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Cortical mastoidectomy
1.
2.
3. 1) Coalescent Mastoiditis and Masked
Mastoiditis.
2) CSOMTTD Active Refractory to antibiotics.
3) It is the initial stage of any transmastoid
surgery
5. • History:
• Ear discharge
• Hearing loss
• Fever
• Pain
• Facial asymmetry
• Previous surgery
• Medical history
6. • Otomicroscopy:
• Cholesteatomas
• Granulations
• Helps in defining extent of the disease
• Pure tone audiometry:
• Establish hearing loss
• Ear swab
• X- ray mastoid
• CBC
• Coagulation profile
7. • HRCT (0.5mm cuts)
• Pneumatisation
• Ventilation
• Tegmen tympani
• Status of ossicles
• Sigmoid sinus
• Jugular bulb
• Carotid artery
• Facial nerve
• Extent of the disease
21. Drill within this triangle and work your
way deeper into the mastoid
22. Identification of LSSC and Dural Plate
Thesafestwaytofindtheantrumis
tofollowdura
Itisidentiefiedbychangeincolour
ofthebone(dura seen shining
through thin layer of bone) or
change in the pitch of burr
Korner's septum is removed and
antrum is entered
Drilling through the septum will
allow visualization of LCC
LCC usually appears yellow in
colour in floor of antrum
24. Identification of Incus
The burr is downsized
and drilling continuous
anteriorly toward the
root of zygoma until
incus seen in fossa
incudis
Take care not touch the
incus by drill
25. Identification of Sigmoid Sinus
Exentrate the air cell
around the sigmoid
sinus till the blue color
of the sinus appeared
Follow the sinodural
plate posteriorly up to
the sinodural angle
26. Identification Facial Nerve
• Landmarks:
• Lateral semicircular
canal – nerve runs
anteroinferiorly
• Short process of
incus – nerve lies
medial at the level of
aditus
• Diagastric ridge –
nerve leaves mastoid
at the anterior end
27. Identification Facial Nerve
• Always drill parallel to the course of facial nerve
• Use ample irrigation to prevent thermal damage
to the nerve
28. Drain is placed and wound closed
• Mastoid cavity is
thoroughly irrigated
with saline to remove
bone dust
• Small rubber drain
placed in the lower
end of incision
• Skin closed
29. Drilling Tips
Hold the drill firmly but don’t press hard on the
bone
• Avoid keyhole surgery; work through a wide space
• The tip of the drill should always be visible
• Use the ‘equator’ of the burr rather than the tip
• Never drill behind edges of bone
• Drilling should always be parallel to structures that
are to be saved with a lots of water for irrigation
• If the burr is to be lengthened, switch to a diamond
burr
33. Extended Cortical Mastoidectomy
INDICATED For mucosal disease without
cholesteatoma, to avoid canal wall down
mastoidectomy
• Extend drilling anteriorly from antrum to the
aditus and short process of incus
• Drill in the narrow space between roof of EAC
and bone over middle fossa dura.
• Drill forwards to reach the root of zygoma
• Open the entire attic and see the head of
malleus and Incus
35. Posterior Tympanotomy
Drilling away of the bone between the
pyramidal (mastoid) segment of the facial
nerve, and the posterior bony canal and
chorda tympani resulting in access to the
middle ear from the mastoid.
36. Indications
• To gain access to mesotympanum via cortical
mastoid cavity
• Cochlear implantation
• Part of combined approach tympanoplasty
• Cholesteatoma in mastoid bowl, and
mesotympanum
39. Postoperative Care
• Drain left for 24-48 hours
• Mastoid pressure dressing for 1 day
postoperatively
• Keep the ear dry
• Bacitracin is applied to the postauricular incision
twice a day for 1 week.
• Stitches removed after 1 week
• Postoperative PTA is done after 4 weeks
• Further follow up is after 6 months and then after
1 year
40. Complications
• Persistent deafness:
• Incus dislocation or removal
• Sensorineural hearing loss
• Facial nerve injury
• Persistent infection due to residual cells
• CSF leak – dura may be inadvertently opened
• Vertigo
• Inadvertent entry into the EAC
• Hemorrhage from injury to sigmoid sinus
• Postoperative wound infection .
41. Instructions to the Patient
• For first 3 weeks : gentle activity e.g., housework,
walking only
• After 3 weeks: gentle exercise
• After 4 weeks: normal gym activity
Keep operation site dry
Notas do Editor
The completed intact canal wall mastoidectomy should be bounded by :
A thin but intact middle fossa plate
The sigmoid sinus should be visible through intact bone
The posterior wall of the EAC should be thinned yet intact
The short process of the incus should be visible via the aditus ad antrum
The horizontal SCC should be clearly identifiable