Musculoperiosteal Flap Research Articles

Mastoid Obliteration: A Comparison of Two Techniques.

To compare the outcome and efficacy of mastoid obliteration following canal wall down mastoidectomy, using two different materials such as bone pâté and bioactive glass granules. This is a prospective, randomized, single blind comparative study conducted for a period of 2years in a tertiary care center. The patients were divided into two groups A and B. In group A, the mastoid was obliterated with bone pâté and inferiorly based musculoperiosteal flap and in group B, bioactive glass with inferiorly based musculoperiosteal flap. They were assessed post operatively at 4th, 12th and 24th week for cavity healing (merchant et.al., score), subjective satisfaction and at the 24th week the effectiveness of obliteration was assessed visually by oto endoscopy and HRCT was done additionally to assess the volume of external auditory canal. A total of 40 patients with chronic otitis media (Squamosal type) were included and divided into 2 groups. At the end of 4weeks, bioactive glass had better healing, which was statistically significant. At the end of 24 weeks both groups had similar rate of healing. There was no difference in subjective satisfaction at end of 24weeks. The patients in bioactive glass group had statistically better obliteration than Group A and the volume of the EAC was less in this group signifying better obliteration. The cavity healing were similar for both bone pâté and Bioactive glass at end of 24weeks. Bioactive glass had better outcomes for effectiveness of obliteration compared to bone pâté.

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.

A Simple Technique to Obliterate Canal Wall Down Mastoid Cavity Concurrently in Squamosal Otitis Media: Our Experience.

Chronic suppurative otitis media is a type of otitis media defined as a long standing infection of a part or whole of the middle ear cleft. Squamosal type of CSOM involves parsflaccida characterised by the formation of cholesteatoma. The present study is retrospective analysis of records of patient who underwent canal wall down mastoidectomy with obliteration of cavity using posteroinferiorly based musculoperiosteal flap with autogenous cartilage and bone pate. Study include patients who underwent canal wall mastoidectomy with cavity obliteration at Tertiary care Hospital Yavatmal, Maharashtra, India; during 2year period of 2016-2018. 41 patients (42 ears) who underwent canal wall down mastoidectomy with cavity obliteration procedure were included and 06 patients were excluded as they failed to follow up. The outcomes were measured by Marchant et al. grading scale. As per the study it was observed that 88% (37 out 42 ears) got adequate control of infection with dry cavity, while 12% (5 ears) failed to attain dry ear. So it's been concluded that canal wall down mastoidectomy is an effective surgical procedure in management of squamosal type of CSOM and mastoid obliteration is proved technique to improve outcomes of canal wall down procedure. Technique used to develop posteroinferiorly based flap to obliterate cavity in our study is simple modification of routine surgical steps commonly practiced by otologist helpful in reducing cavity size and promoting healthy epithelization. Cavity obliteration technique used in study is very effective and simple to develop dry and trouble free cavity in around 90% cases.

Application of amniotic membrane for covering mastoid cavity in canal wall down mastoidectomy.

Prevention of granulation tissue formation and acceleration of epithelialization of the mastoid cavity in canal wall down (CWD) mastoidectomy by use of amniotic membrane (AM) as a biologic dressing. Prospective and randomized study. During CWD mastoidectomy, an inferiorly base musculoperiosteal flap was rotated into the cavity. In order to coverage of this flap, the AM (75 ears) or the temporalis fascia (control group, 73 ears) was used. The times for mastoid cavity epithelialization were compared in both groups. In the AM group, duration of complete epithelialization of the cavity was 41.4 ± 7.7 days, whereas in the control group it was 59.2 ± 9.1 days. Duration of time for complete epithelialization in the AM group was shorter than in the control group, which was significant (P < 0.0001). The use of AM in CWD mastoidectomy is beneficial in minimizing postoperative epithelialization time. 1b Laryngoscope, 129:1453-1457, 2019.

Reexamination of Etiology and Surgical Outcome in Patient With Advanced External Auditory Canal Cholesteatoma.

To describe the etiology of advanced cases of external auditory canal (EAC) cholesteatoma (EACC), and to report the surgical management and outcomes based on canalplasty depending on the extent of adjacent structures involvement around the EAC. Retrospective case review. University hospital. Participants comprised 28 patients (12 males, 16 females) ranging in age from 9 to 86 years old. All patients presented with advanced-stage EACC (Naim's classification: stage III/IV). Surgery ranged from simple bony meatoplasty with cartilage graft repair to more enlarged EAC canalplasty combined with tympanoplasty. EACC was categorized as idiopathic in 22 patients and secondary EACC in six patients. Six patients with idiopathic EACC were receiving hemodialysis, one of whom showed bilateral pathology. Particularly in cases with epithelial invasion into the hypotympanum immediately adjacent to the jugular bulb, multi-layered repair including bone paste, post-auricular pedicled musculo-periosteal flap, auto cartilage, and temporalis muscle fascia were required. Five patients required revision surgery (17%), including one case of recurrent (reconstructed) cholesteatoma and three cases of perforation of the tympanic membrane. In the majority of our series, underlying diseases followed with microangiopathy and angiogenesis could be possible candidates in the etiology of EACC. Enlarged bony meatoplasty and multilayered reconstruction surgery brought about self-cleaning and dried the EAC in advanced-stage EACC.

The new technique of Reconstruction of Posterior Canal Wall by using Skin- Musculoperiosteal Flap on Canal Wall Down Timpanomastoidectomy

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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.

Comment to Masaki Fujioka et al. to their accepted letter to the editor: Vascularized bone graft is a better option for the reconstruction of maxillary defects

Thank you for your interest in our study and also reconstructive criticism. I read it with great interest. Our previous article [1] described the use of pedicled temporal musculoperiosteal flap with or without free calvarial bone graft in maxillary reconstructions. There has been an increasing tendency to reconstruct maxillary defects using free vascularized bone-containing flap. Usually, from a prosthetic and esthetic point of view, the use of free bone-containing flap is superior. However, we have more and more elderly patients, and often patients with many diseases. Those patients may poorly tolerate a long-lasting microvascular surgery with a long postoperative treatment. Usually, when using pedicled flap, the operation time is shorter and postoperative recovery faster than with the use of free flaps. Thus, it is good that we have several options for repairing maxillary defects. Therefore, temporal musculoperiosteal flap is good to keep in mind, especially when repairing defects with elderly patients. The authors also reminded us of an option to use a parietal bone-fascial-periosteal flap based on superficial temporal vessels. This is also an interesting option and good to keep in mind among the other options.

A musculoperiosteal flap cochlear implant device fixation technique: Our experience in one hundred and seventy nine patients

A musculoperiosteal flap cochlear implant device fixation technique: Our experience in one hundred and seventy nine patients

Bioactive Glass S53P4 in Mastoid Obliteration Surgery for Chronic Otitis Media and Cerebrospinal Fluid Leakage

We evaluated the results of cases of chronic otitis media treated with mastoid obliteration surgery using bioactive glass S53P4. Twenty-five patients with chronic otitis media and 1 patient with cerebrospinal fluid leakage without chronic infection were treated with bioactive glass S53P4. Twenty patients had had previous surgery because of chronic otitis media with or without cholesteatoma. A mastoid obliteration was performed with bioactive glass S53P4 granules and a musculoperiosteal flap with or without bone paté. In 2 patients with a bony dehiscence at the middle cranial fossa, a bioactive glass plate was used to support the protruding dura. In addition, in 3 patients, occlusion of a dural fistula was needed The median follow-up period was 34.5 months (range, 1 to 182 months). Excluding the 2 patients with only 1 month of follow-up at our department, 96% of the patients had a dry, safe ear or only intermittent otorrhea. In 92% of the patients, the objective of achieving a smaller or nonexistent cavity was achieved. Bioactive glass S53P4 is a noteworthy material in mastoid obliteration surgery.

Mastoidectomy Cavity Obliteration with Bioactive Glass

To show that mastoid cavities with continuous infections and cleaning problems can be obliterated with bioactive glass (BG) and to present results of a pilot study for 16 operations on adults. Case series with planned data collection. Päijät-Häme Central Hospital, Finland-a single ear, nose, and throat (ENT) hospital department serving a population of 216,000. Fourteen patients had a large open radical cavity with recurrent infections. Two ears had discharge and pain after simple mastoidectomy. A re-mastoidectomy included support of the cavity skin and obliteration with BG. The mean follow-up time was 2.2 years. All ears became dry. One reoperation was needed as the fascia support to the ear canal (EC) skin was too weak, and part of the BG leaked into the EC. The ear stayed dry, and the missing BG was replaced in a reoperation. A slightly short musculoperiosteal flap supported the EC skin in 1 ear. A minor amount of BG leaked into the EC. The ear stayed dry. The aim was an ample ear canal. One ear was overfilled and required meatoplasty. Simple mastoid cavities were isolated from the middle ear and become asymptomatic. In this pilot study, BG works safely and with success as an obliteration material in problematic open radical cavities. Bioactive glass seems to tolerate chronic infection in the mastoid and prevent postoperative infections.

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.

