with various reconstruction methods was 5.8% (n = 2), 15.1% (n = 5), and 13.8% (n = 5) for tragal, conchal, and bone pate, respectively. Cholesteatoma recurrence rates with the use of tragal cartilage for reconstruction of the scutum were significantly lower as compared to that of conchal cartilage ( P = .034, chi square = 3.308) and bone pate ( P = .046, chi square = 2.834). Conclusion: The use of the tragal cartilage for scutum reconstruction is associated with the least recurrence rate for pediatric cholesteatoma. The easy accessibility, stability, and good long-term results with the use of the tragal cartilage makes it an ideal material for outer attic wall reconstruction in pediatric canal wall up mastoidectomies.

Clinical Analysis of 22 Cases of Automastoidectomy

Objective: Automastoidectomy is a destructive condition of the mastoid and middle ear cavity about which very little has been reported. 1) Know the clinical features and severities of automastoidectomy caused by chronic otitis media. 2) Evaluate the results of its surgical outcomes. Method: Retrospective study. Patients who visited outpatient clinic and were diagnosed with COM with automastoidectomy state by temporal bone CT from January 2003 to December 2011 were included in this study. All patients underwent surgery. Their postoperative states were evaluated at the outpatient clinic at least 6 months after surgery. Results: Two patients complained of facial palsy, 7 hearing disturbance, 10 otorrhea, and 3 otalgia. At physical examination, attic destruction and retracted tympanic membrane (TM) were observed in 12 patients, EAC destruction in 8, TM perforation in 4, and 1 had intact TM. All pathologic results were cholesteatoma. A total of 19 had canal wall down mastoidectomy, 2 had canal wall-up mastoidectomy, and 1 had subtotal petrosectomy. One had tympanoplasty type 1, 3 had columella over stapes head, 10 had interposition or columella over stapedial footplate and, 1 had tympanoplasty type 3. Overall hearing improvement rate was 9.0%. There was no recurrence. Conclusion: Automastoidectomy is a relatively rare condition of middle ear diseases. It could be caused by cholesteatomatous COM and non-cholesteatomatous COM. Hearing reconstructive procedures are generally not effective compared with other conditions. This study may be helpful to know the clinical features and surgical outcomes of this condition.

Surgical Outcomes In Children With Chronic Otitis Media

We reviewed our surgical techniques and outcomes of children with chronic otitis media (COM) who had underwent surgery. The surgical outcomes and techniques of 51 ear of 49 patients were analyzed retrospectively in the totally of 89 children, aged between 8 to 16 and underwent surgery for COM. On ear examination, 16 children had perforation, 14 children had polyp, 13 children had cholesteatoma. Tympanoplasty was performed in 43% (22 ears), tympanoplasty with mastoidectomy was performed in 56% (29 ears). The canal-wall up mastoidectomy (CWUM) was performed in 25% (13 ears), and canal-wall-down mastoidectomy (CWDM) in the remaining 31% (16 ears). Graft take rate was 76.84 % and hearing gain average was 10.2 dB. In the early period , recurrent and residual diseases are more frequently in the CWUM group than in the CWDM group. In the CWDM group, the mastoid cavity problems occurred more frequently than in the CWUM group. 14 children had polyp, 12 children had cholesteatoma and one child had Langerhans cell histiocytosis (LCH) on hystopathological examination in postoperative period. Not only the hearing loss was lower in children in preoperative period, but also the hearing gain was lower in chidren in postoperative period. The surgical outcomes of tympanoplasty with or without mastoidectomy in children are successful as the results of adults. We should not avoid to perform CWDM for the risks of recurrent and residual disease in children. LCH should be kept in mind for progressive COM in children.

