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ISSN: Print -2349-0977, Online - 2349-4387

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Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 142-147

Pursuing a flexible approach to tympanomastoidectomy: Benefits of a tailor-made strategy in squamosal otitis media

Department of Otorhinolaryngology, Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Research, New Delhi, India

Date of Web Publication27-Feb-2017

Correspondence Address:
Dr. Isha Preet Tuli
Department of Otorhinolaryngology, Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Research, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2349-0977.200998

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Introduction: The keystone of definitive management in active squamosal chronic otitis media (COM) is surgical correction. Numerous surgical strategies are in vogue, and the choice of surgery is largely governed by the underlying anatomic and pathologic condition. Of recent, much interest has focused on adopting a flexible approach which combines a number of sequential steps that aim to eradicate the disease and reconstruct the hearing apparatus in a single stage procedure, rather than following a traditional approach of modified radical mastoidectomy. Patients and Methods: This randomized, prospective double-blind study comprised 30 patients of various ages and both sexes, diagnosed with a unilateral or bilateral active squamosal chronic otitis media (COM). Of them, 12 (40%) patients were submitted to canal-wall down mastoidectomy, whereas 18 (60%) underwent a canal-wall up procedure. Each patient was followed up for a period of 6 months. The success of the procedure was measured in terms of achieving dry ear; a successful uptake of graft; and improvement in hearing. Results: Post surgery, at the end of 6 weeks, a dry ear was achieved in 25 (83.33%) patients, while the graft was taken up well in 29 (96.67%) patients. At 6 months, the number of patients with dry ear grew to 27 (90%), while the graft was taken up well in 28 (93.33%) patients. Two (6.66%) patients had graft failure. Of the 12 patients with canal-wall down procedure, 9 (75%) patients recorded a hearing improvement of air bone gap (ABG) ≤30 dBHL, while among the 18 patients who had a canal-wall up procedure, 94% had a hearing improvement of ABG ≤ 30 dBHL. Conclusion: Pursuing a flexible approach to tympanomastoidectomy offers a number of distinct benefits. Because the procedure is tailored to the gravity of otologic disease recognized intraoperatively, it fosters a total eradication of the disease and allows a suitable reconstruction of the auditory mechanism. Because the procedure is completed in a single stage, it reduces the time, effort, cost, and discomfort to the patient, while also diminishing the expense and burden on the public healthcare facility.

Keywords: Canal-wall down mastoidectomy, canal-wall up mastoidectomy, chronic otitis media, flexible approach, tympanomastoidectomy

How to cite this article:
Tuli IP, Sarkar A. Pursuing a flexible approach to tympanomastoidectomy: Benefits of a tailor-made strategy in squamosal otitis media. Astrocyte 2016;3:142-7

How to cite this URL:
Tuli IP, Sarkar A. Pursuing a flexible approach to tympanomastoidectomy: Benefits of a tailor-made strategy in squamosal otitis media. Astrocyte [serial online] 2016 [cited 2023 Sep 22];3:142-7. Available from: http://www.astrocyte.in/text.asp?2016/3/3/142/200998

  Introduction Top

Chronic otitis media (COM) is an important aural disorder because of its high incidence and chronicity. Active squamosal COM with or without cholesteatoma formation is the most frequent indication for surgery of the middle ear and mastoid.[1]

Patients with COM have diverse clinical presentations. Children presenting with recurrent acute otitis media, whose middle ear is clear in between episodes, have a different underlying pathological condition and treatment options than the adults presenting with chronically draining ears, and perhaps sensorineural hearing loss induced by COM. In between these two extremes are other variants of COM, with assorted underlying pathologic conditions requiring distinct appropriate surgical responses.[2] The operative intervention on the ear aims to eradicate the disease, make the ear safe and dry, decrease or minimize the risk of recurrent disease, and restore the hearing wherever possible.[1]

The earliest mastoid surgery was reportedly performed in 1772.[1] Despite this, more than two centuries later, debate continues to exist regarding the choice of surgery, closed or open cavity mastoidectomy for the treatment of COM with cholesteatoma.[3],[4],[5] In addition, numerous methods are described to tackle the cavity problems ensuing after the open cavity or canal wall down (CWD) procedures with equivocal results.[6],[7]

An understanding of the interrelationship between the disease and its location dictates the need for a surgical procedure that allows flexibility in the intraoperative setting to expose and remove the disease as it is tracked through various anatomic locations within the ear. Such an approach has been termed as the “flexible approach to tympanomastoidectomy.”First described by Paparella and Jung, this approach consists of a series of tailor-made surgical steps based upon the aggressiveness of the disease determined intraoperatively. Such customization helped correct the problems and prevent future sequel, leading to good long-term results.[8]

Regardless of these benefits, few Indian studies have dwelled on the approach. This study was conducted to analyze the efficacy of this flexible approach to tympanomastoidectomy applied in the manner of sequential steps in keeping with the severity of the disease.

