Deep temporal fascial-periosteal flap for canal wall down mastoidectomy

It is very important to make a safe, dry, trouble-free ear for the canal wall down mastoidectomy. Although fascia graft is the most common material used for the repair of the perforated tympanic membrane, it is usually too small to cover the whole mastoid cavity in canal wall down mastoidectomy. The presence of exposed bone delays the epithelialization and results in prolonged otorrhea. We present a new simple technique that uses a postauricular, inferiorly based pedicled flap. Although our deep temporalis fascial-periosteal flap is not bulky, it is large enough to obliterate a sclerotic mastoid cavity without the need for additional flaps. It shrinks much less than a muscular flap during the healing period. In addition to reducing the cavity volume, this flap promotes the epithelialization over the bone and the shortening of the healing time. Although only a small number of patients were included in this study, coverage of a canal wall down mastoid cavity by a deep temporalis fascial-periosteal flap is expected to be a reliable and effective technique that results in a dry, trouble-free mastoid cavity.     

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.     

自体乳突皮质骨粉在中耳乳突手术中的应用

目的 总结自体乳突皮质骨粉在中耳乳突手术中的应用价值及经验体会。方法 对慢性化脓性中耳炎、胆脂瘤中耳炎患者46例术中应用了自体乳突皮质骨粉修复填充,其中乳突根治术19例,乳突病变切除+鼓室成型术27例。开放乳突前以大号切割钻磨削乳突皮质骨,收集骨粉备用,术中以骨粉填充上鼓室或封闭鼓窦入口,并填充缩小乳突腔,骨粉表面覆盖筋膜。结果 所有病例术后术腔明显缩小,平均干耳时间为6周,3个月内干耳率为95.7%（44/46）,行鼓室成型术者鼓膜形态正常,无回缩袋形成。结论 自体乳突皮质骨粉取材方便、易于塑形、无排斥反应,是中耳乳突手术中理想的修复填充材料。     

耳后双蒂肌骨膜瓣在大乳突腔填塞中的应用

目的探讨耳后双蒂肌骨膜瓣在乳突根治术中,填塞乳突腔对干耳及听力疗效的观察。方法对慢性中耳炎患者行乳突根治术、鼓室成形术和耳甲腔成形术78例（耳）中,进行耳后双蒂肌骨膜瓣填塞乳突腔。结果78例患者中,患耳干耳时间缩短至10～15天,58例听力较术前提高（17．2±4．9）dB。结论耳后双蒂肌骨膜瓣填塞对术后乳突腔的迅速上皮化、易干耳、重建外耳道后壁以及术后听力的提高具有一定的疗效。     

Postauricular periosteal-pericranial flap for mastoid obliteration and canal wall down tympanomastoidectomy.

OBJECTIVE: To describe an effective technique for mastoid cavity obliteration in canal wall down tympanomastoidectomy for chronic otitis media and review its efficacy in producing a dry, low-maintenance, small mastoid cavity. DESIGN:: Retrospective clinical study of a consecutive series of procedures from 1995 to 2000. SETTING: Tertiary referral center and institutional academic practice in otology and neurotology. PATIENTS: Sixty consecutive procedures for active chronic otitis media with a minimum follow-up of 12 months (mean, 31 mo; range, 12-80 mo). INTERVENTION: All patients had canal wall down mastoidectomy with simultaneous tympanoplasty including split-thickness skin grafting. An inferiorly pedicled, periosteal-pericranial flap was used in conjunction with autologous bone pate to obliterate the mastoid cavity. The additional length provided by the pericranial extension of the flap permitted it to reach superior to the lateral canal and into the sinodural angle, with improved coverage of bone pate and better reduction of cavity size. OUTCOME MEASURES: The primary outcome measure was control of suppuration and creation of a dry, low-maintenance mastoid cavity, which was assessed using a previously developed semiquantitative scale. This scale includes a temporal dimension to assess control of infection. Secondary outcome measures included postoperative complications (i.e., hematoma, infection, flap necrosis, and meatal stenosis) and incidence of recurrent or residual cholesteatoma. RESULTS: Forty-nine ears (82%) maintained a small, dry, healthy mastoid cavity. Five ears (8%) had intermittent otorrhea easily controlled by topical treatment. Six ears (10%) had suboptimal control of otorrhea, of which four had meatal stenosis. There were no residual or recurrent cholesteatomas. Outcomes remained stable over progressively longer follow-up, up to 80 months. CONCLUSION: Obliteration of a canal wall down mastoid cavity by a postauricular periosteal-pericranial flap with autologous bone pate is a reliable and effective technique that results in a dry, trouble-free mastoid cavity in 90% of patients with active chronic otitis media.     

