Wall Down Research Articles

Comparison of Different Techniques of Meatoplasty After Canal Wall Down Mastoidectomy.

To compare surgical outcomes with different meatoplasty techniques without removal of a cartilage piece in canal wall down mastoidectomy. Total 61 patients of canal wall down mastoidectomy included in the study where either inferior based flap technique or division in middle technique meatoplasty performed and 2 groups formed. Group A consisted of 33 patients and the inferior based flap technique of meatoplasty used in these patients. Group B consisted of 28 patients and the division in middle technique of meatoplasty used in these patients. Granulations, discharge or stenosis of canal were observed in less than 8% of cases in both the groups. Meatoplasty done without incision or excision of a piece of cartilage from pinna can be achieved with good success rates with either inferiorly based flap technique or division in middle technique.

A Comparative Study on Mastoidectomy Cavity Obliteration with Soft Tissue Graft and Cartilage Graft in Canal Wall Down Mastoidectomy

A Comparative Study on Mastoidectomy Cavity Obliteration with Soft Tissue Graft and Cartilage Graft in Canal Wall Down Mastoidectomy

Study of clinical profile, complications and management of acquired cholesteatoma in pediatric age group: a retrospective study

<p class="abstract"><strong>Background:</strong> Chronic suppurative otitis media when delayed of early treatment results in complications. And the present study is conducted to evaluate the complications and management of acquired cholesteatoma in pediatric age group. Aim of the study was to highlight important aspects and paradigms of clinical profile of pediatric cholesteatoma, its complications and management</p><p class="abstract"><strong>Methods:</strong> A retrospective audit of total 15 cases of acquired paediatric cholesteatoma with complications were studied aged 4-14 years, for a period of 2 years from January 2018 to 2020, at a tertiary referral Centre and teaching hospital. An analysis was made about the clinical profile of pediatric acquired cholesteatoma, its complications and the overall management. </p><p class="abstract"><strong>Results:</strong> The male to female ratio was found to be 2:3. The most common presenting feature was foul smelling otorrhea, decreased hearing and earache with headache, fever in complicated cases. 9 cases among 15 (60%) had complications both intracranial and extra cranial. Surgery was the main modality of management of these conditions. Intraoperatively the major findings were cholesteatoma and granulation in the attic and mesotympanum with erosion of scutum. </p><p class="abstract"><strong>Conclusions:</strong> Acquired cholesteatoma in children is more aggressive than adults, and likely to present with advanced disease with ossicular chain involvement. Patients with unreliable follow up and limited access to operating theatre, Canal Wall Down mastoidectomy is an optimal management for complete exposure and removal of cholesteatoma.</p>

Evaluation of Hearing Status in Pre and Postoperative Canal Wall Down Mastoidectomy with Type III Tympanoplasty with or without Cartilage Augmentation

Objective: To evaluate Hearing Status in Pre and Post-operative Canal Wall Down Mastoidectomy with Type III Tympanoplasty with or without cartilage augmentation.
 Methods: This was a prospective study, done in Otolaryngology & Head Neck Surgery department of Sir Salimullah Medical College Mitford Hospital(SSMCMH) and Bangabandhu Sheikh Mujib Medical University(BSMMU) , Dhaka, Bangladesh. 1stJuly to 31st December, 2012. Forty patients were studied in this series.
 Results: The results concluded that mean pre and post-operative air bone gap were 38.5 dB and 29.69 dB respectively with a net gain of 8.81 dB in Canal wall down mastoidectomy with cartilage augmented Tympanoplasty type III which is statistically significant. The postoperative PTA-ABG ranged from 25-36 dB , the ABG closure was 11-15 dB in 40% case. Whereas mean pre and post-operative air bone gap were 37.19 dB and 34.19 dB respectively with a net gain of 3 dB in Canal wall down mastoidectomy without cartilage augmented Tympanoplasty type III which is statistically insignificant. The post-operative PTA-ABG ranged from 26.25-41.75 dB, the ABG closure was 0-5 dB in 35% case.
 Conclusion: Hearing results after cartilage augmentation in type iii Tympanoplasty showed improvement at individual and mean post-operative PTA-ABG and also improvement in ABG closure suggesting thin cartilage disc increased the effective vibrating area of tympanic membrane graft.
 Bangladesh J Otorhinolaryngol; October 2020; 26(2): 86-94

Clinical analysis of 8 cases of delayed facial paralysis after middle ear surgery

Objective:To investigate the possible causes, prevention, treatment and recovery of delayed facial paralysis after middle ear surgery. Method:A retrospectively analysis of the data of 8 patients with delayed facial paralysis after middle ear surgery under general anesthesia, including one case of tympanoplasty （type Ⅰ） , one case of tympanotomy+tympanoplasty c（type Ⅰ） , one case ofepitympanotomy+reconstruction of attic lateral wall+tympanoplasty （type Ⅱ ）, four cases of canal wall down+tympanoplasty （ type Ⅱ） and one case of canal wall up mastoidectomy. After discovering the facial paralysis, the stuffing in the surgical cavity was released and removed for all patients immediately. Necessary stuffing was replaced by dexamethasone gauze （not press hardl）. Meanwhile, patients took methylprednisolone orally and were intramuscularly injected with mecobalamine. Result:Among eight patients, there were six patients with horizontal exposure of facial nerve and two patients with pyramis exposure of facial nerve. There was one case, five cases and two cases of delayed facial paralysis at five days, one week and two weeks after operation respectively. There were six patients suffering from the facial paralysis of HB Ⅱ grade and two patients suffering from the facial paralysis of HB Ⅲ grade. Four patients recovered four weeks and the remaining four patients returned to normal six weeks after surgery. Conclusion:Delayed facial paralysis is one of complications of the middle ear surgery, and most of patients can recover completely after conservative treatment.

Comparing the Incidence of Residual Cholesteatoma Using two Canal Wall Down and Endoscopic-assisted Intact Canal Wall Tympanomastoidectomy Methods

Background: For many years, Canal Wall Down (CWD) tympanomastoidectomy has been the gold standard for treatment of cholesteatoma; however, this method has long-term complications for the patients. The Intact Canal Wall (ICW) tympanomastoidectomy has relatively lower complications, but access to the middle-ear recesses is difficult in this method. Therefore, endoscopy is used to visualize the underexposed recesses. Objective: This study aims to compare the incidence of residual cholesteatoma using the two methods of CWD and endoscopic-assisted ICW. Materials and Methods: In this prospective randomized clinical trial, participants were 40 patients with cholesteatoma in the middle ear and mastoid who were candidates for tympanomastoidectomy. They were randomly divided into two groups. In the first group, ICW was performed with endoscopic assisted visualization, while in the second group, conventional CWD technique was performed without ossicular reconstruction. All the patients were microscopically examined at 3, 6, 9 and 12 months after surgery. Revision middle ear surgery and possible ossicular reconstruction under local anesthesia were performed one year after the surgery. The presence of cholesteatoma pearl in the middle-ear, evaluated by using a 2.7mm 30° endoscope, was recorded as the sign of residual cholesteatoma. Fisher’s exact test and Mann-Whitney U test were used for statistical analysis. Significance level for the tests was set at 5%. Results: The incidence of residual cholesteatoma was not statistically significant between the two groups (P>0.05). In each group, 20% (n=4) had residual cholesteatoma. The difference in time interval from the first to second surgery was not statistically significant between the study groups (P>0.05). Conclusion: Endoscopic-assisted ICW tympanomastoidectomy is comparable with CWD tympanomastoidectomy in eradication of cholesteatoma, having possibly fewer complications. It is recommended that more studies be conducted with a larger sample size and longer follow-up period.

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.

TYPE III TYMPANOPLASTY: A COMPARATIVE STUDY BETWEEN AUTOLOGOUS INCUS AND TRAGAL CARTILAGE AS OSSICULOPLASTY MATERIAL – OUR EXPERIENCE

Background: Type III tympanoplasty involves complete disease clearance from middle ear cleft and retaining or improving the serviceable hearing by ossiculoplasty. Various auto and allografts have been used with variable outcomes. The objective of the study was to evaluate hearing improvement in patients who underwent type III tympanoplasty using autologous incus and tragal cartilage as ossiculoplasty material. Method: A retrospective chart review of 30 patients who underwent type III tympanoplasty at medical college Srinagar Pauri Garhwal from January 2019 to December 2019 was done. In 10 patients autologous incus and in 20 tragal cartilage was used for ossiculoplasty. Those patients who required wall down were excluded from the study and only patient with limited atticotomy and complete mastoidectomy requiring type III tympanoplasty were included in the study. Pure tone audiograms done after 3 months were compared with the pre operative audiogram. Result: 10 patients who underwent type three tympanoplsty with use of autologous incus for ossiculoplasty had a mean hearing gain of 17.08dB and 20 pateint underwent type three tympanoplasty with use of tragal cartilage for ossiculoplasty had mean hearing gain of 18.26 dB at 3 months after surgery. Hearing gain was similar in both groups irrespective of the material used. The tragal cartilage was used as strut extending from stapes head to the anteroinferior part of annulus supporting the graft throughout and additionally helping in maintaining the middle ear space. Conclusion: The post-operative hearing gain with autologous incus and tragal cartilage as middle ear prosthesis are similar but the additional role of cartilage supporting the graft and maintaining the middle ear space overrule the use of tragal cartilage for ossiculoplasty in type three tympanoplasty. So by this study we recommend the use of tragal cartilage as ossiculoplasty material for type III tympanoplasty over other material.

Bone Pate Obliteration in Canal Wall Down Mastoidectomy: Modifications of an Established Technique.

To describe outcomes with obliteration of the mastoid and medial attic following canal wall down mastoidectomy for cholesteatoma. Our technique uses bone pate in the mastoid and cartilage in the epitympanum and supratubal recess. Retrospective observational study. Tertiary medical center. Ten years of sequential canal wall down mastoidectomies with obliteration from one neurotologist were reviewed. This included primary and revision cases in adults and children. Complications, location and extent of cholesteatoma, the presence of a dry ear after surgery, cholesteatoma recidivism, revision procedures, and postoperative hearing. Seventy-eight patients (79 ears) met inclusion criteria. There were few major complications. There was active follow-up of a year or more in 61. For these, the mean follow-up was 3.1 years, and approximately 90% had a dry cavity for the remainder of their follow-up. About half required minimal (if any) maintenance. There were five cases with residual disease, and no cases with recurrent disease. There were five cases that were considered failures, with three taking several years to manifest. There were no cases where cholesteatoma was buried in bone pate. A sizeable minority continued to have active tubotympanic disease despite successful treatment of the attic and mastoid. This seems to be a safe and reliable means to eradicate cholesteatoma and create a dry, low-maintenance cavity. It is not a cure for tubotympanic disease, and a small minority of initially stable cavities may fail several years following surgery. 4.

Study of Hearing Status After Canal Wall Down Mastoidectomy with Type-III Tympanoplasty

Objective: To observe hearing status in case of canal wall down mastoidectomy with type III tympanoplasty.
 Methods: This was a cross sectional study which was carried out in the departments of Otolaryngology and Head-Neck surgery of Bangabondhu Sheikh Mujib Medical University during the period of July’ 2011 to March’ 2012.A Total 38 patients having cholesteatoma underwent canal down mastoidectomy with type III tympanoplasty,were included in this study. Patients were divided into two groups according to their age. Age belonged to 18 years and more than 18 years were considered as child and adult respectively. Patients were examined thoroughly and preoperative hearing level was assessed by pure tone audiometry one one week before operation. Post operative patients were followed up at regular intervals. Pure tone audiogram (PTA) was done after 8 weeks and hearing assessment was compared by closure of air bone gap.
 Results: In this study majority of patients were within 13-17 years in child group and 18- 35years in adult group. Most of patients were male.Closure of air-bone gap was significantly higher in adults. Improvement of hearing status was more in adults.
 Conclusion: CWD mastoidectomy with tympanoplasty not only lowers recurrence rate but also improves hearing status although less likely in child and younger age group than adults.
 Bangladesh J Otorhinolaryngol; April 2017; 23(1): 52-58

Usefulness of Anterior-Based Periosteal (Palva) Flap for Obliteration of Mastoid Cavity in Canal Wall Down Mastoidectomy

Usefulness of Anterior-Based Periosteal (Palva) Flap for Obliteration of Mastoid Cavity in Canal Wall Down Mastoidectomy

Anterior Attico-antrostomy with Cortical Mastoidectomy and Attic Reconstruction with or without Ossiculoplasty Versus Canal Wall Down Mastoidectomy with Ossiculotympanoplasty using Tragal Cartilage sh

Anterior Attico-antrostomy with Cortical Mastoidectomy and Attic Reconstruction with or without Ossiculoplasty Versus Canal Wall Down Mastoidectomy with Ossiculotympanoplasty using Tragal Cartilage sh