  Patients and Methods Top

Conducted in a tertiary care public teaching institution, this study comprised 30 patients clinically diagnosed to have unsafe type of COM or active squamosal disease. Each patient underwent a thorough clinical examination, pure tone audiometry (PTA), appropriate radiological examination (X-ray mastoid lateral oblique view and/or computed tomography of the temporal bones), and baseline laboratory investigations for surgical fitness.

Clinical criteria guiding selection of cases were: (1) Foul smelling and/or blood stained discharge with or without vertigo, tinnitus, and pain, (2) Marginal, postero-superior, attic, or total perforation of tympanic membrane, (3) Retraction pockets in the tympanic membrane, and (4) Polyp, granulation tissue, or cholesteatoma in the tympanic cavity.

To improve the surgical outcome and increase chances of graft take-up an attempt was made to bring infection under control with a 7 days course of prophylactic antibiotic. Every possible attempt was made to improve the general condition in the ear before the surgery. Most of the cases were performed under general anesthesia; however, few cases were done under local anesthesia using a combination of 0.5% bupivcaine and 2% lignocaine with adrenaline. The following stepwise flexible approach to tympanomastoidectomy was followed:[3]

Step 1. Postaural or endaural Incisions. Step 2. Canalplasty to improve or facilitate access to the middle ear. A posterior canalplasty was performed by making a semicircular incision at the annulus (from 12 o'clock and 6 o'clock position) extended laterally to create a posterior meatal flap and elevated down to the annulus. The bony canal was then drilled down to allow better exposure of annulus and mesotympanum. The presence of mastoid air cells helped in the initial evaluation of the disease. Anterior canalplasty was optional, and was carried out whenever an overhang of the anterior canal wall obstructed the anterior part of the tympanic membrane. The skin of the anterior canal was elevated retrograde to allow drilling of the anterior bony canal wall, while protecting the capsule of the temporomandibular joint. Step 3. Meatoplasty was performed when canalplasty failed to provide adequate exposure; or at the end of the surgery for adequate visualization of the tympanic membrane. A wide meatoplasty was always performed when the end result was either an open cavity or when an intact bridge mastoidectomy (IBM) was performed. Step 4. Exploratory tympanotomy was performed and middle ear entered beneath the annulus. The tensor tympani were severed to lateralize the malleus (lateralizing ossiculoplasty), where the tympanic membrane and malleus were medialized to open up the mesotympanic space. The protympanum was carefully inspected with emphasis on sites of obstruction such as bony prominences in various regions of the middle ear, thickened mucosa, and granulation tissue, regions around promontory, round window, sinus tympani, facial sinus, and lateral tympanic sinus. The disease of the anterior tympanic membrane or anterior mesotympanum such as tympanosclerosis or of the  Eustachian tube More Details area was also looked for. Step 5. Atticotomy was performed routinely. The superior aspect of the bony canal wall was curetted or drilled out; the amount of bone removed being small, medium, or large to facilitate exposure of the pathological conditions at hand. This ranged from preservation of the bony bridge, by drilling superior to the bony annulus to the total removal of the bony bridge together with the lateral attic wall, up to the tegmen tympani. This allowed better exposure of the ossicles and following the mesotympanic disease towards the aditus ad antrum and removal of any pathological or anatomical obstruction. Step 6. Mastoidotomy was an optional step and a “control hole mastoidotomy” was performed where the mastoid pathology was suspected clinically, or by radiology in cases where a well-pneumatized mastoid was present to inspect the antrum, attic, and mastoid air cell system. In patients with diploeic or sclerotic mastoid, an atticoantrotomy was done by drilling retrogradely from the attic to the antrum. The atticotomy was extended in a posterior direction and the lateral attic and aditus walls were removed and antrum entered following the disease. Step 7. Mastoidectomy and tympanoplasty were done in cases with a significant disease in the middle ear and antrum. With well-pneumatized mastoid air cell system, a closed cavity tympanomastoidectomy was done. In the diploeic or sclerotic mastoids, open-cavity mastoidectomy or IBM procedures were done. The atticoantrotomy was the first step to a subcortical open tympanomastoidectomy or IBM. After removal of the pathological tissue, a reassessment was carried out, and wherever it was necessary, a reconstruction of the ossicular chain followed by reconstruction of the tympanic membrane with graft was performed. In short, cholesteatoma was removed from the epitympanum toward the mastoid along with functional reconstruction of the middle ear by tympanoplasty with ossiculoplasty, as per the individual need, in a single stage.

