DEFINITION OF MASTOID SURGICAL TERMS THE EAONO SESSION: EAONO GU IDELINE STUDIES ON CHOLESTEATOMA
Operative terms currently used in ear surgery can be classified according to the anatomic location where the surgical procedure is performed. Most of the ear procedures begin in the mastoid bone. They are not only for infection, but also to access the other regions of the temporal bone such as cochlea or labyrinth.
Surgical procedure for cholesteatoma is defined according to the process on the mastoid bone. However, in the literature, the general term ‘mastoidectomy’ includes different surgical techniques, and many variations of mastoidectomy with many different names have been proposed, performed and published. As a European Guidelines on Otology Study Group on Otitis Media and Cholesteatoma, we aim to outline the surgical procedures for reporting, publications and follow up.
In the literature, different definitions for simple or cortical mastoidectomy can be found. In the beginning, removing of the mastoid cortex and opening of the infected cavity was performed for acute mastoiditis and it was called ‘simple mastoidectomy’. Over time, surgeons realized that complete exenteration of all mastoid cells gives better result and they changed the surgical procedure from removing the mastoid cortex to the complete removal of all mastoid cells. However, sometimes this procedure is incorrectly referred to as ‘simple mastoidectomy’. Originally it is used for coalescent mastoiditis, but it is very rarely indicated anymore. Cortical mastoidectomy would be indicated in chronic suppurative otitis media or it provides access for other ear surgeries such as cochlear implantation, labyrinthectomy and so on. ‘Cortical mastoidectomy’ is the recommended term for this procedure.
Intact-canal-wall mastoidectomy is another closed technique. It has been recommended to avoid the disadvantages of radical mastoidectomy. Originally, Sheehy described this procedure naming intact-canal-wall tympanoplasty with mastoidectomy in his paper published in 1967.1 Over time, several different terminologies such as ‘intact-canal-wall (canal-wall-up complete) mastoidectomy’, ‘mastoidectomy with tympanoplasty’, ‘combined-approach tympanoplasty’ were used for this technique. Facial recess approach, initially described by Claus Jansen in 1968, is part of the technique most of the time. ‘Intact-canal-wall mastoidectomy’ is the recommended term for the procedure of complete removal of the air cell system of the mastoid bone leaving the posterior canal wall intact. It may or may not include a facial recess approach. After that hearing can be reconstructed.
Radical mastoidectomy has been defined by two general surgeons based on the surgical principle that a diseased bony cavity should be opened up extensively. Then Zaufal in 1890, described the first radical mastoidectomy. It is a canal-wall-down procedure with exteriorization of the middle ear. No attempt at restoring middle ear function is made. The Eustachian tube is occluded, and the malleus and incus (and possibly the stapes superstructure) are removed. The tympanic membrane remnant is excised, and no graft is placed, leaving the middle ear open. Although it is very rarely used nowadays, the definition is very clear and there is no need for discussion. It may be indicated in situations in which cholesteatoma cannot be completely excised (e.g., cochlear fistula, disease tracking into the petrous apex).
Most of the confusion over terminology focuses on modified radical mastoidectomy. Frequently, the term ‘modified radical mastoidectomy’ is used interchangeably with canal-wall-down mastoidectomy. Classically, modified radical mastoidectomy refers to the Bondy procedure and in the operation the epitympanum, mastoid antrum and external auditory canal are converted to a common cavity, and tympanic membrane and ossicles are kept to preserve hearing. Originally this operation does not have any reconstructive procedure. However, the term ‘modified radical mastoidectomy’ can be used to describe a canal-wall-down mastoidectomy, even in this procedure; reconstruction of the hearing system is always part of the surgery.
Canal-wall-down mastoidectomy involves removal of the mastoid air cells, saucerization of the cortical edges of the mastoid bone, a complete removal of the superior and posterior canal walls, and a meatoplasty, then tympanoplasty is performed.
The main disadvantage of CWU mastoidectomy is the higher rate of cholesteatoma recurrence. In the open techniques, the rate is lower, however, these techniques have their own disadvantages such as a life-long need for cleaning of the cavity, for avoidance of swimming, possible caloric stimulation and so on. Avoiding these problems, obliteration of the cavity or reconstruction of external auditory canal are the preferred methods. In this case, the technique has been started as an open technique, but the end result is a closed cavity. This technique may define as a closed technique in some papers comparing the rate of recurrent or residual cholesteatoma with the ‘real’ closed technique such as ICW mastoidectomy. For meta-analysis or a correct comparison of scientific papers, the definition of the technique and final situation of the cavity must be clarified.
Reference
1.Sheehy JL and Patterson ME. Intact canal wall tympanoplasty with mastoidectomy. A review of eight years’ experience. Laryngoscope 77:1502–1542, 1967
Address for correspondence: S. Armağan Incesulu, armaganincesulu@yahoo.com
Cholesteatoma and Ear Surgery – An Update, pp. 165–166
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands