Dr.

Supreet Singh Nayyar, AFMC

2012

Cholesteatoma

(Part 9)

Reconstruction Of Mastoid Cavity

( For more ENT Topics, please visit www.nayyarENT.com ) Problems of mastoid cavity o Discharge persistent o Dizziness o Dependency (on otologist for cleaning of ear) o Deafness Reasons for persistent discharge o Residual or recurrence of disease o High facial ridge sump effect o Deep mastoid tip sump effect o Inadequate meatoplasty o Small area of osteitis or granulations in the cavity o Sequestrated air cell that continues to harbour infection o Persistent otitis media due to dysfunctional Eustachian tube o Retained foreign body Aim of reconstruction o To avoid cavity problems after complete removal of disease in a CWD mastoidectomy Timing o Primary o Secondary No evidence of residual / recurrent disease Adequate tubal function No foci of osteitis / granulations Ossicular reconstruction can also be done Types o Open technique no reconstruction of post EAC o Closed technique reconstruction of post EAC

Open Technique No obliteration of cavity Simple, efficient and safe One stage operation with meatoplasty Cholesteatoma recurrence low Cases with doubtful availability for follow up, extensive disease, complications and revision surgery with previous ICW
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Dr. Supreet Singh Nayyar, AFMC

2012

Includes 1. Epithelisation guided by mesenchymal or skin flaps 2. Meatoplasty 3. Attic obliterated / ventilated / open Epithelialization techniques STSG FTSG Pedicled skin grafts inf based (see fig) Pedicled skin subcutis muscle grafts Pedicled ear canal skin grafts Meatoplasty Endaural Korners flap Surdille flap Stacke meatoplasty Farrior meatoplasty Fleury meatoplasty Postaural Korner Stacke Portman small 3 flap technique Portman large 5 flap meatoplasty technique with removal of cartilage Sheehy Fisch Landolfi Sanna Modified palva with korner Attic Bridge removed Attic open malleus head absent fascia over medial wall Attic obliterated malleus head absent fascia over medial wall Attic ventilated malleus head present fascia over tegmen tympani Bridge preserved Attic open malleus head absent fascia over medial wall Attic obliterated malleus missing fascia over bridge Attic ventilated malleus present fascia over bridge

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Dr. Supreet Singh Nayyar, AFMC

2012

Closed technique

(i.e scutumplasty only)

Criteria for cavity ventilation o Adequate tubal function o Adequate mucosal lining o Stapes present o Bridge at least partially present o Large graft Reconstruction of post canal wall o Temporalis fascia o Autogenous cartilage o Allogenous cartilage o Autogenous bone o Gantz & Hansen technique (post EAC removed in one piece, optd & placed back) o Reconstruction with biocompatible materials Reconstruction of attic o Outer attic wall. Tragal or conchal cartilage Cortical bone Hydroxyapatite o Reconstruction of bridge o Medial wall elevation Obliteration of cavity
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Dr. Supreet Singh Nayyar, AFMC

2012

o Pedicled muscle flaps Inf based (SCM rotation flap) (most commonly used) Sup based (temporalis ms) Ant based (post auricular ms, palva flap) Postsup based (Temporalis ms) o Cartilage obliteration o Bone o Biocompatible materials o Obliteration with Fat o Mastoid tip removal (except periosteum) SCM falls in Recent advances Trafermin (genetic recombination) solution basic fibroblast growth factor ( Vrabec et al ) Demineralized bone matrix ( Protein complex ) chemotactic component which attracts bone stem cells from healthy tissue.( Leatherman et al ) The protein complex has a semi-plastic consistency allowing it to be packed into a cavity in the bone. Once the cavity is packed, the complex will recruit bone stem cells, provide a framework for the stem cells to adhere, and stimulate growth and maturation of bone cells

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