Reconstruction Of Posterior Canal Wall Research Articles

A comparative analysis of canal wall reconstruction mastoidectomy over canal wall down mastoidectomy

AimThis study aims to investigate the advantages of canal wall reconstruction mastoidectomy (C.W.R.) over the canal wall down (CWD) mastoidectomy.Material and methodA prospective study was conducted on sixty patients with cholesteatoma who underwent operation from September 2010 to October 2016. Patients were divided into two groups: “Group A," posterior canal wall reconstruction group (C.W.R.) with 28 patients (28 ears) and “Group B” which included 32 patients (32 ears) in whom canal wall down mastoidectomy (CWD) was done without reconstruction. The patients were followed up at 3 months and 6 months postoperatively with otoendoscopy to look for recurrence or residual disease, the occurrence of any complications, and for hearing assessment.ResultsGroup A (C.W.R.) patients were cosmetically better, and none had postoperative cavity problems. While in Group B (CWD), 16 patients (50%) had a cavity problem. Group A CWR group also had early epithelization. Both methods had hearing improvement postoperatively. Group A had more hearing improvement than Group B.ConclusionThe C.W.R. method is a safe method for eliminating the problem of the mastoid cavity. This surgery can be easily taught and applied universally in all cholesteatoma patients as a primary treatment. The C.W.R. technique provides improved exposure to the middle ear without creating a mastoid bowl, which significantly reduces the incidence of residual and recurrent disease. These results indicate that the C.W.R. method is better than the CWD operation.

Revision surgery for chronically discharging mastoid cavities: mastoid obliteration with canal wall reconstruction versus non-obliteration surgery

PurposeTo evaluate the surgical results of revision canal wall down (CWD) surgery for chronically discharging mastoid cavities and to compare the non-obliteration approach to mastoid obliteration with canal wall reconstruction.MethodsThis is a retrospective cohort study. All adult patients (≥ 18 years) who underwent revision surgery for chronically draining mastoid cavities between January 2013 and January 2020 were included. Primary outcome measures included the dry ear rate, complications and postoperative hearing.Results79 ears were included; 56 ears received revision CWD with mastoid obliteration and posterior canal wall reconstruction and 23 ears received CWD without mastoid obliteration. The dry ear rate at the most recent outpatient clinic visit (median 28.0 months postoperative) was significantly higher in the obliteration group with 96.4% compared to 73.9% for the non-obliteration group (p = .002). There were no differences in audiological outcome and incidence of complications between the two techniques.ConclusionWe show that in our study population revision CWD surgery with mastoid obliteration and posterior canal wall reconstruction is superior to revision CWD surgery without mastoid obliteration in the management of chronically discharging mastoid cavities. In the obliteration group, a dry ear was achieved in 96.4% as this was 73.9% in the non-obliteration group. We found no differences in audiological outcome and in incidence of complications between the two techniques.

Posterior Canal Wall Reconstruction in Squamosal Type of Chronic Otitis Media

Introduction: The removal of Cholesteatoma remains a matter of debate with varying opinion, but the primary objectives remain complete eradication of the disease and creation of a safe ear. Restoration of hearing is secondary objective. Reconstruction of posterior canal wall can be attempted after complete removal of cholesteatoma with different materials. Aim and Objectives: The aim of the study was to study the outcome of posterior canal wall reconstruction in patients undergoing modified radical mastoidectomy. Materials and Methods: This prospective interventional cross-sectional study has been done on forty patients in the department of otorhinolaryngology and head-neck surgery, in a tertiary care hospital in Western Uttar Pradesh with an enrolment period of 1 year and a minimum of 1-year follow-up. Results: In the present study, the success rate of canal reconstruction was 85%. The most common site of middle ear cleft which was found to be mostly affected by cholesteatoma was aditus in 94.12%, followed by posterior attic, middle ear, and sinus tympani accounting for 91.18%, 82.35%, and 79.41%, respectively. Incus was found to be the most common ear ossicle affected. A statistically significant result was found in the pre- and post-operative average hearing loss and air-bone gap. Conclusion: Canal reconstruction in patients undergoing canal wall down mastoidectomy is a good option in patients presenting with limited disease of squamosal type of chronic otitis media. A candidacy criterion has been proposed for deciding patients in whom canal reconstruction can be tried.

Transcanal Endoscopic Retrograde Mastoidectomy for Cholesteatoma: A Prospective Study.

To evaluate the feasibility, morphological, and functional outcomes of endoscopic retrograde transcanal mastoidectomy. Prospective study. Tertiary Referral Hospital. We analyzed 31 patients with a diagnosis of chronic otitis media with cholesteatoma that extended to the mastoid cavity who underwent endoscopic transcanal retrograde canal wall down mastoidectomy under general anesthesia. The tympanic membrane and posterior canal wall reconstruction were done using the tragal cartilage palisade technique reinforced with perichondrium. Morphological and functional results were reported in the follow-up of a minimum of 1 year. The graft uptake was also compared with the presence of granulations and discharge status. Graft uptake and disease-free conditions were achieved in 21 of 24 patients, that is, 87.5%, and 3 patients required revision surgery. The graft uptake rate was not affected by the presence of granulation tissues and discharge. The hearing was improved after the surgery, which was statistically significant. Endoscopic retrograde mastoidectomy is a new technique to deal with cholesteatoma with excellent results. It is more functional, ideal for sclerotic mastoid, allows faster wound healing, has excellent outcomes, and is a minimally invasive procedure that avoids postauricular incision and tissue dissection. Because the set up for the surgery costs less, it holds a promising future for the developing countries.

Post operative hearing status in canal wall down mastoidectomy with type III tympanoaplasty

Background: Canal wall down procedure may be with or without reconstruction such as tympanic membrane, ossicular chain or posterior canal wall reconstruction. To preserve and improvement of hearing, prevent discharge and recurrence, now a days canal wall down mastoidectomy with reconstruction such as type III tympanoplasty under magnification is a modern advancement in otology.
 Objectives: To find out hearing status before mastoidectomy and hearing status after canal wall down mastoidectomy with and without reconstruction.
 Methods: Prospectove study done on 3 tertiaty hospitals in Dhaka. Number of patients were 40 who underwent for modified radical mstoidectomy, 20 were with reconstruction and 20 without reconstruction (Type 3 Tympanoplasty)
 Results: hearing was deteriorated in most of the cases (60%) of MRM without tympanoplasty. Air Bone (AB) Gap Increased 3.65dB after CWD without reconstruction. Closer of AB gap (9.77 dB) occurred after CWD with reconstruction.
 Bangladesh J Otorhinolaryngol; October 2017; 23(2): 146-152

Successful Posterior Canal Wall Reconstruction with Tissue-Engineered Cartilage.

Difficulties are associated with reconstruction of middle ear bony structures in surgery for destructive lesions, including cholesteatoma. Although autologous cartilage appears to be the optimal choice because of its resistance to infection, the harvesting of sufficient volumes may be challenging. Therefore, regenerative medicine techniques to obtain sufficient material for reconstruction are awaited. We herein present a case of middle ear surgery for cholesteatoma with a sufficient volume of stick-shaped tissue-engineered cartilage produced from a piece of autologous auricular cartilage and autologous serum, with sufficient firmness to reconstruct bony structures. During surgery, sections of tissue-engineered cartilage were placed side by side to reconstruct the posterior canal wall. The postoperative course was uneventful. This is the first-in-human report of reconstructing middle ear bony structures with tissue-engineered cartilage. The results suggest a promising future for the satisfactory reconstruction of middle ear structures with minimal morbidity at the donor site.

The application of cartilage in middle ear surgery

Summary The aim of this study is to review the application, techniques and procedures of cartilage in the middle ear surgery. Cartilage offers the advantage of higher mechanical stability in tympanoplasty, which is the most common procedure in the middle ear surgery, thus apply to much complicated situation especially for tubal dysfunction and adhesive processes. There are many variations on the shape, size, thickness and technical matters of the cartilage grafts. The past decades and literature have observed excellent graft take rates and good postoperative hearing outcomes for cartilage tympanoplasty and the reservation of perichondrium seems to show better long-term survival. There have been concerns regarding malacia of cartilage struts, as a result, cartilage struts for ossiculoplasty have not gained popularity except for combined application with synthetic materials. Meanwhile, the benefits of cartilage in the reconstruction of posterior canal wall and attic, mastoid obliteration and adhesive otitis media have been demonstrated in the previously published studies. It is well to be reminded that cartilage could be applied in some unusual cases such as vibrant soundbridge, meningoencephalocele.

RECONSTRUCTION OF POSTERIOR MEATAL AND/OR LATERAL ATTIC WALLS IN CHOLESTEATOMA SURGERY

Purpose: To evaluate reconstruction of posterior meatal and/or lateral attic walls in cholesteatoma surgery using the autologous bony posterior canal wall and bone pâte during the first stage operation. Patients and methods: Twenty ears of twenty patients with chronic suppurative otitis media with cholesteatoma. Cases with extensive destruction of posterior canal wall and mastoid cortex, low tegmen, significant anterior or lateral sigmoid sinus, only functioning ear, labyrinthine fistula and previous canal wall down mastoidectomy were excluded. The surgical technique includes cortical mastoidectomy and bone pâte collection,temporary removal of the bony posterosuperior meatal wall(PMW) by cutting the entire PMW as one piece with a microsagittal saw to offer optimal exposure of tympanic cavity,attic and retrotympanum for complete eradication of cholesteatoma and then repositioning of this wall in its anatomical site supported with bone pâte in attic and mastoid.The condition of reconstructed PMW and the status of middle ear were evaluated by computed tomography scan, otoendoscopic examination and staged second–look surgery. Results:Cholesteatoma in the mastoid, antrum , attic and retrotympanum could be removed with safety in all cases; no serous intraoperative complications occurred, intraoperative difficulties included: damage of posterosuperior canal wall during saw cutting in one case(5%) and mild dural injury during superior cutting in one case(5%) , through follow–up , the new reconstructed canal appeared to be of near normal size, shape and contour, and no dislocation or necrosis of the reconstructed posterior canal wall was noted. The postoperative complications included: wound infection in one case (5%) , tinnitus in two cases (10%) and recurrent cholestearoma in one case(5%). Conclusion: Our surgical technique which includes reconstruction of posterior meatal and/or lateral attic walls in cholesteatoma surgery using the autologous bony posterosuperior meatal wall after its temporary removal provides optimal surgical exposure during the procedure, restores near normal anatomy of the external auditory canal , has low recurrence rate(5%) and avoids the troubles of open mastoid cavity, making this surgical procedure an attractive alternative to the standard CWU and CWD procedures. Keywords:Cholesteatoma; Canal wall down mastoidectomy; Canal wall up mastoidectomy; Posterior canal wall reconstruction; Open cavity.

Efficacy of Posterior Canal Wall Reconstruction Using Autologous Auricular Cartilage and Bone Pâté in Chronic Otitis Media with Cholesteatoma.

This study was designed to investigate the long-term results using the technique of canal wall up mastoidectomy and reconstruction of the posterior canal wall using bone pâté and auricular cartilage in the treatment of chronic otitis media with cholesteatoma. A retrospective review was performed on 42 patients who underwent canal wall up mastoidectomy and posterior canal wall reconstruction at a single institution between November 2005 and November 2012. Of the 42 patients, postoperative tympanic membranes were normal in 38 (90.5%), perforated in 1 (2.4%), and retracted in 3 (7.1%). Mean preoperative and postoperative values of the air-bone gap (ABG) were 29.4±12.8 and 23.4±11.7 dB, respectively, which represented a significant average improvement. For patients with ossiculoplasty (n=24), the mean preoperative and postoperative ABG values were 34.7±6.0 and 27.5±8.0 dB, respectively, which also represented a significant average improvement. Thirty-one (73.8%) of the patients were followed up without any complication, but 5 had otorrhea (11.9%), 4 had dizziness (9.5%), and 2 had facial palsy (4.8%). A canal wall up mastoidectomy with reconstruction of the posterior canal wall using auricular cartilage and bone pâté provides successful preservation of the anatomic structure and a significant improvement in hearing without the long-term disadvantages of a canal wall down mastoidectomy.