双软组织血管瓣填塞乳突术腔的临床研究

目的 探讨耳后双软组织血管瓣乳突术腔填塞应用于开放式乳突根治术的临床疗效和意义。方法 胆脂瘤中耳乳突炎患者98例(98耳),在施行开放式乳突根治术基础上,治疗组52例(52耳)应用耳后双软组织血管瓣填塞乳突腔;对照组46例(46耳)应用带血管蒂的颞肌筋膜瓣填塞乳突术腔。结果 治疗组与对照组的干耳时间分别为(17.07±1.28)d和(22.96±6.21)d,治疗组干耳时间明显短于对照组,差异有统计学意义(P<0.05)。结论 耳后区双软组织血管瓣乳突术腔填塞术应用于开放式乳突根治术,有以下优点:①面积更宽广,可最大限度地覆盖术腔骨面;②可加快术腔上皮化,缩短术后干耳时间;③术后基本无需乳突术腔清理。     

双软组织血管瓣填塞乳突术腔的临床研究

目的 探讨耳后双软组织血管瓣乳突术腔填塞应用于开放式乳突根治术的临床疗效和意义。方法 胆脂瘤中耳乳突炎患者98例(98耳),在施行开放式乳突根治术基础上,治疗组52例(52耳)应用耳后双软组织血管瓣填塞乳突腔;对照组46例(46耳)应用带血管蒂的颞肌筋膜瓣填塞乳突术腔。结果 治疗组与对照组的干耳时间分别为(17.07±1.28)d和(22.96±6.21)d,治疗组干耳时间明显短于对照组,差异有统计学意义(P<0.05)。结论 耳后区双软组织血管瓣乳突术腔填塞术应用于开放式乳突根治术,有以下优点:①面积更宽广,可最大限度地覆盖术腔骨面;②可加快术腔上皮化,缩短术后干耳时间;③术后基本无需乳突术腔清理。     

Small cavity mastoidectomy—5 year review

It has been recognized that the traditional method of open mastoid surgery often produces a larger mastoid cavity than necessary. Small cavity mastoidectomy is advocated to reduce the size of the mastoid cavity by exteriorizing the cholesteatoma from the epitympanum backwards. When this operation is performed in a sclerotic mastoid bone, the resulting cavity is very small. The 5 year review of 39 ears with small cavity mastoidectomy is presented. Not only were the mastoid cavities small, they remained stable and trouble-free. It also enabled the patients to enjoy swimming and minimizing wax accumulation within the cavities. The hearing results after 5 years were comparable to that of the closed technique. Formation of cholesterol granuloma behind the concho-meatal flap was an uncommon complication.     

Combined flap of postauricular musculo-periosteal and ear canal skin flap with bone paté for mastoid obliteration and canal wall down mastoidectomy]

OBJECTIVE: To investigate the long-term outcome and clinical value of modified radical mastoidectomy with mastoid obliteration using pedicled combined flap of postauricular musculo-periosteal and ear canal skin flap in conjunction with bone paté. METHODS: During 2 years from April 2003 to March 2005, 71 otitis media patients (71 ears) with cholesteatoma were subjected to this kind of operation. RESULTS: The follow-up period was more than 2 years. The period of complete reepithelialization ranged from 3 weeks to 1.5 months, with the mean period of 29 days. All of the patients, treated by the described method of operation had a dry, disease-free mastoid of ear. CONCLUSIONS: Mastoid obliteration with pedicled combined flap of postauricular musculo-periosteal and ear canal skin flap in conjunction with bone paté, had the advantages as follows: (1) Healing of the mastoid cavity in a short time. (2) Better reepithelialization of the obliterated mastoid cavity. (3) No need of skin grafting in the mastoid cavity. (4) High rate of the dry ear in postoperation. (5) nearly no need of the mastoid cavity cleaning postoperatively.     

