Long-term Outcomes After Secondary Mastoid Obliteration

Surgical Treatment for Troublesome Mastoid Cavities: Canal Wall Reconstruction With Bony Obliteration Versus Subtotal Petrosectomy

INTRODUCTION

A chronically discharging modified radical mastoid cavity may require surgical intervention. We aim to explore two techniques.

OBJECTIVE

To compare outcomes of subtotal petrosectomy (STP) and canal wall reconstruction with bony obliteration technique (CWR-BOT).

STUDY DESIGN

Retrospective cohort study.

SETTING

A tertiary referral center.

PATIENTS

All patients with a chronically discharging mastoid cavity surgically treated at the Radboud University Medical Center by STP or CWR-BOT in 2015 to 2020, excluding patients with preoperative cholesteatoma.

MAIN OUTCOME MEASURES

Dry ear rate, audiometry, and rehabilitation.

SECONDARY OUTCOME MEASURES

Healing time, number of postoperative visits, complications, cholesteatoma, and need for revision surgeries.

RESULTS

Thirty-four (58%) patients underwent STP, and 25 (42%) CWR-BOT. A dry ear was established in 100% of patients (STP) and 87% (CWR-BOT). The air-bone gap (ABG) increased by 12 dB in STP, and decreased by 11 dB in CWR-BOT. Postoperative ABG of CWR-BOT patients was better when preoperative computed tomography imaging showed aerated middle ear aeration. ABG improvement was higher when ossicular chain reconstruction took place. Mean follow-up time was 32.5 months (STP) versus 40.5 months (CWR-BOT). Healing time was 1.2 months (STP) versus 4.1 months (CWR-BOT). The number of postoperative visits was 2.5 (STP) versus 5 (CWR-BOT). Cholesteatoma was found in 15% (STP) versus 4% (CWR-BOT) of patients. Complication rate was 18% (STP) and 24% (CWR-BOT) with a need for revision in 21% (STP) and 8% (CWR-BOT), including revisions for cholesteatoma.

CONCLUSION

STP and CWR-BOT are excellent treatment options for obtaining a dry ear in patients with a chronically discharging mastoid cavity. This article outlines essential contributing factors in counseling patients when opting for one or the other. Magnetic resonance imaging with diffusion-weighted imaging follow-up should be conducted at 3 and 5 years postoperatively.

Mastoid obliteration and canal wall reconstruction with posterior auricular artery (PAA) fascia-periosteum flap

OBJECTIVE

Unstable cavities are defined as cavities with cerumen accumulation that need frequent cavity cleaning in the out-patient clinic, cavities that are intolerant to water due to risk of infection or that are subject to frequent infection and otorrhoea. The objective of this study is to address the problem of troublesome mastoid cavities, with the performance of secondary mastoid obliteration and canal wall reconstruction, using a novel posterior auricular artery (PAA) fascia-periosteum flap.

MATERIALS AND METHODS

A prospective study was designed, only secondary obliterations were included. Unstable mastoid cavities were defined as Merchant grade 2 or 3 and were included for surgery.

RESULTS

At 12 months of follow up, a complete external auditory canal (EAC) and a self-cleaning ear were achieved in all 23 patients. Completely dry ears were achieved in 21 patients (91.3%). An air-bone gap improvement of 5dB was achieved.

CONCLUSION

Mastoid obliteration and EAC reconstruction are effective procedures to treat troublesome post canal wall down mastoid cavities. They improve quality of life and enable patients to overcome ear discharge. A standard EAC size enables the utilization of conventional hearing aids, it also reduces the need for constant mastoid cleaning and decreases healthcare expenses. The PAA flap seems to be an effective procedure to achieve all these features, as it is used to obliterate the mastoid and becomes a structural component of the neo-EAC.

Materials used for mastoid obliteration and its complications: a systematic review

OBJECTIVE

The objectives of this review are to identify the types of materials with their associated complications and respective considerations when used to obliterate the mastoid cavity.

METHODS

A systematic search was performed across PubMed, Embase, Medline and Cochrane databases from January 2009 to January 2020 for randomized controlled trials and observational studies of patients that underwent mastoid obliteration. Studies that fulfilled the inclusion criteria were screened and scored according to the MINORS and relevance scores to determine final inclusion. Types of complications were grouped into minor and major complications based on the Clavien-Dindo classification.