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

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Canal wall reconstruction – surgical considerations

Recurrent cholesteatoma and local mastoid morbidity account for common patient complaints in our pediatric department. Objective. To describe a surgical technique used for 2 difficult cholesteatoma pediatric cases, in order to prevent mastoid cavity associated disease. Material. 2 cases with recurrent cholesteatoma and mastoid morbidity were surgically approached by reconstructing the posterior osseous canal wall. Results. Anatomical results were satisfactory on short term monitoring. Long-term results need further evaluation. Conclusion. Posterior canal wall reconstruction represents a useful option for mastoid cavity patients with local recurrent disease.

SURGICAL RECONSTRUCTION OF THE POSTERIOR MEATAL WALL BY BIOGLASS VERSUS TITANIUM MESH

Canal wall down mastoidectomy has many drawbacks including chronic otorrhea not responding to medications, granulations, dizziness on exposure to cold or hot water, and tendency of debris accumulation in the mastoid cavity, necissating periodic cleaning. Many of these proplems can be solved by reconstruction of the posterior meatal wall. Aim of work: To solve the cavity proplems after CWD mastoidectomy via reconstruction of posterior meatal wall, and to compare between the outcomes of the Bioglass versus titanium mesh in reconstruction of posterior meatal wall. Patients and methods: This study was applied on 40 patients that have chronic sappurative otitis media. All cases were subjected to canal wall down mastoid surgery with complete elimination of the disease and reconstruction of the posterior meatal wall. Patients were divided to 2 groups: group (A) was managed by canal wall down mastoidectomy with reconstruction of the posterior meatal wall by Bioglass and the group (B) was managed by canal wall down mastoidectomy with reconstruction of the posterior meatal wall by titanium micromesh; all patients were exposed to full preoperative evaluation, and full postoperative assessment of complications, appearance of the external auditory canal contour, and the hearing gain expressed by the change of the air bone gap postoperatively. Results: There is a significant difference between the two groups regarding postoperative complications mainly the postoperative granulations and discharge, the postoperative appearance of the external auditory canal contour, and the hearing gain in favor of group (A) but there is no significant difference between the 2 groups as regard the intraoperative difficulties, the other postoperative complications like wound infection, canal stenosis, extrusion or displacement of the materials and recurrence of cholesteatoma. Conclusion: Reconstruction of posterior canal wall can eliminate many of the cavity proplems after CWD mastoidectomy especially by using the Bioglass which shows better advantages than the titanium micromesh Keywords: canal wall reconstruction, Bioglass, titanium, mastoidectomy, mastoid cavity oblitration

Prospective cohort comparison of bioactive glass implants and conchal cartilage in reconstruction of the posterior canal wall during tympanomastoidectomy

To compare the effectiveness of bioactive glass implants and conchal cartilage in reconstructing the posterior canal wall during tympanomastoidectomy. Prospective cohort clinical study. Teaching hospital. Patients with clinically diagnosed chronic suppurative otitis media and cholesteatoma awaiting tympanomastoidectomy were recruited. All patients underwent tympanomastoidectomy by the same surgeon. A first cohort of 12 patients underwent posterior canal wall reconstruction with autogenous conchal cartilage. A second cohort of 12 patients underwent such reconstruction with prefabricated bioactive glass. Primary- All patients underwent out-patient review at 1, 3, 6 and 12 months postoperatively, after which a second-look procedure was performed. Reconstructions were inspected for evidence of epithelialization, granulation, infection, stenosis, depression and extrusion. Secondary- All patients had perioperative serial pure-tone audiometry to check for any change in hearing levels upto 1 year postoperatively. By 1 year postoperatively, both reconstructive graft materials showed good epithelialization, no granulation, no infection, no ear canal stenosis, no depression and no extrusion. At operative second-looks, bioactive glass particularly showed good tissue bonding, including both neovascularization and connective tissue integration. Overall clinical outcome was equivalent for both materials. Both graft materials showed no statistically significant difference in postoperative hearing levels. Bioactive glass and conchal cartilage showed equivalent clinical outcome in reconstructing the posterior canal wall without significantly affecting hearing levels. As bioactive glass does not require second site morbidity and thus also reduces operative time, we prefer it for reconstructing the posterior canal wall following tympanomastoidectomy.

