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Cortical mastoidectomy
1) The document discusses the surgical approach and procedure for cortical mastoidectomy. Key steps include raising skin and periosteal flaps, drilling along anatomical landmarks like the sigmoid sinus and facial nerve to identify structures, and widening the aditus and performing a posterior tympanotomy to access the mesotympanum. 2) Post-operative care involves drain removal within 48 hours and dry dressing of the ear. Potential complications discussed are persistent deafness, facial nerve injury, CSF leak, hemorrhage and infection. 3) The patient is advised restricted activity for 3 weeks followed by a gradual return to normal activity over 4 weeks, and to keep the operation site dry.
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Discusses types of mastoiditis, surgical approaches including endolymphatic sac surgery and cochlear implants.
Details history taking for symptoms like ear discharge and hearing loss; includes otomicroscopy, audiometry, and lab tests.
High-resolution CT scan for assessing mastoid pneumatization, ossicle status, and extent of disease.
General anesthesia preparation with intubation info; position and draping prior to surgery.
Details on infiltration anesthesia, incision methods, and elevation of skin and periosteal flaps.
Drilling methods for accessing structures; identifies facial nerve and sigmoid sinus while avoiding damage.
Post-drilling steps: cavity irrigation, drain placement, and skin closure techniques.
Drilling methods for accessing structures; identifies facial nerve and sigmoid sinus while avoiding damage.
Post-drilling steps: cavity irrigation, drain placement, and skin closure techniques.
Indications for extended cortical mastoidectomy and techniques for accessing the mesotympanum.
Indications for extended cortical mastoidectomy and techniques for accessing the mesotympanum.
Guidelines for postoperative care, potential complications such as deafness and infection, and patient instructions.
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Cortical mastoidectomy
- 3. 1) Coalescent Mastoiditisand Masked Mastoiditis. 2) CSOMTTD Active Refractory to antibiotics. 3) It is the initial stage of any transmastoid surgery
- 4. Approach to: -Endolymphatic sacsurgery. -Facial nerve decompression. -Vestibulo cochlear nerve section. -Translabyrinthine Approach for CP angle. -Cochlear implant surgery. -Combined ApproachTympanoplasty.
- 5. • History: • Eardischarge • 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 (0.5mmcuts) • Pneumatisation • Ventilation • Tegmen tympani • Status of ossicles • Sigmoid sinus • Jugular bulb • Carotid artery • Facial nerve • Extent of the disease
- 9. Anesthesia General anesthesiawith endotracheal intubation • Avoid long acting muscle relaxants – facial nerve monitoring.
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- 12. Local Anaesthesia Infilteration •Lidocaine and adrenaline
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- 21. Drill within thistriangle and work your way deeper into the mastoid
- 22. Identification of LSSCand 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
- 23. Identification of LSSCand Dural Plate
- 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 SigmoidSinus 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 placedand 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 Holdthe 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
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- 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
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- 35. Posterior Tympanotomy Drillingaway 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 gainaccess to mesotympanum via cortical mastoid cavity • Cochlear implantation • Part of combined approach tympanoplasty • Cholesteatoma in mastoid bowl, and mesotympanum
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- 39. Postoperative Care • Drainleft 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 thePatient • 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
Editor's Notes
- #31 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