Detection of Postoperative Residual Cholesteatoma With Non-Echo-Planar Diffusion-Weighted Magnetic Resonance Imaging

The aim of this study was to analyze the role of non-echo-planar imaging (non-EPI)-based diffusion-weighted (DW) magnetic resonance imaging (MRI) for the detection of residual cholesteatoma after canal wall-up mastoidectomy before eventual second-look surgery. Prospective and blinded study. Tertiary referral center. The study group included the surgical, clinical, and imaging follow-up of 32 consecutive patients after primary cholesteatoma surgery. All patients were investigated with MRI, including late postgadolinium T1-weighted sequence and non-EPI-DW sequence, 10 to 18 months after first-stage cholesteatoma surgery by experienced surgeons using a canal wall-up mastoidectomy. The non-EPI-DW images were evaluated for the presence of a high-signal intensity lesion consistent with residual cholesteatoma. Imaging findings were correlated with findings from second-stage surgery in 19 patients, clinical follow-up examination in 11 patients, and, in 2 patients, clinical and MRI follow-up examination. Non-EPI-DW sequences depicted 9 of 10 residual cholesteatomas. The only lesion missed was a 2-mm cholesteatoma in an examination degraded by motion artifacts in a child. All other diagnosed cholesteatomas measured between 2 and 6 mm. Sensitivity, specificity, positive predictive value, and negative predictive value were 90, 100, 100, and 96%, respectively. Except for motion artifact-degraded examinations, non-EPI-DW MRI is able to detect even very small residual cholesteatoma after first-stage surgery by showing a high-signal intensity lesion. It has the capability of selecting patients for second-look surgery, avoiding unnecessary second-look surgery.

Assessment of visualization of structures in the middle ear via Tos modified canal wall-up mastoidectomy versus classic canal wall-up and canal wall-down mastoidectomies

The aim of this prospective study is to evaluate the differences in the ability to view structures in the middle ear between Tos modified canal wall-up mastoidectomy and classic canal wall-up (CWU) and canal wall-down (CWD) mastoidectomies. Eighteen temporal bones of 10 cadaver heads were used. Six bones were randomly selected for each surgical technique (Tos' technique, CWU and CWD mastoidectomies) and fixed on an operating table. In the Tos' technique: (1) transmeatal posterior tympanotomy with drilling of the supero-posterior bony annulus, (2) transmeatal atticotomy with preservation of the bony bridge and (3) cortical mastoidectomy were performed. In the classic CWU mastoidectomy, cortical mastoidectomy and posterior atticotympanotomy (facial recess approach) were performed. Incus and posterior half of the tympanic membrane were removed from all temporal bones. An independent specialist performing otologic surgery evaluated all of the temporal bones and approved the proper extent of dissections. Two another independent observers blinded to the purpose of the study were asked to point five anatomic structures and locations (sinus tympani, anterior attic, posterior crus, lateral attic and the Eustachian tube orifice) in two different sessions. Observers were allowed to rotate the operating table as it has been done during otologic surgery, and the line of view for the observers was both transmastoid and transcanal. The ability to view these structures was recorded as "correct/visible" or "incorrect/invisible". These records were also verified after removing the posterior and superior walls of the outer ear canal in temporal bones of the Tos and CWU groups at the end of the study. Significant differences were found in the ability to view middle ear structures between the Tos' technique and CWU mastoidectomy as well as between CWU and CWD mastoidectomies, with the Tos' and CWD techniques almost equally showing superiority to CWU (p<.0001). Of the five locations, sinus tympani and anterior attic were observed more frequently with the Tos' technique versus CWU (p=.001). Sinus tympani (p<.005), anterior attic (p=.001) and posterior crus (p<.05) were observed more frequently with CWD versus CWU. There was no significant difference in the ability to observe lateral attic and the Eustachian tube orifice among the three techniques. In addition, there was no significant difference in the ability to visualize all the five locations between the Tos' and CWD technique. Statistical analysis showed good reproducibility of this randomised, blinded study. Tos' modified CWU mastoidectomy, in which most part of the canal wall is intact, showed similar advantage of the CWD in viewing structures in the middle ear. The Tos' technique and CWD mastoidectomy provided better visualization of sinus tympani and anterior attic that are the most frequent places of residual cholesteatoma in the classic CWU mastoidectomy.