Chronic suppurative otitis media following paediatric cochlear implantation

The objective of this study was to report and discuss the management of chronic suppurative otitis media (CSOM) following cochlear implantation in children. The study was a retrospective review of 650 patients receiving an implant at two paediatric tertiary referral centres for cochlear implantation. Nine patients were identified who developed CSOM following cochlear implantation (incidence 1.38%). The mean time interval between implantation and symptom development was 3.66 years (range 2–8 years) and the mean time interval between implantation and CSOM surgery was 5.02 years (range 2.2–8 years). All patients presented with otorrhoea and/or abscess formation over the implant site. Two patients underwent a modified radical mastoidectomy and seven underwent a combined approach tympanoplasty, three of whom required posterior canal wall reconstruction with cortical bone and one with cartilage. In four cases it was possible to remove the cholesteatoma without removing the implant. All but two patients were fitted with a contralateral implant. In the explanted ears the cochlear implant electrode was cut at the cochleostomy site, which was then covered with muscle. Chronic suppurative otitis media following cochlear implantation may occur either as a result of a posterior canal wall defect related to surgery or possibly de novo. Attempts should be made to save the implant, but explantation with reimplantation of the contralateral ear may be the only option. In these cases the intracochlear part of the electrode array should be left in situ to facilitate possible future reimplantation. Surgical options for management of CSOM should be individualized and may include both canal-wall up and canal-wall down techniques. To reduce the incidence of CSOM following implantation the authors recommend: (1) prompt treatment and careful follow-up of patients with a history of otitis media with effusion, (2) avoidance of excessive thinning of the posterior canal wall during mastoidectomy and (3) reconstruction of any accidental trauma to the annulus or posterior canal wall during posterior tympanotomy. Copyright © 2006 John Wiley & Sons, Ltd.

Posterior canal wall reconstruction with a composite cartilage titanium mesh graft in canal wall down tympanoplasty and revision surgery for radical cavities

To investigate posterior external ear canal wall reconstruction with a composite cartilage titanium mesh graft in canal wall down tympanoplasty and revision surgery for open mastoids. Retrospective case review. Tertiary referral centre. As a preliminary study, 15 selected patients underwent reconstruction of a posterior ear canal wall defect with titanium mesh. Large defects of the posterior external auditory canal wall, resulting from canal wall down tympanoplasty or present in revision surgery, were eliminated by reconstruction using a titanium mesh. The mesh was covered with conchal cartilage and attached to the cortical mastoid bone using 3-mm titanium screws. All patients maintained a normal contour of the external ear canal, without depression, extrusion or infection. There were no failures, based on short-term post-operative controls. However, two procedures had to be revised due to incomplete coverage of the titanium mesh. This study shows that reconstruction of the posterior ear canal wall with a composite cartilage titanium mesh is a valuable method for preserving the morphology of the external auditory canal in selected cases. Problems occurring in canal wall down tympanomastoidectomy and radical cavities may therefore be avoided. However, long-term results have yet to be evaluated.

Posterior Canal Wall Reconstruction Tympanoplasty for Operated Ears with Open Mastoid

We investigated the postoperative conditions of ears and the hearing acuity of patients who underwent posterior canal wall reconstruction tympanoplasty for operated ears with open mastoid. The study included 118 ears of 105 patients (57 males, 48 females; age range 5-75 years) and the patients were followed for >1 year after the final operation. Although 114 ears (97%) were dry after the final operation, retraction pockets and eardrums in a lateral position were observed in 5 ears and in 1 ear, respectively. Ossicular reconstruction was performed in 83 ears and in these the mean air conduction hearing levels were significantly improved after the final operation in those that were subjected to type III and IV tympanoplasty. These results indicate that posterior canal wall reconstruction tympanoplasty can be considered to be an effective procedure.

Demineralized bone matrix as an alternative for mastoid obliteration and posterior canal wall reconstruction: results in an animal model.

