Information on Ear, Nose and Throat Surgeries Mastoid Surgery - Mastoidectomy
Mastoidectomy
Mastoidectomy for Cholesteatoma
 
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Mastoidectomy ( Mastoid Surgery ):  

Before the advent of antibiotics, mastoid surgery used to be one of the most frequent surgeries performed.  Acute mastoiditis was common and the treatment is a mastoidectomy.  Today, mastoid surgery is performed less often.  The most common indication is to remove a cholesteatoma or a skin cyst in the ear.  A cholesteatoma most commonly starts to form from a retraction pocket in the eardrum.  The sequence of events begins with eustachian tube dysfunction which leads to negative pressure in the middle ear.  The eardrum is sucked into the middle ear and slowly forms a pocket.  The pocket enlarges and retracts deep into the ear.  Skin debris gets caught, it becomes infected and slowly expands.  A cholesteatoma is formed, it erodes bone and can cause hearing loss, dizziness, facial paralysis and can even erode into the brain.  The picture on the right shows a large attic  cholesteatoma tympanosclerosis and an  ear tube in the eardrum. 
      

  
Attic Cholesteatoma

          

  
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Large Attic Cholesteatoma

Attic Cholesteatoma with Granulation TissueThe picture on the left is of a large cholesteatoma of ear with exposure of head of malleus  The picture on the right shows a large attic  cholesteatoma with a granuloma covering an attic retraction pocket.    Click on Pictures to Enlarge

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If a cholesteatoma is very small, it can rarely be pulled out through the eardrum.  The picture on the right shows a deep anterior superior eardrum retraction pocket filled with crust and debris.  The ear was anesthetized and the debris was removed and the thin eardrum was everted.  It the eardrum tears or is adheased to the inner structures of the middle ear, then  a tympanoplasty and possibly a mastoidectomy must be performed.  Mouse over the picture to see the result after the eardrum pocket has been everted and an ear tube placed in the eardrum.   
Click on Pictures to Enlarge
  
  

Mastoid Cutaneous Fistual from a CholesteatomaAn
operation on the mastoid is usually performed to remove a cholesteatoma, similar to the one shown in the picture on the right.  Two types of mastoidectomies are performed, canal wall down and canal wall up.  The canal wall up operation preserves the ear canal and has less post operative care.  However, there is upto a 40% chance of recurrence or persistence of the cholesteatoma.  In 2003, Syms and Lusford reported a 31.5% failure rate with canal wall up mastoidectomies with 27% of patients having residual cholesteatomas. View Abstract    McRackan et al. also reported a high failure rate in the treatment of cholesteomas in pediatric patients.  Almost half had recurrence at the time of a second look procedure.  Overall there was a 22.7% recurrence in their patients.   View Abstract

The picture on the right shows a mastoid cutaneous fistula caused by a recurrent cholesteatoma after a canal wall operation.  The ear canal was filled with large bleeding granulation tissue.   
View CT Scan of Patient     View Normal CT Scan of Ear

 

CT Scan of a Mastoid CholesteatomaMastoid Cholesteatoma with a GranulomaThe picture of the eardrum on the right shows a recurrent attic cholesteatoma in a 40 year old patient who had a previous canal wall up mastoidectomy.   A granuloma covers the  cholesteatoma's opening.  At the time of revision surgery, a large cholesteatoma was found in the mastoid - See Photographs Below.   
Click on Pictures to Enlarge

 
 

 

 
Recurrent Cholesteatoma after Canal Wall Down MastoidectomyThe patient's canal wall up mastoidectomy was converted to a canal wall down mastoidectomy.   The canal wall down operation is 95% effective in removing the disease but leaves a larger than normal ear canal opening and creates a large cavity (mastoid bowl) where the ear canal used to be.  This cavity must be cleaned by the doctor every 6 to 12 months.  The chorda tympani, nerve which innervates part of the tongue is sacrificed and some numbness may occur on the lateral tongue surface.   In addition, the patient must not go swimming because water in the ear may cause severe dizziness.  Water in the ear may also cause an infection.   The picture on the right shows a plugged ear tube and a recurrent cholesteatoma (blue arrow) in a patient who had a canal wall down mastoidectomy.
  
 
 

Posterior Superior Retraction PocketRisks of the surgery are the same as if the cholesteatoma is not removed, but occur less frequently.  Hearing loss and dizziness may occur along with injury to the lining or dura of the brain.  The VII Nerve runs through the center of the middle ear and mastoid cavity and can be injured during surgery.  This may cause a facial paralysis.  However, from the picture on the right, one can see how this nerve can be easily damaged by the cholesteatoma.  Thus, once diagnosed, most cholesteatoma should be surgically removed.  Kos et al. reported on the results for canal wall down mastoidectomies.  He found the average pre-operative hearing loss was 52 dB.  Post-operatively the hearing was unchanged in 41%, improved in 31% and worse in 28%.  Other complications were persistent vertigo and one case of facial paralysis.  View Abstract

A long standing cholesteatoma can erode through the dura and into the brain or into the inner ear.  The horizontal semicircular canal is the inner ear structure most prone to damage.  Below is a link to a CT Scan of a cholesteatoma which produced a fistula of the horizontal semicircular canal.  The patient had a chronic history of hearing loss and ear drainage.  He recently, experienced a severe episode of vertigo from labyrinthitis.  

 

Attic CholesteatomaDehiscent Facial NerveThe picture on the far right shows a patient with a relatively small attic retraction pocket which has formed a cholesteatoma.  At the time of surgery the skin sack of the cholesteatoma had filled the attic and was extending downward.  It had eroded into the facial nerve, which was found to be swollen and dehiscent.  If left untreated this patient would have soon developed a facial paralysis.
 
 
 
 

Click on Pictures to Enlarge

Mastoid Cavity and BowlMastoidectomy External Auditory Canal MeatusIn a canal wall down operation the entire mastoid is exteriorized into the ear canal and the posterior and superior portion of the ear canal is removed down to the region of the facial nerve.  The facial nerve is left intact covered by a ridge of bone called the facial ridge.  This leaves a large cavity called a mastoid bowl which has to be cleaned by the doctor every 3 to 12 months.  In order to clean this cavity, the meatus or the external opening into the ear canal is surgically widened -- see pictures on right. 
    


If the
mastoid bowl is not cleaned, skin debris can accumulate which can cause a superficial infection.  The picture on the right shows a mastoid bowl filled with exudates covered by a fungal growth.  Treatment consists of cleaning the ear and daily irrigations of diluted vinegar or an antifungal agent.

Click on Pictures to Enlarge

 


Pictured to the right is a
mastoid bowl which has developed a cholesteatoma over the Horizontal semicircular canal.  The cholesteatoma appears as a white pearl (arrow) and was removed in the office using a micro pick.  This case illustrates the necessity of routine follow-up in the office.

Click on Pictures to Enlarge

 

 
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