Desciption of chronic and suppurative infections
of the mastoid have been discovered dating back
to ancient Greece.
Mastoid surgery has evolved from simple
trephination for acute infections, to the canal wall
The complete (or simple) mastoid operation,
refers to canal-wall-up (CWU) mastoidectomy,
with complete removal of diseases from temporal
bone lateral to otic capsule.
It is usually accompanied by tympanoplasty &
ossicular chain reconstruction.
Mastoid operation have been employed for over 300
years to control suppurative diseases of the ear, but
first proposed mastoidectomy date back more than
Ambrose Pare proposed to operate on skull & drain
Jean Petit of Paris reported the first successful mastoid
trephination operation in late 1700s.
The first postauricular incision was introduced in 1853
by Sir Willian Wilde of Dublin.
Schwartze & Eyeshell reported the use of cortical
mastoidectomy for management of acute mastoid
5. Zaufal, in 1890, described the radical mastoidectomy with
the additional removal of the TM, ossicles & post. wall of EAC.
Bondy described opening the epitympanum and leaving the
middle ear intact.
In 1902, Sir Charles Balance was the first to advocate the
complete mastoid operation for control of advanced
suppuration of the ear.
Lempart popularised the use of a drill & loupe magnification
in the 1928.
With the introduction of Zeiss operating otologic microscope
in 1923 & description of CWU mastoidectomy by JANSEN, the
paradism for mastoid surgery changed dramatically for acute
& chronic mastoid infections.
1958, the canal wall up mastoid was then popularized by
House. He also introduced the suction irrigation system and
retractors in mastoid surgery.
6. RELATION OF THE MASTOID ANTRUM
There are four parts to
the temporal bone:
mastoid, and squamous
procedure allows access
to the facial nerve,
internal carotid, jugular,
and internal auditory
Primary role of CWU mastiodectomy is in the control of
chronic otitis media, with and without cholesteatoma &
It is also used as a standard approach for cochlear
implantation, excision of tumors & surgery for vertigo.
Incision & drainage of subperiosteal abscess,& placement
of tympanostomy tubes & antibiotics, without
mastoidectomy, suffice in the treatment of most of cases of
10. Acute mastoiditis arises from untreated acute otitis
media, otitis media that fails to respond to antibiotics.
Coalescent mastoiditis is acute mastoiditis in which a
localised collection of pus has accumulated in the
mastoid, with evidence of erosion of the normal bony
septae within the mastoid cavity.
Persistant purulent otorrhea for more than 3 weeks
after AOM, pain behind the ear, or pain deep in the ear
are indications that coalescence may be developing.
Many signs & symptoms seen in both AOM &
coalescent mastoiditis, but their persistance 2-3
weeks after the onset of infection is more s/o
11. It can present as a postauricular subperiosteal
abscess & definatively diagnosed by CT scan.
Subacute mastoiditis – slow, silent progression of a
coalescent abscess, is a potentially dangerous
consequence of partially treated AOM. It evolves over
CSOM defined as chronic inflammation of the middle
ear & mastoid, can be seen with or without
Most commanly it manifests as hearing loss &
intermittant otorrhea. Usually painless but acute
condition is painful. Vertigo is uncomman but if
present concerns for labyrinthine fistula or
12. Pathologic findings of CSOM includes osteitis (most
often seen in ossicle, otic capsule & mastoid bone) ,
mucosal edema with submucosal gland formation,
granulation tissue, tympanosclerosis, cholesterol
granulomas, cholesteatoma, & TM retraction and
Bone erosion from osteitis can result in ossicular
discontinuity, dural exposure with or without brain
herniation, meningitis & labyrinthine fistula.
Granulation tissue most commanly seen in
epitympanum & round window niche, blocking the
aditus preventing aeration of the mastoid &
subsequent resolution of infection.
13. ETIOLOGY OF CSOM
CSOM is believed to caused by
1. ETD persistant middle ear discharge
(serous/purulent) mucosal edema formation of
2. Bacterial infection via chemical mediators
Granulation tissue formation initiated in inflamed
mucosa bacterial toxin + inflammatory mediators
acts on edematous mucosa rupture of the BM of
Inflammatory cells in underlying lamina propria
extrude through BM secrets AGF, EGF leads to
fibroblast recruitment, neovascularisation & polyp
14. TM affected by the enzymes contained in the granulation
tissue & chronic effusion breaks down its collagen
The weakening of TM & negetive pressure in the middle
ear from ETD develops retraction pocket in the TM.
Deepening of the retraction pockets leads to contact with
the underlying mucosa or granulation tissue & fibrous
band cause perforation.
Deep retraction pockets & perforation set the stage for the
genesis of cholesteatoma.
a) Begins as AOM Deep thrombing ear pain with
asso. with pus in the middle ear purulent
b) TM erythematous & bulges laterally
c) Fever, leukocytosis, tender mastoid, tender post
a) AOM persisting over days or weeks after
b) Disproportionate deep pain, mastoid tenderness,
erythema or swelling.
a) Foul smelling intermittant otorrhoea, hearing loss,
b) Conductive hearing loss is comman. Its greater than
30dB suggest ossicular erosion. SNHL ranging from 5
to 33 Db.
c) EAC should be noated for edema, cholesteatoma. TM
should be noated for perforation, retraction,
atelectasis, or cholesteatoma.
d) Look for scutum erosion, ossicular erosion,
granulation tissue, vertigo(raising suspicion of
labyrinthitis or fistulas)
17. PAEDIATRIC CHOLESTEATOMA
Cholesteatoma is more aggressive in paediatric patients
due to the following reasons:-
a) Immature eustachian tube facilitate TM retraction &
b) Increased amount of growth factor in children faster
growth rates in cholesteatoma
c) Increased & better aeration in paediatric patients
facilitate spread of cholesteatoma through middle ear &
mastoid complicate disease removal
d) Faster replication rate of keratinocytes in paediatric
cholesteatoma Vs adults.
a) Broad spectrum antibiotics – oral or i.v.
b) Ototopical antibiotics.
c) Insertion of tympanostomy tube.
f) Antacids – oral or i.v.
19. SURGICAL THEORY & PRACTICES
Closed or Canal Wall Up Mastoidectomy
a) Cortical mastoidectomy
b) Combined approach tympanoplasty
c) Tympanoplasty with mastoidectomy
Open or Canal Wall Down Mastoidectomy
b) Radical mastoidectomy
c) Modified radical mastoidectomy
20. Modifications of intact canal wall Mastoidectomy:
1) Atticotomy with preservation of the intact
2) Atticotomy with preservation of a partly
resorbed bony bridge
3) Atticotomy with removal of the bridge
4) Widening of the ear canal
Atticotomy openings of various sizes with
preservation of the intact non resorbed bony
The goal of this atticotomy is to obtain a good view
into the anterior attic. The bridge remains in its
Cortical mastoidectomy:- This is an operation
performed to remove the mastoid antrum & air cell
system and aditus & antrum, with preservation of
intact post. bony EAC wall without disturbing the
existing middle ear content.
Combined approach tympanoplasty:- This is an
operation performed to remove disease from the
middle ear & mastoid by the way of
a) the mastoid
b) a posterior tympanotomy, &
c) the transcanal route, followed by the
reconstruction Of the middle ear transformation
23. Tympanoplasty with mastoidectomy:- This is an
operation performed to eradicate disease from the
middle ear and mastoid & to reconstruct the hearing
mechanism with or without tympanic membrane
a) Combined approach tympanoplasty or cortical
mastoidectomy with tympanoplasty
b) Obliteration technique – muscle or other
obliteration of an open mastoid cavity with
c) Canal wall reconstruction technique –
reconstruction of the outer attic post. Canal wall of
an open mastoid cavity, with tympanoplasty
d) Open cavity technique – open or canal wall down
mastoidectomy with tympanoplasty
24. ATTICOTOMY- remove all part of outer attic wall( scutum)
and adjacent deeper post meatal wall to expose the attic
(epitympanum) and when necessary the aditus and
antrum to gain acess to these sites and their content and /
or to remove disease limited to this site
RADICAL MASTOIDECTOMY- to eradicate all middle ear
and mastoid disease , in which mastoid antrum and air cell
system ( when present) , aditus and antrum, attic and
middle ear( mesotympanum and hypotympanum) are
converted in to a common cavity exteriorzed to the
external auditory meatus. During this procedure TM, incus,
malleus all removed except stapes ( foot plate alone or with
stapes supra structure if healthy.
RM- TM or reminant thereof and ossicular remenants
( usually the malleus handle and stapes) are retained
3 priorities in surgery for CSOM are :-
a) eradication of disease
b) prevention of disease recurrence
c) preservation or restoration of hearing
Mastoidectomy in CSOM has 3 primary
a) eradication of disease & infection
b) approach for removal of cholesteatoma
c) establishing aeration
d) previous tympanoplasty failure & perforated TM
with persistant suppurative drainage.
27. CONTRAINDICATIONS TO CWU
1) Unresectable posterior canal wall defect
2) Patient in which proper follow up is questionable
3) Unresectable matrix involving the labyrinth, facial
nerve, carotid, dura, sinus tympani.
4) Only hearing ear
5) Patients with labyrinthine fistula
6) Long-standing ear disease
7) Poor eustachian tube function
Active infection &
otorrhoea are not c/i
to surgery, but ear
should be made dry
pre op. since the rate
of post op infection is
higher when an ear is
28. PREOPERATIVE EVALUATION
X RAY mastoid
HRCT scan of the Temporal bone.
(pneumatization, and position of the tegmen and
the sigmoid sinus and extend of the disease)
29. PRE-OP COUNSELING - RISKS OF SURGERY
Need for long term follow-up and routine aural
30. OPERATIVE TECHNIQUE FOR CWU
Pre operative antibiotic or steriods
Supine position with head turned away from affected
Hair may be shaven if it is in the operating field, or
taped to keep it out of the field.
Injection with lignocaine with epinephrine
(postaurally and canal skin in sup. , post, inf )
Antibiotics ( ciprofloxacin 400 mg iv or betadine soln
mixed with saline) for irrigation
32. Retroauaral approach Endaural approach
Attic is oblique in postero
distance to attic is longer.
Mastoidectomy is easy to
Cavity obliteration by
flaps is possible
Both trans meatal and
transcortical routes can
Cavities produce is larger
Attic view is direct latero
medially and distance to
attic is shorter
Difficult to extend
Cavity obliteration not
Posterior tympanum and
sinus tympani is better
Only transmeatal route is
route of choice
Cavities produce is
33. ROUTES: (BONE)
starts over cortex of mastoid process
also described as outside in
starts in the bone of ear canal
also described as inside out
atticotomy antrostomy retrograde
34. SIMPLE MASTOIDECTOMY
1) acute mastoiditis,
2) Medical management
failure of chronic
3) As an approach to:
a) Facial nerve decompression
b) Endolymphatic sac
35. A post-auricular 1cm post. to sulcus approach is used .
Young children the mastoid tip is not well developed
and the stylomastoid foramen is located more
superficially, making the facial nerve vulnerable to
surgical trauma. The inferior aspect of the incision is
more posterior and is not carried down as far to avoid
injuring the facial nerve .
36. Carry the incision to the loose areolar tissue over the
The cortex is exposed by an
incision through the linea
temporalis, with a vertical cut
extended to the posterior
mastoid tip, in a T fashion. An
elevator is then used to free the
cortex off the soft tissue.
C shaped incision provides better exposure in a previously
drilled cavity, prevent injury to the important underlying
structure such as sigmoid sinus & middle cranial fossa.
37. Cortex exposed
a) Sup. - over the tegmen
b) Post. - over sigmoid
c) Ant. - level of EAC
d) Inf. – mastoid tip
Self retaining retractors
are positioned and the
surface landmarks are
the spine of Henle,
cribriform area, & linea
40. MacEwen’s triangle shows the
location of the antrum.