This study was conducted to evaluate the use of Grafton human demineralized bone matrix as a graft material for mastoid cavity obliteration and canal wall reconstruction in an animal model. Canal wall down procedures in the treatment of cholesteatoma may result in a problematic mastoid cavity. Elimination of the mastoid cavity by obliteration or canal wall reconstruction can prevent or correct this problem. Many techniques and implant materials have been used for this application, yet no single material has proven to be ideal. Athymic rats received tympanic bulla obliteration and lateral bulla wall reconstruction utilizing the Grafton Putty and Flex formulations, respectively. Wound healing was monitored twice a week. Auditory brainstem evoked responses were obtained 8 weeks after implantation. Nine weeks after implantation, the animals were killed, and histologic sections were prepared. A histologic bone formation score (range 0-4) was determined for each implant. Wound healing occurred without complication. Auditory brainstem response thresholds (average 23.5) fell within the normal range for all ears tested. The average histologic bone formation score for all implants was 3.7. The average scores for obliteration implants and wall reconstruction implants were 3.5 and 3.9, respectively. All wall reconstruction implants underwent partial or total collapse into the bulla. The high level of bone formation obtained by the use of Grafton implants in this study makes this material a promising resource for use in mastoid obliteration. The use of the material for canal wall reconstruction will likely require a sturdier preparation to prevent collapse into the mastoid cavity.

Long-term results of Feldmann's osteoplastic approach for chronic middle ear disease

Between 1978 and 1981, Feldmann's osteopathic approach was often used to manage chronic middle ear disease. In this procedure, the superior and posterior segment of the ear canal wall was cut after complete mastoidectomy, removed temporarily and re-positioned in the previous position after handling the diseased focus in the tympanic isthmus area. Forty-one cases (24 cases of non-cholesteatomatous chronic otitis media and 17 cases of cholesteatoma) were followed and long-term results of this procedure were studied with regard to re-operative findings following this procedure. Among the 41 patients, 13 (31.7%) required revision surgery because of cholesteatoma formation, infection etc. Seven of these 13 patients (53.8%) required revision surgery because of cholesteatoma formation after this procedure. None of these 7 cases appeared to involve residual cholesteatoma. The most important problem is that 3 of the 7 patients showing cholesteatoma formation had non-cholesteatomatous chronic otitis media before this procedure. In other words, the Feldmann's osteoplastic approach may iatrogenically induce cholesteatoma formation in non-cholesteatomatous chronic otitis media. The re-operative findings indicated that the re-positioned canal wall in this procedure may have small bony defects or bony erosion, inducing pocket formation through these defects to create a new cholesteatoma. Although recent literature concerning tympanoplasty recommends posterior canal wall reconstruction using cartilage, bone, ceramic material or bone-pate rather than the canal wall down method, careful follow-up should be continued with regard to pocket formation and/or cholesteatoma formation.

Ionomer-based bone substitute in otologic surgery.

During post-set hardening the self-curing bone substitute Ionocem develops a solid bond with the adjacent bony tissue, leaving no empty spaces. The fully matured material can be fixed to bone with freshly mixed cement or it may be used as a blank, e.g. an ossicular implant (Ionos ossicle). After insertion of 945 alloplastic middle ear prostheses over a period of 4.5 years, the take-rate was 94%. In some patients revision surgery became necessary, in 50% of cases because of prosthesis dislocation. A granular version of the cement (Ionogran) was implanted in 46 ears for obliteration of mastoid cavities and showed complete mucosal overgrowth within a maximal period of 3 months. Posterior canal wall reconstruction with the self-curing bone substitute was done in 74 patients, with revisions required in 12 cases because of persistent epithelial deficits in the external ear canal or epitympanic retraction. Overall results showed that the ionomer-based cement was a useful substitute for bone in reconstructive otologic surgery.

外耳道削除後の乳突腔に発生する諸問題

Mastoid cavity problems were studied in 113 ears that had the posterior canal wall removed during surgery (open tympanoplasty, radical mastoidectomy, modified radical mastoidectomy) for middle ear cholesteatoma. Posterior canal wall reconstruction with mastoid obliteration was performed in 19 ears, mastoid obliteration only in 10 ears, and no treatment for the open mastoid cavity in 84 ears.The total incidence of mastoid cavity problems was 30.1%. Aural discharge was most frequently observed (24.8%). Other problems included postoperative development of mastoid air cells, cholesteatoma or cyst formation, the absorption of the reconstructed canal wall, and mycosis. Cavity problems were more frequently observed in the groups with reconstruction or obliteration because of the absorption of those materials. Patients under 9 years old frequently had cavity problems, and additional surgery was performed in 44.1%.Preservation of the canal wall is most important in preventing the cavity problems, and firm obliteration of the open mastoid cavity with bone tissue or ceramics is necessary in patients that have the canal wall removed.