Bone pâté obliteration or revision mastoidectomy: a five-symptom comparative study

A survey of 47 patients who underwent surgical treatment for persistent symptomatic mastoid cavities following mastoidectomy for cholesteatoma, was carried out. There were two groups comprising 26 patients who underwent revision mastoidectomy (14 with meatoplasty); the technique favoured early in the series, and 21 managed by mastoid revision and obliteration with autologous bone pate and a superiorly based temporalis musculo-periosteal flap. A questionnaire¹ was used to assign a symptom score to each patient's pre and post-operative condition, with a maximum score of 15 and minimum of zero. The pre-operative scores for the two groups were not significantly different, but the patients treated by obliteration with bone pate had a significantly lower (P= 0.05) postoperative symptom score than those who had their mastoids simply revised. This study suggests that revision mastoidectomy with bone pate obliteration achieves a more favourable result than revision mastoidectomy alone, and is, we believe, the technique of choice for the patient with a symptomatic mastoid cavity.     

Mastoid obliteration and canal wall reconstruction with posterior auricular artery (PAA) fascia-periosteum flap

ObjectiveUnstable cavities are defined as cavities with cerumen accumulation that need frequent cavity cleaning in the out-patient clinic, cavities that are intolerant to water due to risk of infection or that are subject to frequent infection and otorrhoea. The objective of this study is to address the problem of troublesome mastoid cavities, with the performance of secondary mastoid obliteration and canal wall reconstruction, using a novel posterior auricular artery (PAA) fascia-periosteum flap.Materials and methodsA prospective study was designed, only secondary obliterations were included. Unstable mastoid cavities were defined as Merchant grade 2 or 3 and were included for surgery.ResultsAt 12 months of follow up, a complete external auditory canal (EAC) and a self-cleaning ear were achieved in all 23 patients. Completely dry ears were achieved in 21 patients (91.3%). An air-bone gap improvement of 5 dB was achieved.ConclusionMastoid obliteration and EAC reconstruction are effective procedures to treat troublesome post canal wall down mastoid cavities. They improve quality of life and enable patients to overcome ear discharge. A standard EAC size enables the utilization of conventional hearing aids, it also reduces the need for constant mastoid cleaning and decreases healthcare expenses. The PAA flap seems to be an effective procedure to achieve all these features, as it is used to obliterate the mastoid and becomes a structural component of the neo-EAC.     

耳后带蒂复合皮瓣移植填塞乳突术腔 并重建外耳道后壁

目的探讨陈旧性根治性乳突术腔填塞及外耳道后壁缺损的修复方法。方法采用耳后带蒂复合皮瓣移植,对10例(11耳)行乳突根治术后1～6年的患者,行陈旧性乳突术腔填塞及外耳道后壁缺损重建术,并同期行鼓室成形术。结果术后随访3～30个月,全部患者乳突术腔消失,外耳道大小接近正常;术后干耳时间2～3周,“根治腔病”症状明显好转,平均听阈下降13.6dBHL。结论本方法缩短了术后干耳时间,对乳突根治术后的“根治腔病”具有明显的治疗效果,有利于鼓室成形术。     

二次开放式乳突根治术的远期疗效

目的探讨慢性中耳炎首次乳突根治术后持续不干耳的原因及再次开放式乳突根治术施行乳突腔填塞、外耳道后壁重建及鼓室成形术的远期疗效。方法收集外院曾行经典开放式乳突根治术后长期不干耳患者14例(14耳),采用带血管蒂的耳后软组织瓣及颞肌瓣填塞乳突腔,取乳突骨皮质重建上鼓室及外耳道后壁,有适应证者同期行鼓室成形术。结果二次开放式乳突根治术后随访1～5年,14耳均保持干耳,外耳道形态大致正常或略扩大。结论二次开放式乳突根治术在分析首次手术失败原因的基础上加以改进,其优点为:①术后基本无乳突腔,外耳道形态近正常或略扩大,有利于保持干耳;②有适应证者均同期行鼓室成形术,有利于改善听力。乳突腔填塞、外耳道后壁重建及鼓室成形术值得推广。     