Reconstruction of outer attic wall defects using bone paté: long-term clinical and histological evaluation

The objective was to evaluate the long-term clinical outcome of the bony outer attic wall reconstruction (scutumplasty) by using autogenous bone paté in a series of patients who underwent canal wall up (CWU) mastoidectomy for middle ear cholesteatoma. In addition, an histological analysis of bone paté graft specimens taken during the second-look procedure 12 months after the first surgery, was carried out. A series of 134 ears from 128 patients with cholesteatoma who underwent staged CWU mastoidectomy and attic reconstruction with bone paté, between 1995 and 2000 inclusive, was retrospectively analyzed. In ten randomly selected ears, biopsies from the newly built outer attic wall were taken during the second-look operation and were microscopically analyzed. At the second stage operation, the bone paté graft was found normal in 64.9% of cases. In 39 (29.1%) patients there was a remarkable hypertrophy of the bone paté which was subsequently thinned out by using a diamond burr. A partial resorption of the bone paté was observed in 4.4% of ears and a total resorption in 1.4%. Residual cholesteatoma was found in 13.4% of ears. At the last follow-up visit, recurrent cholesteatoma was observed in 5.2% of ears. Self cleaning attic retraction pocket occurred in 4.4% of ears. Twelve months after implantation, histologic examination on the newly built bone showed a well-structured bony tissue. In particular, osteoblasts lined bone trabeculae with signs of an active tissue remodeling. In conclusion, the reconstruction of the outer attic wall should be considered a fundamental step when performing a CWU procedure in order to prevent attic retractions and recurrences of cholesteatoma. In our experience, autogenous bone paté graft has demonstrated good long-term results in outer attic wall reconstruction being adaptable, well tolerated, stable and of low cost.

IERAPSI project: Simulation of a canal wall-up mastoidectomy

Among the various EU research projects concerning the medical application of virtual reality, the project Ist-1999-12175, called IERAPSI (Integrated Environment for the Rehearsal and Planning of Surgical Interventions), specifically addressed the creation of a virtual and interactive surgical field for the temporal bone using three-dimensional images derived from CT data. We report on the experience obtained in the IERAPSI project in simulating a canal wall-up mastoidectomy. A surgeon with extensive experience in surgery of the petrous bone performed the mastoidectomy. The operative field included the mastoid, with its substantial differences in density between the cortex and the pneumatized bone, together with soft tissue structures, both on the border and inside the bone. The simulation is better in the first part of the operation than in the second part, suffering from a lack of haptic feedback from soft tissue and the surgical tool in deeper contexts, and under-representation of the variability inherent in pneumatized bone. This said, the excellent representation of dust production and removal, 3D simulation through color, and very good visual and haptic feedback in the early stage of the procedure are impressive. IERAPSI represents a potential surgical planning theater for the training of students and young surgeons, but is also expected to aid expert surgeons in the preoperative planning of difficult cases.

Effect of i.v. dexamethasone on postoperative dizziness, nausea and pain during canal wall-up mastoidectomy

Conclusion. Prophylactic i.v. administration of 10 mg of dexamethasone reduced postoperative dizziness and nausea without adverse effects in patients undergoing canal wall-up mastoidectomy, but did not reduce postoperative pain. Objective. To investigate the efficacy of dexamethasone in reducing postoperative dizziness, nausea and pain in patients undergoing canal wall-up mastoidectomy. Material and methods. A prospective, randomized, double-blind study was performed between January 2002 and December 2004. A total of 162 patients (66 males, 96 females) scheduled for canal wall-up mastoidectomy were enrolled and randomly assigned to receive either i.v. dexamethasone (10 mg in 2 ml) or i.v. placebo (2 ml of normal saline) during mastoidectomy. A standard general anesthetic technique was employed throughout the surgical procedure. At 3, 6 and 24 h after surgery, patients completed questionnaires regarding postoperative dizziness, nausea and pain, with their responses being given on a visual analog scale. Results. There were no postoperative complications in either group. Compared to the placebo group, the dexamethasone group showed reduced postoperative dizziness and reduced nausea (p<0.05 for both) at 24 h postoperatively. Compared to the placebo group, dexamethasone had no effect on postoperative pain.