Mastoid Obliteration with Silicone Blocks after Canal Wall Down Mastoidectomy

ObjectivesTo evaluate the usefulness of silicone blocks as graft material for mastoid cavity obliteration in the prevention of problematic mastoid cavities after canal wall down mastoidectomies.MethodsRetrospective evaluation of 20 patients who underwent mastoid obliteration with silicone blocks between 2002 and 2009 at the Chonnam National University Hospital. The cases consisted of 17 patients with chronic otitis media with cholesteatoma and 3 patients with adhesive otitis media. The postoperative follow-up period was an average 49 months (range, 6 to 90 months). The surgical technique used at our institution composed four major steps: First, the canal wall down mastoidectomy was performed and the middle ear procedure was completed. The silicone blocks were used to fill up the mastoidectomized cavity. Then, a cortical bone pate was used to cover the surface of the silicone blocks. Finally, temporalis fascia and a split musculoperiosteal flap were used to surround the bone pate for reinforcement of the reconstructed canal wall. We examined postoperative success rate and hearing outcomes.ResultsIn 19 cases (95%), the reconstructed canal wall maintained a cylindrical shape and the ear drum healed without perforation. In only 1 case (5%), the reconstructed canal wall was destroyed with ear drum perforation. The mean improvement in air-bone gap was about 12 dB (P<0.05), and the mean improvement in air-conduction was about 16 dB (P<0.05).ConclusionWe suggest that silicone blocks could be valuable resources as graft materials for mastoid obliteration after canal wall down mastoidectomies.

Cochlear implantation for total deafness after ipsilateral ventriculoperitoneal shunt surgery: technical report

Cochlear implantation (CI) becomes more challenging when a programmable ventriculoperitoneal (VP) shunt is present on the same side of the head. We report a successful ipsilateral CI in a patient who suffered bilateral hearing loss after shunt surgery. We describe the CI case of a 49-year-old woman with an implanted VP shunt device, and perform a retrospective review of the clinical, audiological, and radiological features, surgical techniques, and postoperative functional outcomes. During CI, the magnet in the core of internal antenna of the CI device was positioned approximately 8 cm from the shunt valve so that it would not be affected by the magnetic field of the programmable valve. Although the CI antenna tip and shunt catheter overlapped, we were very careful not to pull the shunt catheter out of position while the musculoperiosteal flap was elevated. The present result suggests that ipsilateral CI is an option for deaf adult patients who have a programmable shunt.

Mastoidectomy Cavity Obliteration with Bioactive Glass

Objective: 1) Show that mastoid cavities with continuous infections and cleaning problems can be obliterated with bioactive glass (BG). Bioactive glass S53P4 inhibits bacterial growth, turns slowly into bone, and activates new bone formation. 2) Present results of a pilot study for 16 operations on adults. Method: A prospective follow-up of mastoid obliterations started in 2007. The mean follow-up time is 1.16 years. Fourteen ears had a large open radical cavity with recurrent infections. Two ears had discharge and pain after simple mastoidectomy. A re-mastoidectomy included support of the cavity skin and obliteration with BG. Results: All ears become dry. One reoperation was needed, as the fascia support to the EC skin was too weak and part of the BG leaked into the EC. The ear stayed dry, and the missing BG was replaced in a reoperation. A slightly short musculoperiosteal flap supported the EC skin in one ear. A minor amount of BG leaked into the EC. The ear stayed dry. The aim was an ample ear canal (EC). One ear was overfilled and waits for meatoplasty. Simple mastoid cavities were isolated from the middle ear and became asymptomatic. Conclusion: BG works as obliteration material in problematic open radical cavities safely and with success. BG seems to tolerate chronic infection in the mastoid and prevent postoperative infections.

Surgical Treatment of Spontaneous Meningocele of the Temporal Bone Causing a Pulsatile Tinnitus

A meningocele is a protrusion of meninges through a defect in the skull base. It is a rare but potentially life-threatening condition requiring surgery. It can present with conductive hearing loss, persistent middle ear effusion, cerebrospinal fluid otorrhea, recurrent meningitis, and epilepsy. We report a patient who presented with a three-year history of intermittent pulsatile tinnitus in her left ear. She had clear middle ear effusion and radiological evaluations suggesting an attic cholesteatoma. She underwent a tympanomastoidectomy and we discovered a meningocele in the epitympanum and a bony defect of the tegmen tympani. We easily restored the meningocele using a microelevator and bolstered the bone with temporalis fascia, conchal cartilage and musculoperiosteal flap. There was no evidence of cerebrospinal flu id leakage and the patient’s tinnitus disappeared six months after the operation. � Korean J Otorhinolaryngol-Head Neck Surg 2011;54:308-11 Key WordsZZMeningocele ㆍPulsatile tinnitus ㆍTemporal bone.

Die Anlage einer selbstreinigenden offenen Mastoidhöhle

Our experience from multiple open mastoid cavity revisions is that some of the well-proven techniques to create a self-cleaning small open cavity are not anymore practiced everywhere.The crucial steps are to considerably drill down the facial ridge, as well as the lateral bone (to the level of the sigmoid sinus) and - in cases of a well pneumatized mastoid - to ground down the mastoid tip. The bony rims should be smoothened with a diamond burr. Furthermore, the size of the cavity can be reduced by partial obliteration of the retrofacial space and the sinus-dura-angle using bone substitutes. In our hands cartilage chips have proven to be a good substitute, hydroxy apatite pellets or a musculoperiosteal flap according to Palva might be used alternatively. Finally a wide auditory canal entrance has to be created. By applying these techniques, for a selected number of cases the "open technique" still represents an essential part of cholesteatoma surgery these days.

