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. 

The 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. 

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The 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.   
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The 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.

Risks 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

The 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.

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Page last updated 05/09/2008,    Hits as of 12/31/2002