Detection of Postoperative Relapsing/Residual Cholesteatomas With Diffusion-Weighted Echo-Planar Magnetic Resonance Imaging

To assess the capability of echo-planar diffusion-weighted magnetic resonance imaging (MRI) (EPI-DWI) in diagnosing relapsing/residual cholesteatomas after canal wall-up mastoidectomy. In a blinded study design, we investigated with MRI, including standard spin-echo sequences, 18 patients evaluated with clinical examination and computed tomography (CT) suspected for relapsing/residual cholesteatoma 7 to 19 months after a canal wall-up mastoidectomy. Images were evaluated by two radiologists blinded to patients' identities, CT findings, and clinical data set, who decided in a consensus agreement whether there was a pathologic signal increase in the petrous bone in a single-shot EPI-DWI sequence. All the patients underwent a second tympanoplasty or revision surgery of the mastoidectomy cavity within 15 days after magnetic resonance investigation.Sensitivity, specificity, and predictive values were evaluated separately for standard sequences and EPI-DWI. In EPI-DWI, five of six patients with cholesteatoma showed a bright signal, whereas those patients with a noncholesteatomatous tissue showed no anomalies. The only misdiagnosed cholesteatoma was a pearl 2 mm in diameter. Sensitivity, specificity, and positive predictive values, and negative predictive values of EPI-DWI in diagnosing relapsing/residual cholesteatomas were 86, 100, 100, and 92%, respectively. EPI-DWI may be a useful tool in differentiating between cholesteatomatous and noncholesteatomatous tissues after closed cavity mastoidectomy. Further investigations are, however, required to establish the practical utility of EPI-DWI on larger series as a screening modality in the follow-up after closed cavity mastoidectomies.

Surgical classification of variations in the anatomy of the sigmoid sinus

Objective Analyze the variability of anatomic relations between the sigmoid sinus and other surgical landmarks within the mastoid cavity to establish a classification of sinus location to facilitate surgical planning. Study design A descriptive study of surgical landmarks using 96 temporal bones from the Temporal Bone Laboratory at the Department of Otorhinolaryngology, Valle University at Cali, Colombia. Methods A dissection simulating a canal wall-up mastoidectomy extended to include exposure of the facial recess, epitympanum, and sigmoid sinus was performed on 96 adult disease-free temporal bones. Seven standard measurements were taken on each bone between the sigmoid sinus and other structures in the mastoid cavity. All data were analyzed using Epi-Info 2000. Results This parametric study was consistent with three classes of anatomic variations in the location of the sigmoid sinus (type 1, type 2, and type 3) based on a Gaussian distribution of the seven variables. Conclusions Variability in the anatomic location of the sigmoid sinus in the mastoid cavity is common and has surgical relevance. Significance This classification will help to rapidly identify the sigmoid sinus relationship within the mastoid cavity and to use the sigmoid sinus as a landmark during ear surgery in those cases in which traditional landmarks, such as the posterior auditory canal wall or the semicircular canals, are destroyed by a pathologic process.

Tegmen tympani cerebrospinal fluid leak epair

ObjectiveTo describe the transmastoid approach for closing cerebrospinal fluid leaks in the tegmen tympani usingautologous materials (temporal muscle fascia and abdominal fat) and heterologous materials (bovine collagen), together withits advantages and disadvantages.Material and MethodsWe present the cases of three patients who underwent closure of spontaneous cerebrospinal fluidleaks in the tegmen tympani in which we used the transmastoid approach and autologous and heterologous materials. Thethree patients underwent canal wall-up mastoidectomy, posterior tympanotomy, removal of the malleus head and incus and,consequently, exposure of the tegmen tympani and the cerebrospinal fluid leak. Closure was performed using temporalmuscle fascia, abdominal fat and bovine collagen, fixed in place with fibrin glue. A lumbar shunt was established, as isroutine.ResultsThe cerebrospinal fluid leak was closed in all patients using the technique described, with a minimum follow-up of14 months.ConclusionThe technique presented herein is an excellent option in cases of cerebrospinal fluid leakage in the tegmentympani; it is easy to perform and results in minimal risk to patients.

Changes in external ear resonance after 3 types of surgery in the patients with chronic otitis media

Objective: This study was designed to identify the external ear resonance characteristics of patients with tympanic membrane perforation and to investigate subsequent changes in external ear resonance, depending on the length of the postoperative period and which of 3 different types of operation was performed: tympanoplasty with canal wall-up mastoidectomy, epitympanoplasty, and canal wall-down mastoidectomy. Study design and setting: A total of 227 ears of 188 patients and 96 control ears comprised the study. We measured the gain and frequency of the first peak of external ear resonance with a real ear analyzer. Results: Gain and frequency of the first peak recorded in the preoperative group did not differ from those of the control group. However, negative peaks appeared around 1 to 1.5 kHz in half of these ears. The gain increased markedly in all 3 postoperative groups. The canal wall-down mastoidectomy and epitympanoplasty groups showed significantly lower frequencies compared with the tympanoplasty with canal wall-up mastoidectomy and control groups, but there was no difference between them. The increased gain diminished over time, but the peak gain did not equalize with that of the controls, even after 15 months. Conclusions: Additional gain should be considered of around 1 to 1.5 kHz for hearing aid users with tympanic membrane perforation. Postoperative changes in external ear resonance should be expected in patients with chronic otitis media, suggesting that fine readjustments of the hearing aid may be necessary. (Otolaryngol Head Neck Surg 2001;125:364-9.)

Surgical strategy for cholesteatoma in children

Objective: We reviewed our experience with childhood cholesteatoma in children under 15 years old. Based on cumulative postoperative data, we propose a modified canal-wall-up technique in conjunction with a planned, staged operation. Methods: From 1982 to 1997, 56 children with cholesteatoma (58 ears, total) underwent surgery in our department. In the early period (1982–1990), canal wall-down mastoidectomy was performed in 52% (21 of 40 ears), and canal wall-up mastoidectomy in 48% (the remaining 19 ears). In the late period (1991–1997), 18 ears with cholesteatoma underwent surgery. The canal-wall up mastoidectomy was performed in 89% (16 ears), and canal-wall-down mastoidectomy in the remaining 11% (two ears). Results: In the early period (1982–1990), cholesteatoma recurred more frequently in the canal-wall-up mastoidectomy group than in the canal-wall down mastoidectomy group (53 vs. 14%). Other postoperative complications, such as erosion of the mastoid cavity, otorrhea, and perforation of the eardrum, occurred more frequently in the canal-wall-down mastoidectomy group than in the canal-wall-up mastoidectomy group. In the late period (1991–1997), in the canal-wall-up mastoidectomy group, ten ears underwent one-stage surgery. Planned staged tympanoplasty was completed in six ears. After one-stage surgery, four of ten ears experienced residual cholesteatoma. Two of the recurrent ears had undergone planned staged tympanoplasty. As revealed by postoperative computed tomography (CT) images, 12 of 15 ears had aeration in the attic and antrum as well as in the tympanic cavity. In these cases, no attic retraction pocket formation was observed. Conclusion: Our strategy for pediatric cholesteatoma in the future is to use canal-wall-up mastoidectomy when possible. If aeration in the attic and antrum is observed by preoperative CT-scan image and no erosion in the malleus and incus exists, the one-stage surgery will be chosen. If no aeration is observed by CT-scan and/or erosion exists in the surgical findings, planned staged tympanoplasty will be necessary. This strategy allows a high incidence of aeration of the attic and antrum, and prevents the formation of the attic retraction pocket while enabling the early detection of residual cholesteatoma by means of CT.

