Transcript Document
C.S.O.M.: Mastoidectomy Dr. Vishal Sharma Schwartze’s Cortical Mastoidectomy Middle ear cleft (Right) Cortical Mastoidectomy Boundaries of cavity • Superior: Dural or Tegmen plate • Anterior: Posterior wall of external auditory canal • Inferior: Digastric ridge • Posterior: Sigmoid sinus plate • Medially: Lateral semicircular canal Normal temporal bone (right) Cortical Mastoidectomy Indications 1. Coalescent mastoiditis & Masked mastoiditis 2. CSOM T.T.D. active refractory to antibiotics 3. Secretory otitis media refractory to antibiotics 4. Approach to: Endolymphatic sac surgery Facial nerve decompression Vestibulo-cochlear nerve section Translabyrinthine approach for C.P. angle Cochlear implant surgery Combined approach tympanoplasty Antiseptic dressing Draping Infiltration with Lignocaine Marking of incision Wilde’s post-aural incision Incision deepened till periosteum Musculo-periosteal flap elevated Bezold’s abscess Aspiration of pus Drainage of abscess Drainage of abscess Corical mastoidectomy begun Exposure of mastoid antrum Widening of aditus Aditus widened Final Cavity (right) Final Cavity (left) Drain put in mastoid cavity Mastoid dressing Healed post-aural scar Treatment for Attico-antral disease Medical Treatment Topical ear drops + frequent suction clearance Indications: 1. Early disease with shallow retraction pocket 2. Only hearing ear with cholesteatoma 3. Elderly patients 4. Pts who are not fit for surgery under G.A. 5. Pts who can regularly come for follow up Surgical Treatment Canal Wall down: • Attico-antrostomy • Modified Radical Mastoidectomy (MRM) • Radical Mastoidectomy Canal Wall up: • Combined Approach Tympanoplasty (CAT) Mac Ewan’s triangle Canal Wall Up Mastoidectomy Canal Wall Down Mastoidectomy Middle ear cleft Attico-antrostomy Modified Radical Mastoidectomy Pre-operative Anatomy Cortical Mastoidectomy done Modified Radical Mastoidectomy Surgical Steps • Perform cortical mastoidectomy • Lower facial ridge & break facial bridge • Remove cholesteatoma & granulations from mastoid air cells & middle ear cavity • Preserve healthy mucosa, T.M. remnant & ossicles • Mastoid cavity & E.A.C. become a single cavity seperated by middle ear cavity • Perform tympanoplasty. Do concho-meatoplasty. Antiseptic dressing Draping Infiltration Infiltration Marking of incision Wilde’s post-aural incision Wilde’s post-aural incision End-aural incision Incision deepened till periosteum Incision deepened till periosteum Temporalis fascia graft Periosteum incised Periosteal flap elevated Mastoid cortex exposed Posterior canal wall incision Posterior canal wall vascular strip Vascular strip retracted laterally Drill cuts on mastoid cortex Corical mastoidectomy begun Cholesteatoma in mastoid cavity Exposure of mastoid antrum Widening of aditus Aditus widened Cortical mastoidectomy cavity Facial ridge lowering started Breaking of facial bridge Elevation of tympanomeatal flap Elevation of tympanomeatal flap Removal of cholesteatoma over lateral SCC Retrofacial & labyrinthine cells removed Incudo-stapedial joint separated Malleus head nipped off Tensor tympani tendon cut Cholesteatoma removal from attic Exposure of sinus tympani ET orifice plugged with malleus head MRM cavity MRM cavity (ossicles preserved) Sites of facial nerve injury Korner’s meatoplasty incision Flap elevated Conchal cartilage cut Flap sutured posteriorly Healed Concho-meatoplasty Post-aural incision closed Radical Mastoidectomy Radical Mastoidectomy Surgical Steps • Perform cortical mastoidectomy. Lower facial ridge & break facial bridge. Remove cholesteatoma & granulations from mastoid air cells & middle ear. • Remove normal middle ear mucosa, T.M. remnant & ossicles (except stapes footplate). • Close Eustachian tube opening. No tympanoplasty done. Concho-meatoplasty performed. • Mastoid, E.A.C. & middle ear become single cavity. Indications 1. CSOM attico-antral disease with Intra-cranial complication Recurrence after modified radical mastoidectomy Profound sensori-neural hearing loss (?) 2. Limited malignancy of middle ear 3. Glomus jugulare 4. Osteomyelitis of temporal bone Causes of discharging mastoid cavity 1. Inadequate concho-meatoplasty 2. Recurrence of cholesteatoma 3. Residual cholesteatoma: facial ridge, facial bridge, anterior + posterior buttress, mastoid tip, sinus tympani, anterior epitympanum 4. Persistent infection: petrositis, T.B., sinusitis 5. Persistent allergy 6. Retained foreign body: cotton ball 7. Persistent extra-dural abscess 8. Wrong indication Combined Approach Tympanoplasty Surgical Steps 1. Cortical Mastoidectomy 2. Anterior tympanotomy: via tympano-meatal flap 3. Posterior tympanotomy: via facial recess 4. Tympanoplasty Cortical Mastoidectomy Anterior Tympanotomy Posterior Tympanotomy Tympanoplasty Thank You