Follow-up examination of all patients was carried out at 1 week, 4 weeks, 6 weeks, 3 months, and 6 months post-surgery. This included detailed otoscopic examination with PTA. The following end-points were studied to indicate success of this surgical approach: (1) The achievement of dry ear, (2) The success in the uptake of graft, and (3) Improvement in hearing.

A good functional result with regards to hearing was defined as a postoperative air-bone gap closure in pure tone average of 20 dBHL or less.

  Results Top

The maximum number of patients with unsafe CSOM were in the ages between 11 and 20 years, i.e., 17 (56.67%) followed by 7 (23.33%) patients in the age group of 21–30 years [Figure 1]. A total of 83.3% patients had conductive hearing loss. Majority had mild-to-moderate hearing loss (21 cases, 70%). One patient (3.33%) had severe hearing impairment whereas 5 cases (16.7%) had mixed type of hearing loss [Figure 2].
Figure 1: Age distribution of study participants with unsafe CSOM.

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Figure 2: Degree of preoperative hearing loss in the study participants.

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Pathologically, cholesteatoma with granulations was seen in 9 patients (30%) followed by cholesteatoma alone in 8 patients (26.66%), whereas 4 (13.33%) patients had granulations alone. Three (10%) cases had aditus block, whereas cholesteatoma with thick glue like discharge, granulation with thick glue-like discharge; mesotympanic block was found in 2 patients (6.67%) each. Thus, cholesteatoma either alone or with another accompanying pathology was present in 63.3% of the patients [Figure 3].
Figure 3: Distribution of per-operative pathology in the study participants.

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The most commonly affected ossicle was incus. It was eroded in 17 (56.67%) and absent in 10 (33.33%) patients. In most patients, the long process of incus was eroded. Malleus was the next commonly affected ossicle, being eroded in 13 (43.33%) patients and absent in 1 (3.33%) patient. Stapes was intact in 24 (80%) patients while it was eroded in 6 (20%) [Table 1].
Table 1: Status of ossicles on per-operative assessment

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The flexible approach resulted in 12 patients (40%) undergoing CWD mastoidectomy and 18 (60%) patients undergoing CWU procedure. Of the latter 18 patients, seven patients (23.33%) each underwent intact bridge mastoidectomy and atticotomy, whereas 4 patients (13.34%) had an atticoantrostomy [Table 2].
Table 2: Extent of mastoid exploration (using flexible approach)

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Surgical reconstruction (tympanoplasty) was performed in single stage in all the 30 cases after complete removal of the disease from the middle ear cleft. Tympanomalleostapediopexy (malleus-stapes assembly) was the most common procedure performed [17 (56.67%) patients], followed by tympanomalleostapediopexy with incus interposition in 9 (30%). In 3 (10%) patients, tympanoplasty type I was performed. In one patient, tympanostapediopexy with bone interposition, i.e., incus reconstruction using autologous bone was performed [Table 3].
Table 3: Distribution of the reconstruction procedures

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Follow up of the patients was done at 1 week, 4 weeks, 6 weeks, 3 months, and 6 months. At 4 weeks, 16 (53.33%) patients had dry ear and graft was taken up well in 29 (96.67%) patients. One patient failed to take up the graft because of immediate postoperative Staphylococcus aureus infection.

At 6 weeks, 25 (83.33%) patients had dry ear and 5 (16.67%) had ear discharge. Of these 5 ears, 2 had granulations.