Pre and intraoperative findings of chronic otitis media

Chronic otitis media (COM) is still highly prevalent in developing countries and often become main cause of deafness and morbid complication. Appropriate management may decrease the morbidity and mortality rate. The aim of the study are to evaluate preoperative and intraoperative finding among COM patients. A descriptive study was conducted at Mohammad Hoesin Hospital Palembang from April 2015 to April 2018. A secondary data was taken from medical records. A total of 252 patients were included in this study with the highest incidence was at 21-30 years old group (29,36 %) with male predominance. The most frequent preoperative assessment were total perforation of tympanic membrane in 104 patients (41.26 %), moderately severe mixed hearing loss in 61 patients (24,2%), and mastoiditis with cholesteatoma in computed tomography (CT) finding in 158 patients (62,69 %). In intraoperative finding, there were 202 patients (80,15%) with cholesteatoma whereas 103 patients (40,87 %) with granulation tissue. Ossicular chain destruction were found in 141 patients (55,95 %). Canal Wall Down Mastoidectomy (CWD) were performed in 190 patients (75,39 %). The prevalence of COM with cholesteatoma at Mohammad Hoesin hospital is still high. Operative management using CWD technique is preferred in cases of COM with cholesteatoma.

A Clinical Study on Audiological Evaluation in Patients with Active Squamous Variety of Chronic Otitis Media Following Canal Wall Down Mastoidectomy with Ossicular Reconstruction.

To evaluate hearing results following canal wall down mastoidectomy with ossicular reconstruction for Chronic Suppurative Otitis Media of Active Squamosal variety & evaluate various factors related to surgery impacting hearing results. This prospective study involves 40 patients of active squamosal variety of chronic otitis media who attended ENT OPD and underwent canal wall down mastoidectomy with ossiculoplasty during the period from November 2014 to October 2015. All the patients were subjected to pre and 3months post-op hearing assessment. Based on the hearing outcome, we expressed our study results into two groups, those with statistically significant improvement after surgery (T1) and those whose hearing got worsened or remained the same (T2). The mean post operative hearing gain of patients was 5.25 ± 7.30dB, The median post-op hearing gain was 5.20dB. Mean pre-operative hearing loss (AB gap) was 41.28dB. Mean post-operative hearing loss (AB gap) was 36.24 with the average 3months post-operative hearing gain was 5.2dB, which reflects a definite improvement. There is a statistically significant hearing improvement (with an average of 5.2dB AB gap closure) following Canal Wall Down Mastoidectomy with ossiculoplasty as established in the study.

External Auditory Canal Reconstruction and Mastoid Obliteration Using Modified Palva Flap in Canal Wall Down Mastoidectomy With Tympanoplasty.

To evaluate the effectiveness of a modified Palva flap used for external auditory canal reconstruction and mastoid obliteration in canal wall down mastoidectomy. We retrospectively analyzed patients who underwent canal wall down mastoidectomy with tympanoplasty using modified Palva flap. All patients underwent pure tone audiometry and temporal bone computed tomography (CT) before surgery, and the same tests were performed in the first year after surgery. The external auditory canal volumes were calculated by summing the areas of each section selected in temporal bone CT. For each patient, the ratio of external auditory canal volume was calculated from CT taken before and after surgery. The mean of external auditory canal volume after canal wall down with a modified Palva flap was about 1.4 times larger than before surgery. The modified Palva flap is effective for the reconstruction of the external auditory canal. Both pure tone audiometry level and air-bone gap showed statistically significant improvement after surgery ( Ps = .001 and .002, respectively). The external auditory canal volume slightly increased, but the status of mastoid obliteration was well maintained 1 year after surgery. The modified Palva flap used in this study is an easy and effective method in external auditory canal reconstruction and mastoid obliteration.

Use of Biodesign® Otologic Graft in Canal Wall Down Mastoidectomy: A Prospective, Randomized Trial

Use of Biodesign® Otologic Graft in Canal Wall Down Mastoidectomy: A Prospective, Randomized Trial

Hearing Outcomes Following Type 3 Tympanoplasty With Stapes Columella Grafting in Canal Wall Down Mastoidectomy.

To analyze hearing outcomes following Type 3 tympanoplasty with stapes columella grafting after canal wall down mastoidectomy and determine disease recurrence rates in patients undergoing this procedure. This retrospective cohort analysis examines patients undergoing Type 3 tympanoplasty with stapes columella grafting following canal wall down mastoidectomy for cholesteatoma at a tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if they were found to have undergone the aforementioned procedure. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 6 months and 1 year postoperatively. Nineteen patients met criteria for this study. Erosion of the otic capsule, posterior fossa plate, or tegmen was noted in 37% of cases, highlighting disease severity. Eighteen (95%) had undergone prior otologic surgery. Mean time to short-term follow-up was 6 ± 3 months. The average short-term ABG was 26 ± 11 dB HL; 26% achieved an ABG <20 dB, and 58% achieved an ABG <30 dB. Fifteen had follow-up at least 1 year postoperatively (mean = 33 ± 16 months). At longer-term follow-up, mean ABG was 25 ± 10 dB HL; 33% achieved an ABG <20 dB, while 66% achieved an ABG <30 dB. Hearing remained stable over time (P = .52). At date of last clinical follow-up, only 1 (5%) patient had undergone revision for recurrent disease. In some patients undergoing canal wall down mastoidectomy for advanced or recurrent cholesteatoma, Type 3 tympanoplasty with stapes columella grafting yields marginal hearing benefit. This type of reconstruction is a viable option in this challenging patient cohort, particularly as it is associated with low rates of revision surgery.