MacEwen’s triangle is defined as
the posterior EAC border, the
anterior line of the zygomatic
arch and the line that connects
The antrum is 15 mm medial the
Removing bone along the linea
Identify underlying tegmen ( pink
Middle cranial fossa dura
delineated to its superior extend.
Using 2mm diamond burr, excess tympanic bone at
the tympanomastoid & tympanosquamous suture line
If required, the entire EAC can be enlarged, from 12
o’clock to 6 o’clock position posteriorly.
The distance of facial nerve from the annulus in the
posterior-inferior quadrant of the EAC ranges from
1.9mm to 5.7mm facial nerve is at most risk to
injury during surgery.
Often removal of this small amount of bone greatly
improves the exposure, ensuring better disease
resection & graft placement.
43. Various drills are available and there are common
principles related to bur selection
Larger bur preferred over smaller ones when possible
A bur with a cutting surface is selected for cortical
bone, were diamond grain surface is for removing the
last layer of bone over facial nerve, sigmoid sinus,
tegmen, & opening the facial recess.
Suction irrigation is critical to prevent excessive heat
transfer to underlying structures & to keep the bone
Diamond burrs are effective at controlling bleeding in
the bone by driving bone dust into the lumen of the
Also, it is important to “saucerize” the edges of the
mastoid cavity to provide visualization.
44. Cortical bone removed post to EAC (post- sigmoid
sinus bluish hue and sinodural angle , inf-
mastoid tip). Cortical bone is removed inferiorly
to the mastoid tip
Surface of the tegmen followed medially towards
the antrum and the air cells are exposed.
46. Dural plate and lateral
Postero-anterior view through
antrotomy and aditus ad
antrum into epitympanum
47. Sigmoid sinus, sinodural angle
and dural plate
Correct length of a cutting burr in
A diamond burr can be
lengthened in order to safely drill
deeper in the mastoid
48. SIMPLE (DISEASED) CANAL WALL UP
This is an extension of the simple mastoidectomy
with greater access to the attic, labyrinth,
endolyphatic sac, antrum and facial nerve.
Opening of the aditus ad antrum allows access to
the epitympanum, and the incus and malleus may
be removed for greater access
The canal wall remains up.
Treatment of Cholesteatoma & suppurative mastoiditis
Exposure of mastoid segment of facial nerve.
Cochlear implant, in which a posterior tympanotomy is
part of the procedure
Labyrinthectomy and mastoid trauma
Retrolabyrinthine approachs to the vestibular nerves
Exposere of the sigmoid sinus for obliteration before
50. Exposure of the mastoid region in CAT, to
delineate the descending portion of the
facial nerve & to provide the access for
opening the posterior tympanotomy into
the middle ear.
Saccus decompression surgery, to offer the
safest & widest access to the posterior fossa
Translabyrinthine operations, to provide
the exposure of the bony labyrinth needed
for its exenteration to allow access to the
51. ATTIC DISSECTION POST.
Performed by following the tegmen anteriorly & by
thining the canal wall posteriorly & superiorly.
Canal wall thinned laterally to medially.
Drilling out of zygometic root opening of the attic
Granulation & cholesteatoma removed.
Attic cell are opened completely & fully exposed in
any epitympanic disease. Ant. attic is most comman
site of residual disease.
As the epitympanum approached from the post to
ant,the tegmen is carefully followed as it usually dips
52. After the Dissection , the anterior epitympanum,
zygomatic cells, body of incus and head of malleus are
Cultures can then be taken from the mastoid mucosa,
53. FACIAL NERVE:-
IDENTIFICATION is most
important to avoid injury
Travels as GG sup to
cochleariform process &
oval window. Post to oval
window takes inf. turn to
take on a more vertical
LSC lies just sup to facial
nerve as it complete it
transition to the vertical
54. SECOND GENU is located a few mm
anteromedial to the lat. SSC & is ANATOMICAL
LANDMARK for localizing the facial nerve.