At 3 months, 25 patients remained dry but 2 ears of CWD procedure failed to take up the graft. At 6 months, 27 (90%) ears were dry and 3 ears (10%) continued discharging, out of which 2 had had a CWU procedure and 1 had a CWD procedure. One patient who had CWU procedure had granulations, and in the other 2, no cause for discharge could be found [Figure 4].
Figure 4: Postsurgery temporal follow-up findings in the study participants.

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At 6 months, 10 (33.33%) of the operated patients had hearing improvement of 0–10 dBHL and 11–20 dBHL each. Six patients (20%) had hearing improvement of 21–30 dBHL and 4 (13.34%) had more than 31 dBHL hearing improvement. The present study showed that, in 86.67% patients, ABG of 30 dB or less was achieved. Only 13.33% patients had ABG >31 dBHL. Out of these, 9 (75%) cases of CWD procedure and 94% of CWU procedure had hearing improvement of ABG of 30 dBHL or less. No patient reported decrease in hearing or sensorineural hearing loss [Figure 5].
Figure 5: Postsurgery hearing improvement (air bone gap closure) at 6 months.

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  Discussion Top

A cholesteatoma can be completely eradicated by employing an open cavity or a CWD procedure. However, the wide cavity created during the surgery requires a lifelong periodic postoperative cleaning, the recovery period is long, and the deafness and disability has to be borne through. Such precautions as avoidance of swimming are hard to comply with.[4],[6]

CWU mastoidectomy, therefore, is the preferred procedure. It preserves the anatomic structures but suffers with the limitation that the major anatomic structures are hard to visualize. Since the posterior wall of external auditory canal is preserved, complete removal of lesion may not be possible. The incomplete removal of pathology accounts for a higher recurrence rate, reportedly between 5 and 20%.[4],[6]

The present paradigm, particularly for pediatric cholesteatomas, is to perform a CWD procedure because children often present with advanced cholesteatoma and ossicular chain involvement, poor preoperative hearing, and higher rate of complications and postoperative recurrence. It is also considered appropriate because of unreliable patient follow-up.[9]

In an audit of surgeries for cholesteatoma over a 4-year period, McGuire et al. reported that CWD procedure was performed for 71% cases with 45% cases having improved postoperative hearing (within 15 dB of better hearing ear). Forty-five percent of CWU cases as opposed to 23% of CWD surgeries had recidivistic cholesteatoma.[9]

However, the flexible approach offers more than 90% success in terms of dry ear with a good reported hearing improvement, particularly in children, while reducing the incidence of CWD procedure.[4],[10] Harvey et al. used the flexible approach for 20 children with refractory suppurative COM, and for only 35% cases the surgery resulted in a CWD procedure.[10] In the present series, similarly, only 40% cases needed a CWD mastoidectomy with good postoperative results.

Conventional CWD surgeries such as radical and modified radical mastoidectomy are also associated with numerous postoperative problems. Rohan and Majumdar in their study of 65 patients reported moist cavity in 19.2%, debris and wax in mastoid cavity in 14.3%, and 17.54% with recurrent cholesteatoma.[11] However, with our approach, we had no case of recurrent cholesteatoma and 90% dry ears at 6-month follow-up.

Sonkhya et al. similarly achieved a dry ear with intact drum in 89.4% cases after 1 year of follow up, only 6.4% cases had discharge with residual perforation and 4.2% had discharge with granulations.[12] De Rowe et al. in their series of atticotomy for pediatric cholesteatoma in 53 children followed up for 5.1 years achieved dry ear in 52 cases (98%).[13]

The flexible approach also offers good functional results. Harvey et al. reported an improvement of speech reception threshold of an average 11.2 to 14.2 dBHL even in pediatric cholesteatomas.[10] Likewise, Dasgupta et al. achieved good postoperative hearing with AB gap within 20 dBHL in 51.28% ears.[14] Functional results were better in the present study with 66.67% patients having an AB gap within 20 dBHL and 86.67% with an AB gap within 30 dBHL.

Roth et al., in their series of 130 pediatric cholesteatomas operated by this technique and with a mean postoperative follow-up of 8.5 years, reported good surgical results. Dry ear was reported in 89.2% cases, 80.9% of the ears reached a postoperative air-bone gap of 30 dB or less, and in 60.9% of cases hearing improved postoperatively, conclusively proving the advantage of this technique.[15]

The present study supports the case for pursuing a flexible surgical approach in context of each specific case. This is essential to optimize the outcome.

