MASTOID CAVITY OBLITERATION WITH PALVA FLAP AND BONE PATE
Background
Chronic otitis media with cholesteatoma is a common disease in the field of otology. Canal-wall-down (CWD) tympanomastoidectomy is a well-established method in surgery to complete removal of cholesteatoma. It provides a good intra-operative exposure and an easy post-operative monitoring. A large cavity of mastoid in CWD tympanomastoidectomy technique could be troublesome. Problems are cosmetic, cleaning, draining ear, bathing, swimming, dizziness, and difficult ossicular reconstruction. The size of the surgical cavity can be diminished with obliteration to create a small cavity that is self-cleaning and easily maintained. Both autologous and synthetic materials have been used for obliteration, such as fat, cartilage, bone, periostomas-cular flaps and hydroxtapatitis. In this study we obliterated the mastoid cavity with bone paté and a Palva flap. Objective of this study is evaluation of outcome of mastoid cavity obliteration where bone paté and a Palva flap were used.
Material and methods
Between 2008 and 2011 in a prospective longitudinal study with a minimum follow up of 20 months, a series of 42 ears in 40 patients with chronic otitis media, due to a cholesteatoma, underwent surgery. Of these, 13 were revision surgery, the others were primary surgery. All patients underwent open-cavity tympanomasto-dectomy in which their mastoid cavity was obliterated with bone paté and a meatally-based musculoperiosteal flap (Palva flap).
Surgical technique
In general anesthesia and by post-auricular approach, a meatally-based musculoperiosteal flap (Palva flap) was prepared (Fig. 1), CWD tympanomastoidectomy (Fig. 2) was performed and bone dust was collected by means of a bone dust collector, from healthy cortical mastoid bone (Figs. 3 and 4). Then all of the pathologic material, such as cholesteatoma, was removed. After meatoplasty and placing of an underlay of fresh temporal fascia graft, the mastoid cavity was filled up by bone paté and a Palva flap (Fig. 5). Then a panrose was put in the cavity and the post-auricular incision was closed using Vicryl 3–0 subcutaneously. An antibiotic was given intravenously for one week.
Fig. 2. CWD tympanomastoidectomy.
Fig. 3. Bone dust collector.
Fig. 4. Collected bone paté.
Fig. 5. Obliterated mastoid cavity with bone paté.
Results
In our study there was a female preponderance, 23 females versus 17 males participated. The mean age of the patients at the operation was 31 (± 11 SD) years (range from 9 to 58 years).
A total of 42 consecutive ears underwent open-cavity tympanomastoidectomy with mastoid obliteration; 35 (83%) had a very small dry healthy mastoid cavity, five ears (12%) had occasional otorrhea that was relatively easily managed by topical therapy, two ears (5%) had small granulation tissue that was treated with silver nitrate. In all patients ossicular reconstruction was needed. The most common ossicular lesion was incus lenticular erosion. All patients had second-stage surgery for detection of cholesteatoma recurrence and ossicular reconstruction.
Conclusion
In modern ear surgery, all mastoid cavities due to CWD tympanomastoidectomy were obliterated by various techniques and materials. In our experience, mastoid cavity obliteration using a Palva flap and bone paté is an effective method to manage patients with pre-existing mastoid cavities and also those not previously operated upon.
Address for correspondence: Samad Ghiasi MD, Otolaryngology department, Imam Reza hospital, Gholghasht Ave, Tabriz, Iran. ghiasis2000@yahoo.com
Cholesteatoma and Ear Surgery – An Update, pp. 445–447
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands