Dry Mastoid Cavity Research Articles

Post-operative healing and long-term stability after mastoid cavity reconstruction using the middle temporal artery and inferior musculoperiosteal flaps.

This study aims to evaluate the surgical outcomes with the use of a combination of the middle temporal artery (MTA) flap and the inferior musculoperiosteal (IMP) flap for mastoid obliteration after canal wall down mastoidectomy. Seventy-five patients who have undergone canal wall down mastoidectomy and mastoid obliteration with the MTA and the IMP flaps at a single tertiary hospital were included. Surgical outcomes measured included the creation of a dry mastoid cavity as measured by a previously developed semi-quantitative scale, mastoid cavity epithelization time, rate of revision surgery needed, and rate of recurrent cholesteatoma. Patients were followed up for a median of 29months. The median time to epithelization of the mastoid cavity was 2 months. At 1 and 3 months, 36.0% and 76.0% of patients had grade 0 and grade 1 cavities, respectively, with either a dry cavity or one or less episodes of mild otorrhea or sensation of wetness. Hundred percent of the patients achieved a grade 2 (more than one episode of otorrhea or the presence of granulation tissue that promptly resolved with simple treatment) or better cavity at 3 months. One patient re-presented with a grade 3 cavity with uncontrolled infection and daily otorrhea secondary to an attic perforation that manifested at 6 months, requiring revision surgery. There were no recurrent cholesteatomas during the follow-up period. The use of the MTA and the IMP flaps for mastoid obliteration may be considered as an adjunct to achieving a safe, dry ear after canal wall down mastoidectomy.

Comparison between outcome of Inside-out & Outside-in mastoidectomy

Background: Chronic suppurative otitis media is a disease that is known worldwide and that is more common in developing countries. Many techniques are available for operating the disease.
 Objectives: To compare outcome between Inside-out & Outside-in mastoidectomy.
 Methods: A cross-sectional study was conducted to compare outcome between Inside-Out & Outside-in mastoidectomy. Period of study was from July’ 2010 to March, 2012 in the Department of Otolaryngology and Head-Neck Surgery, BSMMU- Dhaka
 Result: majority of the patient were found dry mastoid cavity 13(68.42%) and rest were wet mastoid cavity 6 (31.58%).On the other hand in outside–in mastoidectomy dry mastoid cavity were 80.6% and wet were 19.4%. In inside-out mastoidectomy, among 8 attic cholesteatoma cases 5(62.50%) had gained hearing (average 6.66 dB) and 3(37.50%) had no gain or loss of hearing (average 3.89dB); among 11 entire mastoid bowl cholesteatoma cases 3(27.27%) had gained of hearing (average 6.11dB) and 8(72.73%) had no gain or loss of hearing (average 6.87dB)
 Bangladesh J Otorhinolaryngol; April 2018; 24(1): 29-36

Modified radical mastoidectomy in children: mastoid cavity problem and its management

<p class="abstract"><strong>Background:</strong> Various factors are responsible for post MRM chronically discharging mastoid cavity which has to be identified and treated properly so as to avoid further complications. The aim of this study is to evaluate the causative factors responsible for persistent ear discharge in post mastoidectomy cases and their management in paediatric age group.</p><p class="abstract"><strong>Methods:</strong> This is a cross sectional study done from May 2013 to April 2017 in the Paediatric ENT unit of Department of ENT & HNS, TUTH, Kathmandu, Nepal. Children were evaluated for persistent ear discharge and managed for one year. Risk factors like high facial ridge, inadequate meatoplasty, unepithelize mastoid cavity, tympanic membrane perforation and residual or recurrent choleateatoma, infections, nasal or nasopharngeal pathology were evaluated and treated. Outcome of management was measured in terms of achieving dry mastoid cavity over one year period. </p><p class="abstract"><strong>Results:</strong> A total of 92 post MRM children with persistent discharge were included in the study. 33/92 (35.8%) had anatomical defects. Four cases had recurrent or residual cholesteatoma. 22/92 (23.9%) of the cases had granulation and infection. 14 cases had nasophayngeal inflammation and 13 cases had recurrent accumulation of wax or debris. After the treatment of various factors, 43/75 (53.7%) ear became dry within 3 months, 22/75 (29%) ear became dry within 6 months, 6/75 had persistent discharge even 1 year after treatment. Whereas, in 5/75 (13.4%) had on and off discharge.</p><p class="abstract"><strong>Conclusions:</strong> The chronically discharging mastoid cavity can be well managed by early identification of causative factors.</p>