Prospective study of treatment outcome in chronic suppurative otitis media (Attico - antral Disease)

Aim: To analyse the post operative outcome in patients with CSOM – Atticoantral type and compare the outcomes in terms of disease clearance and improvement in hearing. Material and Methods: 50 Patients who were diagnosed as Chronic Suppurative otitis Media of Attico-antral type, detailed history & clinical examination and investigations were performed. Per-operative findings (status of ossicles, middle ear, antrum, mastoid), Post operative follow up (1, 3 and 6 months) -disease clearance and hearing status was done. Results: Out of total 50 patients, Canal Wall Down Procedures (Modified radical mastoidectomy with Tympanoplasty) had a good success rate in disease clearance when compared with Canal Wall Up Procedures (Cortical Mastoidectomy/ Atticotomy With Tympanoplasty). Irrespective of canal wall up (or) canal wall down procedures, Type II Tympanoplasty show better results of hearing improvement when compared to other surgical procedures. Conclusion: In our study, postoperative surgical outcome were statistically analyzed using Chi square test, in which Canal wall down procedures showed good result in terms of disease clearance and Type II tympanoplasty showed good result in terms of hearing improvement.

Outcomes of Modified Canal Wall Down Mastoidectomy and Mastoid Obliteration Using Autologous Materials

ObjectivesThe traditional canal wall down mastoidectomy (CWDM) procedure commonly has potential problems of altering the anatomy and physiology of the middle ear and mastoid. This study evaluated outcomes in patients who underwent modified canal wall down mastoidectomy (mCWDM) and mastoid obliteration using autologous materials.MethodsOur study included 76 patients with chronic otitis media, cholesteatoma, and adhesive otitis who underwent mCWDM and mastoid obliteration using autologous materials between 2010 and 2015. Postoperative hearing airbone gap and complications were evaluated.ResultsDuring the average follow-up of 64 months (range, 20 to 89 months), there was no recurrent or residual cholesteatoma or chronic otitis media. No patient had a cavity problem and anatomic integrity of the posterior canal wall was obtained. There was a significant improvement in hearing with respect to the postoperative air-bone gap (P<0.05). A retroauricular skin depression was a common complication of this technique.ConclusionThe present study suggests that our technique can prevent various complications of the classical CWDM technique using autologous tissues for mastoid cavity obliteration. It is also an appropriate method to obtain adequate volume for safe obliteration.

Quality of life and functional results in canal wall down vs canal wall up mastoidectomy.

SUMMARYSocial functioning and personal satisfaction about quality of life are issues in the spotlight in most fields of otolaryngology. However, in ear surgery, few studies performed standardised measurements through interviews and validated questionnaires. We enrolled 81 patients undergoing tympanomastoidectomy from January 2011 to December 2014, at the “A. Gemelli” Hospital of the Catholic University, Rome. 50 patients (61.7%) underwent non-obliterative Canal Wall Down (CWD) mastoidectomy, whereas 31 patients (38.3%) underwent Canal Wall Up (CWU) mastoidectomy. We administered the Chronic Ear Survey (CES) 3 and 12-months post-operatively and the Chronic Otitis Media Outcome Test-15 (COMOT-15) 12 months post-operatively. Results were compared to hearing threshold, sex and age. In the CWD Group, significant improvements were observed in all CES subscale scores and total scores over time (p < 0.001) whereas in the CWU Group we found a partial improvement. Inter-group comparison showed no significant differences in administration of CES in CWD vs CWU (p > 0.05 for all subsections and overall scores). A significant difference was found only in the COMOT-15 “Hearing Function” subsection, in favour of CWU over CWD (61 vs 39 respectively; p < 0.05). A significant association was found between PTA and COMOT-15 “Hearing Function” subsection scores. According to our results, a significant difference in the post-operative QoL between CWD and CWU should not be taken for granted.