Mastoidectomy For Cholesteatoma: A Ten Years review

Objective: To evaluate our experience in treating cholesteatoma surgically to compare the results with published ones and lo draw conclusions which may improve or modify our surgical technique. Methods: Between 19S5 and 1994, 135 files of patients who underwent mastoidectomy as treatment of cholesteatoma were reviewed . Personal data and radiological, audiologica., surgical technique and follow-up results were captured and analyzed. Follow-up period ranged from 0 to 8 years. Results: TI,ere were 135 patients, 96 males and 39 females with an age range of 2-61. The main symptoms were otor- rhoea, hearing loss, tinnitus and vertigo. Fourteen had mastoid abscesses, three facial pals.es, three dead ears and three positive fistulae. The majority were attic disease with polyp formation. Canal Wall Down Mastoidectomy (CWDM) was performed in 93.6% and Canal Wall Up Mastoidectomy (CWUM) in 6.4%. In the group w.th CWDM 42% had con- chomeatoplasty. 31 soft tissue meatoplasty and 34% with no operative detail. Only 100 ears with CWDM had more than 6 months follow-up. of these 7% had dry cavities and 24 wet cavities. CWUM was performed in 9 ears, of which 5 had Cholesteatoma. Four of these kept discharging; hence they underwent revision surgery in the form of CWDM. Conclusion: Middle ear cholesteatoma in our community is an extensive, destructive and complicated disease. CWDM results usually in dry and safe ears while CWUM is unsafe. Special attention should be given to the facial nerve during surgery. Adequate meatoplasty is very important to achieve dry ears.

Modified canal wall-up mastoidectomy with mastoid obliteration for severe chronic otitis media.

Mastoid tympanoplasty with a canal wall-up technique provides better conditions for a healthy skin lining than canal wall-down techniques. The formation of retraction pockets in residual pneumatized cavities is however a major cause of cholesteatoma recurrence with canal wall-up techniques. We have therefore attempted to combine the advantages of both canal wall-down and canal wall-up techniques. The posterior wall is kept up, the mastoid is obliterated with adipose tissue, the attic is exteriorized in the ear canal and hearing is restored with a minimal-size hypotympanic cavity only. Preliminary results from 41 cases with a follow-up of 6 months to 6 years suggest that skin conditions in the enlarged ear canal are adequate and that cholesteatoma do not recur.

Tensa retraction cholesteatoma: treatment and long-term results.

To obtain the best possible results of treatment of acquired cholesteatoma, we made a subdivision of cholesteatoma types into attic and pars tensa cholesteatomas, and subdivided the latter further into tensa retraction cholesteatoma and sinus cholesteatomas. Tensa retraction cholesteatoma is defined as arising from a retraction or perforation of the whole pars tensa, whereas sinus cholesteatoma is defined as arising from a retraction or perforation of the postero-superior part of the tensa. We present the long-term results obtained in tensa retraction cholesteatomas treated with one stage surgery from 1964 to 1980. Median observation time was 9 years, range 2 to 19 years. Sixty-one ears were treated without mastoidectomy, whereas 71 ears had canal wall-up mastoidectomy and 64 ears had canal wall-down mastoidectomy. The total recurrence rate was 13.3 per cent; 17 ears had residual cholesteatoma, and nine ears had recurrent cholesteatoma. The best results were obtained in ears with an intact ossicular chain where mastoidectomy was not performed. In 49 per cent of the cases, the cholesteatoma was confined to the tympanic cavity without reaching the aditus, antrum or mastoid process. About one-third to one-quarter of the ears had tympanoplasty only, with removal of the cholesteatoma through the ear canal.