RESULTS

Two thousand five hundred and seventy-eight ears were evaluated. There were a total of 165 (7.9%) minor and 142 (6.8%) major complications in the autologous group. Overall complication rate is 14.8%. The major complications were largely recurrent and residual disease requiring revision surgery. There were 10 (18.5%) minor complications and three (5.6%) major complications in the allogenic group. The cumulative complications risk is 24%. For the synthetic group, there were 39 (8.0%) minor and 34 (7.6%) major complications. The cumulative complication rate is 16.6%.

CONCLUSION

Current evidence on materials for mastoid obliteration has been evolving. Each material has its strengths and limitations. The trend over the last decade favours the use of autologous materials. The principle of using a material remains being cautious of not reimplanting skin that can lead to the development of a cholesteatoma. The choice of materials is dependent on patient factors as well as the surgeons' preference and experience.

Bone Pate Obliteration in Canal Wall Down Mastoidectomy: Modifications of an Established Technique

OBJECTIVE

To describe outcomes with obliteration of the mastoid and medial attic following canal wall down mastoidectomy for cholesteatoma. Our technique uses bone pate in the mastoid and cartilage in the epitympanum and supratubal recess.

STUDY DESIGN

Retrospective observational study.

SETTING

Tertiary medical center.

PATIENTS

Ten years of sequential canal wall down mastoidectomies with obliteration from one neurotologist were reviewed. This included primary and revision cases in adults and children.

MAIN OUTCOME MEASURES

Complications, location and extent of cholesteatoma, the presence of a dry ear after surgery, cholesteatoma recidivism, revision procedures, and postoperative hearing.

RESULTS

Seventy-eight patients (79 ears) met inclusion criteria. There were few major complications. There was active follow-up of a year or more in 61. For these, the mean follow-up was 3.1 years, and approximately 90% had a dry cavity for the remainder of their follow-up. About half required minimal (if any) maintenance. There were five cases with residual disease, and no cases with recurrent disease. There were five cases that were considered failures, with three taking several years to manifest. There were no cases where cholesteatoma was buried in bone pate. A sizeable minority continued to have active tubotympanic disease despite successful treatment of the attic and mastoid.

CONCLUSIONS

This seems to be a safe and reliable means to eradicate cholesteatoma and create a dry, low-maintenance cavity. It is not a cure for tubotympanic disease, and a small minority of initially stable cavities may fail several years following surgery.

LEVEL OF EVIDENCE

4.

Post-operative healing and long-term stability after mastoid cavity reconstruction using the middle temporal artery and inferior musculoperiosteal flaps

PURPOSE

This study aims to evaluate the surgical outcomes with the use of a combination of the middle temporal artery (MTA) flap and the inferior musculoperiosteal (IMP) flap for mastoid obliteration after canal wall down mastoidectomy.

METHODS

Seventy-five patients who have undergone canal wall down mastoidectomy and mastoid obliteration with the MTA and the IMP flaps at a single tertiary hospital were included. Surgical outcomes measured included the creation of a dry mastoid cavity as measured by a previously developed semi-quantitative scale, mastoid cavity epithelization time, rate of revision surgery needed, and rate of recurrent cholesteatoma.

RESULTS

Patients were followed up for a median of 29 months. The median time to epithelization of the mastoid cavity was 2 months. At 1 and 3 months, 36.0% and 76.0% of patients had grade 0 and grade 1 cavities, respectively, with either a dry cavity or one or less episodes of mild otorrhea or sensation of wetness. Hundred percent of the patients achieved a grade 2 (more than one episode of otorrhea or the presence of granulation tissue that promptly resolved with simple treatment) or better cavity at 3 months. One patient re-presented with a grade 3 cavity with uncontrolled infection and daily otorrhea secondary to an attic perforation that manifested at 6 months, requiring revision surgery. There were no recurrent cholesteatomas during the follow-up period.

CONCLUSIONS

The use of the MTA and the IMP flaps for mastoid obliteration may be considered as an adjunct to achieving a safe, dry ear after canal wall down mastoidectomy.