Bioactive Glass S53P4 in the Filling of Cavities in the Mastoid Cell Area in Surgery for Chronic Otitis Media

Chronic infection of the middle ear and cholesteatoma can be treated surgically by exenteration of the mastoid air cells behind the ear. After a procedure with the canal wall-down technique, a cavity remains that is sometimes difficult to clean, collects crust, and becomes repeatedly infected. Such problematic mastoid cavities can be eliminated by filling the created cavity surgically after thorough removal of mucous membranes and cleaning of the bone. We treated 7 patients with cavities after canal wall-down surgery for the treatment of chronic suppurative otitis media or cholesteatoma by filling the difficult-to-clean cavity in the mastoid cell area with granules of bioactive glass (BAG) S53P4 to avoid further retraction formation. The area with BAG was carefully closed with a musculoperiosteal flap. After the canal wall-down tympanomastoidectomy, the mastoid cavities were successfully filled in all 7 patients. No biomaterial-associated infection was seen, and no disadvantages for the patients due to the BAG were observed. The cavity in the mastoid cell area decreased in size in all patients treated. This BAG seems to be a promising material for filling mastoid cavities after canal wall-down tympanomastoidectomy.

The use of pedicled temporal musculoperiosteal flap with or without free calvarial bone graft in maxillary reconstructions

Various techniques have been used to repair maxillary defects. The aim of this study was to evaluate the suitability of pedicled temporal musculoperiosteal flap (PTMF) and free calvarial bone graft for the reconstruction of maxillary defects. In this retrospective series, 34 patients operated on from 1995 to 2006 at Turku University Central Hospital because of defects of maxilla reconstructed using PTMF with or without free calvarial bone graft were evaluated. The diagnosis, the indication for surgery, the location and staging of the tumours, and the type of radiotherapy used were reviewed. The classification of the maxillary defects was performed according to the classification of Brown (Br J Oral Maxillofac Surg 40:183-190, 2002) and the success rates of the reconstructions were evaluated. Of the patients, 32 had been operated on due to a malignant tumour, one due to a benign tumour and one due to posttraumatic palatal defect. Preoperative radiotherapy (n = 14), preoperative chemoradiotherapy (n = 2) or postoperative radiotherapy (n = 11) had been used in the tumour group. As a reconstructive method, PTMF had been used with (n = 21) or without (n = 13) free calvarial bone graft. The use of free calvarial bone graft did not have a significant effect on flap survival. At 1-month follow-up, the flap survival in the 32 patients was 71.9%, whereas 28.1% of the patients suffered from partial flap loss, but there was no total flap loss. At 6-month follow-up, the flap survival in 26 patients was 76.9%, whereas 7.7% of the patients suffered from partial flap loss, and there were four (15.4%) total flap losses. If unilateral alveolar maxillectomy had been performed (Brown classification a), at 1-month follow-up, the flap survival was 82.6%, 17.4% of the patients suffered from partial flap loss, and there was no total flap loss. At 6-month follow-up, the flap survival was 89.5%, while 10.5% of the patients suffered from partial flap loss, and there was no total flap loss. The application of PTMF with or without free calvarial bone graft for reconstruction of limited palatal and maxillary defects appears to be feasible.

The Vastus Intermedius Periosteal (VIP) Flap: A Novel Flap for Osteoinduction

Periosteum's role in fracture healing is widely recognized, and its function in bone tissue engineering shows great potential. Here we introduce a novel periosteal free flap to be used as an abundant source of periosteum in the engineering and repair of bone. The descending branch of the lateral femoral circumflex vessels were isolated on 11 fresh human cadavers, preserving perforators to the vastus intermedius muscle. A cuff of vastus intermedius and approximately 75% of the circumference of the femoral periosteum were harvested from 6 cm proximal to the knee to 8 cm distal to the greater trochanter. Flap pedicle length and periosteal dimensions were measured. The pedicle arteries were injected with radiopaque dye, and radiographs were taken. A musculoperiosteal flap was elevated with visible descending perforators in each case. Mean flap surface area was 128 cm(2) (+/-99-143 cm(2)). Average pedicle length was 8 cm (+/-6-11 cm). Dye injection confirmed that the flaps blood supply was the descending branch of the lateral femoral circumflex artery. This anatomical study confirms the vascular supply of this large musculoperiosteal flap. Future work will test its efficacy as an osteoinductive agent in bone repair and tissue engineering in humans.