带蒂颞肌瓣填塞在二次乳突根治术中的应用

目的 探讨耳后带蒂筋膜-颞肌瓣在二次开放式乳突根治术中乳突腔填塞的临床应用.方法 对开放式乳突根治术后长期渗液不干耳患者20例(20耳),行二次开放式乳突根治术.行开放式乳突根治术(RM)10例,行开放式乳突根治术伴乳突填塞术(CWDM)10例.CWDM均采用耳后带蒂筋膜-颞肌瓣乳突腔填塞.结果 术后均随访2年,RM干耳时间平均(58.4±4.45)d,复诊次数平均(17.1±2.33)次,持续不干耳1例.CWDM 干耳时间平均(29.6±2.37)d,复诊次数平均(6.1±1.52)次,无不干耳及术后复发.两组比较,CWDM干耳时间短、复诊次数少(P<0.001).结论 CWDM干耳时间、复诊次数、术后复发等指标均优于RM,采用带蒂筋膜-颞肌瓣乳突腔填塞效果良好.     

Reconstruction of the radical mastoid.

Open cavity techniques (radical mastoidectomy, canal wall down tympanomastoidectomy, modified radical mastoidectomy) are well established surgical procedures for the treatment of chronic otitis media. Despite their effectiveness in exteriorizing cholesteatoma, they are associated with a 20 to 60 percent incidence of persistent intermittent drainage. In an effort to eliminate this problem, we have employed a Palva flap and medial graft technique to reconstruct the mastoid cavity and middle ear space in those patients with chronically draining ears. Between 1987 and 1990, 28 patients underwent this procedure. Twenty-six of these (93%) had complete obliteration of the mastoid cavity and successful tympanic membrane reconstruction. Two of 28 (7%) had a persistent tympanic membrane perforation and intermittent drainage following their surgery. Based on these results, this procedure is effective in eliminating intermittent drainage associated with the open cavity techniques. The indications for this procedure, the specifics of the surgical technique, and the postoperative results are discussed.     

Management options for cochlear implantation in patients with chronic otitis media

ObjectivePatients with chronic otitis media with/without cholesteatoma present a significant challenge to safe cochlear implantation (CI). The aim of our study is to describe our experience and propose management options for CI in patients with chronic otitis media.Study designRetrospective case study.SettingTertiary academic center.Subject and methodsWe enrolled the 9 ears of 8 subjects who received CI in the ear with chronic otitis media from 2006 to 2013 by a single surgeon. CI was performed as a single-stage or staged operation with mastoid surgery according to the activity of ear infection.ResultsSix patients had bilateral chronic otitis media and 2 patients had long history of sensorineural hearing loss at contralateral ear. CI was performed with simultaneous radical mastoidectomy with closure of the EAC as a single-stage in 3 ears with a history of previous open cavity mastoidectomy and no active discharge. Staged CI was performed in 6 ears, after radical mastoidectomy with closure of the EAC in 3 ears and after intact canal wall mastoidectomy in 3 ears, due to active inflammation or complications related to otitis media. In one patient, wound infection had occurred, and implant was removed along with implantation at contralateral ear. Other subjects showed no evidence of recurrence.ConclusionDecision whether implantation as a single-stage or staged operation depends on the presence of active inflammation. Single-stage CI with proper mastoid surgery can be performed in patients without active inflammation. Staged procedure need to be done in ears with active inflammation. Proper application of mastoid surgery leads to safe CI for patients with chronic otitis media.     

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

Objective

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.

Methods

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.

Results

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 ± 13.8 dB preoperatively and 23 ± 13.2 dB postoperatively. There were 5 patients with failure of control of infection postoperatively and 3 patients of recidivistic cholesteatoma.

Conclusion

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.     

Cochlear Implantation Without Mastoidectomy: The Pericanal Electrode Insertion Technique

Objective - A new minimally invasive cochlear implantation method with direct electrode insertion through the external auditory canal (EAC) is presented. Material and methods - Surgery begins with a retroauricular skin incision. The bony surface of the mastoid plane behind the ear is dissected free and the skin of the EAC is elevated together with the posterior part of the tympanic membrane. Cochleostomy is performed through the EAC with a microdrill anterior to the round window. A rim is drilled into the postero-superior region of the bony EAC immediately above the incus towards the outer border of the EAC and connected to the retroauricular surface by a short tunnel. The implant device is placed in the usual retroauricular area. The electrode is inserted through the tunnel and rim into the tympanic cavity and pushed into the cochleostomy hole. The electrode is immobilized in the rim using glass ionomer cement and covered with bone dust. After placement of the ground electrode, the retroauricular incision is closed. The tympano-meatal flap is replaced and a dressing is put into the EAC. Results - The new method has been applied thus far in 15 adults and pre-adolescent deaf patients (8 females, 7 males). A MED-EL Combi 40+ device was used in 14 patients and a Nucleus CI24M in 1. Pericanal electrode insertion was easy, with insertion depths into the cochlea of &;#83 30 mm with the MED-EL and of 20 mm with the Nucleus device. There were no surgical complications, infections or electrode extrusions during postoperative observation periods ranging from 6 months to >2 years. The functional results were comparable to those obtained with cochlear implantation via mastoidectomy. The pericanal electrode insertion technique has several advantages, the most important being that the danger of facial nerve damage is minimized and that the operating time is reduced by up to 50%. Conclusion - Cochlear implantation with pericanal electrode insertion is a simple, fast and particularly safe option which may replace the classical transmastoidal cochlear implantation method in adults and older children.     

Cochlear implantation without mastoidectomy: the pericanal electrode insertion technique

OBJECTIVE: A new minimally invasive cochlear implantation method with direct electrode insertion through the external auditory canal (EAC) is presented. MATERIAL AND METHODS: Surgery begins with a retroauricular skin incision. The bony surface of the mastoid plane behind the ear is dissected free and the skin of the EAC is elevated together with the posterior part of the tympanic membrane. Cochleostomy is performed through the EAC with a microdrill anterior to the round window. A rim is drilled into the postero-superior region of the bony EAC immediately above the incus towards the outer border of the EAC and connected to the retroauricular surface by a short tunnel. The implant device is placed in the usual retroauricular area. The electrode is inserted through the tunnel and rim into the tympanic cavity and pushed into the cochleostomy hole. The electrode is immobilized in the rim using glass ionomer cement and covered with bone dust. After placement of the ground electrode, the retroauricular incision is closed. The tympano-meatal flap is replaced and a dressing is put into the EAC. RESULTS: The new method has been applied thus far in 15 adults and pre-adolescent deaf patients (8 females, 7 males). A MED-EL Combi 40 + device was used in 14 patients and a Nucleus CI24M in 1. Pericanal electrode insertion was easy, with insertion depths into the cochlea of > or = 30 mm with the MED-EL and of 20 mm with the Nucleus device. There were no surgical complications, infections or electrode extrusions during postoperative observation periods ranging from 6 months to > 2 years. The functional results were comparable to those obtained with cochlear implantation via mastoidectomy. The pericanal electrode insertion technique has several advantages, the most important being that the danger of facial nerve damage is minimized and that the operating time is reduced by up to 50%. CONCLUSION: Cochlear implantation with pericanal electrode insertion is a simple, fast and particularly safe option which may replace the classical transmastoidal cochlear implantation method in adults and older children.     

Cochlear implant after reconstruction of the external bony canal wall and tympanic cavity in radically mastoidectomized patients with cholesteatoma

One of the postoperative complications of cochlear implants in patients, who previously received radical mastoidectomy, is an exposure of electrode by breakdown of thin epithelium in the open mastoid cavity. To avoid such complications, in the first stage, radical mastoidectomy with the reconstruction of the posterior bony canal wall and mastoid obliteration with bone chips and plates and the creation of the new tympanic cavity, were performed. One or 3 years later, implantation of a 22-channel cochlear implant, as the second stage procedure, was successfully performed in three patients with profound sensorineural hearing loss, due to cholesteatoma in the side of the ear in which cochlear implantation was indicated. The advantages of this technique are as follows: (1) Electrode is protected from the cavity problems, such as chronic infection or erosion of the epithelium in the open mastoid cavity; and (2) reconstruction of the new tympanic cavity and tympanic membrane is beneficial for avoidance of electrode exposure in the mastoid and tympanic cavity.