  Conclusion Top

Following a flexible approach to tympanomastoidectomy offers several distinct benefits. Because the procedure is tailored to the gravity of otologic disease identified intraoperatively, it paves the ground for total eradication of the pathology while permitting a suitable reconstruction of the auditory mechanism through a tympanoplastic procedure. This strategy obviates the need for creating a large mastoid cavity, which was unpreventable when modified radical mastoidectomy was the rule. In the immediate and long run, this approach saves the patient from complications consequent upon a large mastoid cavity. Furthermore, because the procedure is completed in a single sitting, the burden on the patient is significantly lesser, reducing the time, effort, and financial costs. In developing economies, where public healthcare facilities are scarce, it also reduces the burden on the system and diminishes the backlog of patients.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Johnson GD. Simple mastoid operation. In: Glasscock ME, Gulya AJ, editors. Glasscock-Shambaugh surgery of the ear. 5th edition. Ontario: BC Decker Inc; 2003. pp. 487-93.  Back to cited text no. 1
Kimberley BP, Fromovich O. Flexible approach to tympanomastoidectomy. Otolaryngol Clin North Am 1999;32:585-95.  Back to cited text no. 2
Cruz OL, Kasse CA, Leonhart FD. Efficacy of surgical treatment of chronic otitis media. Otolaryngol Head Neck Surg 2003;128:263-6.  Back to cited text no. 3
Reddy TN, Dutt SN, Shetty A, Maini S. Transcanal atticoaditotomy and transcortical mastoidectomy for cholesteatoma: The Farrior-Olaizola technique revisited. Ann Otol Rhinol Laryngol 2001;110:739-45.  Back to cited text no. 4
Göçmen H, Kiliç R, Özdek A, Kizilkaya Z, Safak MA, Samim E. Surgicaltreatment of cholesteatoma in children. Int J Pediatr Otorhinolaryngol 2003;67:867-72.  Back to cited text no. 5
Baek MK, Choi SH, Kim DY, Cho CH, Kim YW, Moon KH, et al. Efficacy of Posterior Canal Wall Reconstruction Using Autologous Auricular Cartilage and Bone Pâté in Chronic Otitis Media with Cholesteatoma. J Int Adv Otol 2016;12:247-51.  Back to cited text no. 6
Sun J, Sun J, Hu Y, Lv Q, Wang Y, Li X, et al. Canal wall-down mastoidectomy with mastoid obliteration for pediatric cholesteatoma. Acta Otolaryngol 2010;130:259-62.  Back to cited text no. 7
Paparella MM, Morris MS, da Costa SS. Flexible methodology in the surgical approach to otologic disease. Presented at the Middle Section Meeting of the Triological Society; 1988.  Back to cited text no. 8
McGuire JK, Wasl H, Harris T, Copley GJ, Fagan JJ. Management of pediatric cholesteatoma based on presentations, complications, and outcomes. Int J Pediatr Otorhinolaryngol 2016;80:69-73.  Back to cited text no. 9
Harvey SA, Paparella MM, Sperling NM, Alleva M. The flexible (conservative surgical) approach for chronic otitis media in young children. Laryngoscope 1992;102(12 Pt 1):1399-403.  Back to cited text no. 10
Rohan R, Majumdar AB. Post Operative Study of Different Problems in CSOM With Cholesteatoma. PARIPEX-Indian J Res 2016;5.  Back to cited text no. 11
Sonkhya N, Mishra P, Srivastava S. Aerating mastoidectomy in granulomatous chronic otitis media by modified intact canal wall tympanomastoid surgery. Indian J Otol 2005;11:49-54.  Back to cited text no. 12
DeRowe A, Stein G, Fishman G, Berco E, Avraham S, Landsberg R, et al. Long term outcome of atticotomy for cholesteatoma in children. Otol Neurotol 2005;26:472-5.  Back to cited text no. 13
Dasgupta KS, Gupta M, Lanjewar KY. Pars tensa cholesteatoma: The underestimated threat. Indian J Otol 2005;11:17-20.  Back to cited text no. 14
Roth TN, Ziglinas P, Haeusler R, Caversaccio MD. Cholesteatoma surgery in children: Long-term results of the inside-out technique. Int J Pediatr Otorhinolaryngol 2013;77:843-6.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3]


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