Diagrastric ridge another land mark
Burr stroke should be the parallel to the
course of the nerve
Its gently uncovered until it is observed
through a thin layer of bone.
If the disease is limited to the antrum,
uncovering the vertical segment of the facial
nerve is rarely done.
55. Relations of VIIn to short process of incus;
superior semicircular canal (SCC); lateral
semicircular canal (LSC); posterior semicircular
canal (PSC); dura; and sigmoid sinus
56. Distal portion of mastoid segment of facial
nerve (arrow) is identified close to digastric
57. FACIAL RECESS (POST. TYMPANOTOMY)
Not required in all CWU mastoidectomy, employed
only when dictated by the location of the disease.
Thin the posterior canal wall
a) Superior: Incus or incus buttress
b) Posterior: Facial nerve
c) Anterior: Bony EAC , chordae tympani
d) Inferior: Bifircation of facial nerve &
59. Access to the mesotympanum can be gained by
removing the bone in the facial recess after thinning
the post. canal wall.
For additional exposure, the facial recess can be
extended inf. by sacrificing the chorda tympani nerve.
Entire mesotympanum &
hypotympanum can usually be
accessed through the mastoid by the
extended facial recess approach.
60. Chorda tympani nerve is identified as it branches off
the vertical segment of the facial nerve & traced sup.
Toward the incus.
Facial recess is opened with a 2 mm diamond burr,
starting sup. where it is widest.
EXTENDED FACIAL RECESS approach involve sharply
sectioning the chorda tympani nerve & extending the
recess ear inferior along the facial nerve course.
The lateral boundary of the exposure becomes the
annulus of the tympanic membrane.
63. FACIAL RECESS
A = antrum, C = chorda tympani, F = facial nerve, HSC
= horizontal semicircular canal, I = incus, R = round
window, S = stapes
If the cholesteatoma does not extend significantly into
the epitympanum, an epitympanotomy (atticotomy) is
This involves exposure of the head of the malleus and
the incus to remove soft tissue from the epitympanum.
The lateral wall of the epitympanum or attic is
removed with a diamond burr; drilling is commenced
at 12 o’clock relative to EAC, taking care not to make
drill contact with the malleus or incus which is
immediately medial to the outer attic wall, or to breach
This is indicated when cholesteatoma extends medial
to the ossicles or overlies the lateral semicircular
canal; in cases of bony erosion of the ossicles due to
cholesteatoma, the ossicles need to be removed
The incus is removed by mobilising it with a 2,5mm.
45° hook and rotating it laterally, taking care not to
injure the underlying facial nerve .
The malleus head is severed with a malleus nipper
applied across its neck.
68. The head of the malleus is removed leaving the
tensor tympani tendon intact.
Clear cholesteatoma from the epitympanum.
Detailed knowledge of facial nerve anatomy is
crucial to avoid injury to the nerve when drilling or
removing cholesteatoma in the epitympanum.
The tympanic and labyrinthine segments and
geniculum all lie in this very confined space and
may be dehiscent.
The tympanic segment lies in the floor of the
anterior epitympanic recess.
69. Anatomy of anterior epitympanic recess: Facial nerve
(VIIn); Tegmen tympani (TT); Cog; Supratubal recess
StR; Cochleariform process (CP); Eustachian tube (ET
70. The cochleariform process is a fairly consistent
landmark and the nerve lies directly superior to it;
the semicanal of the tensor tympani is sometimes
mistaken for the facial nerve; however this canal
ends at the cochleariform process.
The Cog is a bony process in the anterior
epitympanum which extends from the tegmen
tympani and points to the facial nerve.