Acetic Acid Instillation after Canal Wall Down Mastoidectomy

Introduction:
 Persistent otorrhoea and granulation tissue in the mastoid cavity are common post-operative complications of Canal Wall Down Mastoidectomy. In order to avoid the same and to achieve a dry cavity instillation of acetic acid into the mastoid cavity during the post operative period is common practice.
 Materials and Methods 
 In this study we assessed the results of 4% acetic acid instillation in varying quantity and frequency, in the ears after modified radical mastoidectomy.
 40 Patients of chronic suppurative otitis media (atticoantral) / cholesteatoma, who underwent modified radical mastoidectomy during one and a half year period, were included in the study. The patients were divided into two groups; Group A with 30 patients and Group B with 10 patients, by simple randomization method. Group A patients were asked to instill 4% acetic acid approximately 10 to 12 drops (generously) into the mastoid cavity thrice a day for 8 weeks and were followed up every week. 10 patients of Group B were asked to instill the same preparation only once weekly and followed up for the next 12 weeks. 
 Results: 
 In Group A, dry mastoid cavity was achieved remarkably faster within six to eight weeks and in all the 30 patients. In Group B the results were delayed by up to 4 to 6 weeks in comparison to the Group A patients.
 Conclusion:
 Though acetic acid instillation is known to help in achieving a dry cavity but a slightly higher concentration (4% acetic acid) used more frequently is highly effective in rendering dry cavity much earlier without proliferation of granulation tissue.

Mastoid Reduction in Combination with Corner‐Tag Meatoplasty: Refining Mastoidectomy and Canalplasty Outcomes

Objectives:Prevention of “a problem cavity” following modified radical mastoidectomies (MRM) and canalplasties requires careful preoperative consideration and an adept surgical technique. We aim to describe our technique of a superiorly‐based middle temporal artery flap, with an inferiorly‐based musculoperiosteal flap, in combination with a Corner‐Tag‐meatoplasty, and to evaluate the surgical outcomes on a semi‐quantitative scale.Methods:Retrospective consecutive case review from 2010‐2013. Primary end‐point measure of creating a low maintenance dry mastoid cavity was graded using Merchant's grading system.Results:Twenty‐four patients (13 males and 11 females) with a mean age of 42.6 years (range, 17‐76 years) were included. All except 3 cases were primary ear cases. None had previous reduction procedures done. Nineteen cases were MRMs, 3 were revision mastoidectomies, and 2 were canalplasties. A well‐epithelized, dry mastoid cavity was achieved in 12 patients by 1‐month post surgery, with another 9 achieving this by 3‐months. Twenty‐three cases (96%) resulted in cavities with adequate control of infection based on Merchant's summary grade. The cavities took an average of 1.75 months to epithelize. Three patients had recurrent tympanic membrane perforation with one requiring revision surgery. None had disease recurrence at mean 15.8 months follow‐up (range, 6‐25 months). Our technique of meatoplasty allowed excellent visualization of the mastoid bowl affording bimanual instrumentation in the clinic setting.Conclusion:The middle temporal artery and inferior musculoperiosteal flap in combination with the Corner‐Tag meatoplasty is an effective technique in reducing the mastoid cavity, aiding epithelization, has low complication rates, and allows good surveillance postoperatively.

The behavior of mastoidectomy cavities following modified radical mastoidectomy

An analysis of the frequency and intensity of postoperative aftercare required for modified radical mastoidectomy (MRM) and patterns of healing in the postoperative period. A retrospective review of all primary modified radical mastoidectomies carried out for cholesteatoma under the care of the senior author between the years of 2004 and 2009 with minimum follow-up of 2 years. The time and number of interventions required to achieve a stable and dry mastoid cavity were collected. Cross-sectional and longitudinal analysis of the behavior of the cavities was carried out. Overall, 73 cases (71 patients) were identified. Patients were followed up for a median of 45.7 months (interquartile range, 31.8-70.5). After initial debridement, most cavities settled rapidly, but this was not always predictable, with a large proportion requiring further clinical intervention after the cavity was stable, sometimes for prolonged periods of time. At the time of analysis, 73% had achieved a stable cavity, 17 (23%) still required attention (nine for wax removal and eight for debridement); two were lost to follow-up. No revision surgeries were required. At 6 months, 36% of cavities were settled, 42% at 1 year, 53% at 18 months, and 62% at 2 years. After two standard postoperative visits, a total of 632 visits were made by these patients. Following MRM, the majority of patients achieve a dry, self-cleaning mastoid cavity. This might require periods of intense care interspersed with periods of quiescence. These results allow the benefits of this procedure to be put in the context of the entire patient journey.

A technique for concurrent procedure of mastoid obliteration and meatoplasty after canal wall down mastoidectomy

To present a simple technique for concurrent procedure of mastoid obliteration and meatoplasty after canal wall down mastoidectomy, and to assess the efficacy and the surgical results of this technique. Retrospective clinical study of a consecutive series of procedures from 2004 to 2008. One hundred thirteen patients undergone canal wall down mastoidectomy with tympanoplasty and concurrent procedure of mastoid obliteration and meatoplasty that uses an anteriorly based musculoperiosteal flap and a horizontal skin incision on the concha were included. Preoperative diagnoses were classified into cholesteatoma, adhesive otitis media, and chronic suppurative otitis media. The mean duration of follow-up was 38 months, with a range of 12-75 months. We analyzed control of suppuration and creation of a dry mastoid cavity according to the Merchant's grading system for evaluation of the efficacy of this technique, and hearing outcome. We evaluated postoperative complications including development of recurrent or residual cholesteatomas and duration of the mastoid cavity achieving a complete healing. Seventy-two patients had cholesteatoma, whereas 27 patients had adhesive otitis media and 14 patients had chronic suppurative otitis media. Eighty-three percent of all patients, in 86% of patients with cholesteatoma, in 78% of patients with adhesive otitis media, and in 78% of patients with chronic suppurative otitis media were achieved a dry and self-cleaning mastoid and complete control of infection. Duration of the mastoid cavity achieving a dry and self-cleaning mastoid ranged from 4 weeks to 24 weeks and the mean time of the complete epithelialization was 11.1±4.6 weeks. The average ABGs were 32.4±13.8dB preoperatively and 23±13.2dB postoperatively. There were 5 patients with failure of control of infection postoperatively and 3 patients of recidivistic cholesteatoma. The efficacy of our technique to make a dry and healthy mastoid cavity after a canal wall down mastoidectomy is satisfactory, and the rate of complication is acceptably low. We believe that our technique could be a convenient method to prevent cavity problems after canal wall down mastoidectomy.

Single flap with three pedicles, bone paté and split-thickness skin graft for immediate mastoid obliteration after canal wall down mastoidectomy

Our objective was to evaluate single flap with three pedicles, bone paté and split-thickness skin graft for mastoid cavity obliteration after canal wall down mastoidectomy done for chronic suppurative otitis media and its efficacy in producing a small and dry mastoid cavity. Over a period of 7 years (2003-2010), 100 consecutive procedures in 100 patients with chronic suppurative otitis media were performed at the Mansoura University Hospital (Egypt) with a minimum follow-up of 12 months (range 12-72 months). All patients had canal wall down mastoidectomy with simultaneous tympanoplasty. Anteriorly, inferiorly and superiorly pedicled periosteal flap, which was covered by split-thickness skin graft, was used in conjunction with autologous bone paté to obliterate the mastoid cavity. Postoperative evaluation was done based on certain criteria and grading system from 0 to 3. Grade 0 is considered perfect, grade 3 represents failure and grade 1 and 2 are adequate but not perfect. The summation of grade "0" (perfect dry) and grade "1" (adequate dry) was 88, 95, 97.23 and 98.44% after follow-up periods of 12, 24, 36 and 48 months, and 100% after 60 and 72 months. Periosteal flap based on three pedicles (anterior, inferior and superior) covering the bone paté is simple, perfect and adequate for obliteration of mastoid cavity after canal wall down mastoidectomy. Split-thickness skin graft is important to hasten the epithelialization that helps to obtain a dry cavity. The use of local tissues saves costs and avoids complications from the synthetic materials.

Endaural meatoplasty: the Whipps Cross technique

To describe our technique of endaural meatoplasty for mastoid surgery, and to publish an online video demonstration. After the endaural incision, a skin incision is accurately marked over the anterior conchal bowl, identified by pushing the anti-helix anteriorly. This should meet the line of the endaural incision superiorly and extend inferiorly to the lower anterior edge of the conchal cartilage. After performing the incision, a segment of conchal cartilage is removed. The soft tissue meatoplasty is facilitated by resecting a triangular segment of skin and underlying soft tissue medial to the conchal incision (on which it is based). The free edges are closed with absorbable sutures after the (attico)mastoidectomy. We have used this method on 64 patients over the past two years. Satisfactory functional and cosmetic outcomes were achieved in all. Our technique is simple, easy to learn, quick and effective in helping to achieve our goal of a dry mastoid cavity with an adequate meatoplasty.

Surgical Treatment of Pediatric Cholesteatomas

: Management of pediatric cholesteatomas remains controversial. We reviewed our 16-year experience in the surgical treatment of cholesteatomas in children and describe a treatment paradigm. : The authors conducted a retrospective review. : A total of 106 mastoidectomies (86 for an acquired cholesteatoma and 20 for a congenital cholesteatoma) were performed in children 16 years old and younger from 1988 to 2003. Follow up ranged from 2 years to 12 years with a mean follow-up period of 6 years. Hearing outcomes, cholesteatoma recidivism, and dry mastoid cavity were the main outcomes measured. : Seven (7%) patients had revision surgery for cholesteatoma recidivism. Rates of cholesteatoma recurrence for canal all up (CWU) and canal wall down (CWD) mastoidectomy groups were similar (8% vs. 6%). The percentage of patient with good serviceable hearing (pure-tone average </=25 dB) was higher in those with a CWU mastoidectomy as compared with the CWD mastoidectomy group (81% vs. 47%) (P < .05). Extent of disease and stapes superstructure erosion on presentation were significant (P < .05) predictors of both cholesteatoma recidivism and poor hearing. All 106 subjects studied had a dry mastoid and 78 patients (74%) had a maintenance-free cavity at the time the study was completed. : The treatment of pediatric cholesteatomas should be individualized with CWD mastoidectomy chosen for patients with recurrent or more extensive disease. We conclude that the CWU procedure is an adequate surgical option for treating most acquired and congenital cholesteatomas, preventing disease recurrence, and maintaining good hearing outcomes.

Analysis of Modified Radical Mastoidectomies Cavity Results in a Tertiary Care Hospital

Background: Discharging Modified Radical Mastoidectomy cavity is a troublesome and frustrating problem both for the operating surgeon and patient. Etiology of discharging MRM cavity is multifactorial. Knowing and addressing the etiological factors at the time of surgery is important to provide dry and safe ear to the patient. Objective: To evaluate the post-operative status of mastoid cavity after modified radical mastoidectomy.Material and Methods: This prospective Cross sectional study was conducted among 450 patients who came for open mastoidectomies in ENT Department, Saidu Group of Teaching Hospitals, Saidu Sharif Swat, Khyber Pakhtunkhwa, Pakistan. The study duration was from January 16, 2012 to December 09, 2019. Patients were postoperatively followed according to protocol and evaluated for residual cholestetoma and post mastoidectomy cavity status. The evaluation was conducted with endoscope and microscope. Data was obtained on pro-forma and SPSS 22 was used for analysis.Results: Out of 450 patients 109 (24.3%) were having recurrent persistent discharging mastoid cavities and 341 (75.7%) were having dry mastoid cavity. Multiple factors contributed to be the cause of discharging mastoid cavity with high facial ridge (89.9%) being the most common. More than one etiological factor in individual patients were also identified to be the cause for wet mastoid cavities.Conclusion: We concluded that complete exenteration of cholestetoma with lowered facial ridge, adequate meatoplasty and regular follow up is necessary to avoid post-operative mastoid cavity problems.Key words: Modified Radical Mastoidectomy, Mastoid Cavity, Cholestetoma.