Geniculate ganglion and GSPN seen once the Cog
and cochleariform process have been drilled away
(as shown follow)
71. View of epitympanum with cog and cochleariform process drilled
away: Tympanic (VII.T) and Labyrinthine (VII.L) segments of
facial nerve and Geniculate Ganglion (GG) and Greater Superficial
Petrosal nerve (GSP); Superior Semicircular Canal (SSC); Lateral
Semicircular Canal (LSC); Dura; Tensor Tympani tendon (cut)
73. FISTULA OF LSC
A small dimple or flatttening in the matrix
covering the bone over LSC may believe as a
Greater then 2 mm diameter Smaller then 2 mm
Convert it in to a canal wall
Second look procedure 12
month later or repair it by
fascia or perichondrium
76. Aditus enlarged to readily visualise incus
epitympanum inspected through the aditus &
The facial recess & sinus tympani are exposed
& cleared of disease tympanoplasty is
A silicone rubber sheet may be placed,
extending from the middle ear into the
antrum ensures the free flow of air between
the middle ear & mastoid cavity.
78. Incus identified & aditus enlarged
to expose attic
Critical oval window area & recess
visualised through a) canal &
79. Open Cavity Mastoidectomy
Excision of the conchal cartilage via endaural or
postaural approach Korner flap or endaural
incision to creat a flap can be constructed
connect them with post. incision parallel to
The endaural incision extended from the post.
annulus incision in EAC to conchal bow large
crescent shaped piece of conchal cartilage
removed without injuring canal skin & retaining
continuity with the Korner flap.
80. To provide an opening adequate to allow
drainage & surgical defect, meatoplasty should
comfirtably accept the surgeon’s finger.
To prevent post op. stenosis by granulation
tissue formation curettage, steroid antibiotic
ointment, Thiersch grafting using very thin
split thickness skin (3 weeks after surgery).
If stenosis occurs, it will be necessary to
elevate & preserve meatal skin & to drill or
curette the bone widely to creat a large meatus.
82. The graft is placed in position(a). & the musculofacial
pedicle is placed into the finished mastoid cavity(b).If
it is large, post. Wound will be sutured & drained &
the Korner flap placed on top of the muscle through
an endaural exposure.
84. DISADVANTAGES OF CWU
Technically more difficult
Staged operation often necessary
Higher chances of recurrent or residual
Residual disease harder to detect
Children with cholesteatoma
2nd look is required to rule out recurrence
or residual disease.
Periodical & meticulous follow up needed.
It occurs as a result of :–
a) Inadequete surgical exposure
b) Failure to recognize the anatomical variation.
c) Granulation or bleeding obscuring the surgical
They are as follows-
86. 1) Bleeding due to injury to the jugular bulb and
dural plate or sigmoid sinus
2) SNHL high frequences losses
5) Granulation tissue
6) Brain herniation
7) CSF leak
87. 6) Intracranial injury:-
a) Exposure of dura with spinal fluid leak
b) Small herniation of brain (less than 5mm)
managed with gentle bipolar cautery.
c) Large herniation of brain (more than 5mm)
managed with middle fossa craniotomy approach,
with the assistance of nerurosurgeon
88. 7) Facial nerve injury:-
a) Mastoidectomy is the most comman cause of iatrogenic
facial nerve palsy.
b) When graeter than 50% of nerve is transected, managed
by resecting the injured segment & grafting the nerve.
c) In case of subtotal transection of the facial nerve, it is
proximally & distally decompressed and injury is assessed.
8) Suppurative labyrinthitis.
9) Postauricular haematomas ( if the patient coughs
or strains during the postoperative period)
Bailey BJ, et al, eds. Head and Neck Surgery -
Otolaryngology. 4nd ed. Philadelphia Pa: Lippincott-
Antonelli PJ, Dhanani N, Giannoni CM, et al. Impact of
resistant pneumococcus on rates of acute
mastoiditis. Otolaryngol Head Neck
Surg. Sep 1999;121(3):190-4
Shambaugh GE, Glasscock ME. Canal wall up
mastidectomy. Surgery of the Ear.
Shambaugh GE, Glasscock ME: open cavity mastoid
operation Surgery of the Ear.
Scott brown 6th edition anatomy of the middle ear
Bluestone CD. Acute and chronic mastoiditis and chronic
suppurative otitis media. In: Feigin RD, editor, Wald ER,
Dashefsky B, guest editors. Seminars in pediatric infectious
diseases. Vol 9. Philadelphia: WB Saunders; 1998;9:12–26.