LONG-PALVA-OBLITERATION TECHNIQUE IN CHOLESTEATOMA SURGERY: RESULTS OF A NEW TECHNIQUE
Introduction
Post-operative care in radical mastoid surgeries is challenging due to many possible problems. These problems include, late cavity epithelialization, wax and epithelium debris impaction, overwhelming infection, and not ideal amplification.1
Soft posterior canal wall reconstruction and mastoid exclusion procedures are aimed to overcome these problems.2 Traditional soft posterior canal wall reconstruction although helpful in some patients, has negative points such as difficult technique and common retraction of the posterior wall. Frequent posterior wall retraction in the absence of large meatoplasty results in difficulties in cavity post-op care.3
Mastoid obliteration with hydroxyapatite has some complications and infection and in most of patients does not lead to smaller cavity.4,5 Bone pate is another option, but in case of post-op infection it resorbs and no obliteration can be achieved.6
Here we present a new technique of soft posterior canal wall reconstruction and long term results.
Methods
Cholesteatoma patients undergoing canal-wall-down procedure were included in the study (2000–2011). Seventy-seven patients had good follow up and technique related outcomes could be studied such as achievement of posterior-canal-wall reconstruction, self-cleaning external auditory canal, retraction of canal wall, and flap necrosis.
After retro-auricular skin incision, temporal fascia graft was harvested. In order to elevate the periosteal flap, incisions were made more posterior than usual and a flap of twice the usual length (antero-posteriorly) was elevated (Fig. 1). After canal-wall-down mastoidectomy, a long temporalis fascia graft was inserted beneath the anterior remnant of the tympanic membrane and extended laterally posterior to the vascular strip. The muscle-periosteal flap was then pushed posterior to the fascia to be a soft-tissue support of the posterior canal. If good obliteration was achieved, no further meatoplasty was made.
This study is a retrospective analysis of clinical records, operative notes and audiologic data of patients.
Data from every patient were collected from pre-operative records, operative notes, and post-operative office visits. Statistical Package for Social Sciences (SPSS; version 16.0) was used for the data analysis. Parametric and non-parametric statistical tests were used to compare different variables. The statistical significance was set at p < .05 two tailed.
Address for correspondence: Ali Kouhi, MD., Otorhinolaryngology Research Center, Amir-A’lam Hospital, North Sa’adi Ave., P.O. Box:11457–65111, Tehran, Iran. a-kouhi@tums.ac.ir
Cholesteatoma and Ear Surgery – An Update, pp. 317–319
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands
Fig. 1. Harvesting the long palva flap: 1) usual post-auricular approach; 2) elevating posterior skin flap to have access to the periosteal flap; 3) incising flap; 4) elevating flap.
Results
The mean follow-up time was 34 months (range: 10–84). In all of our 77 patients obliteration was possible, but in seven patients (9%) the mucoperiosteal flap could not completely obliterate the mastoid cavity and meatoplasty was performed. In patients with complete obliteration no meatoplasty was necessary.
Four patients (5.2%) had flap necrosis in post-op visits. After out-patient debridement of necrotic muscle, the mastoid cavity enlarged but not to an extent needing revision surgery for meatoplasty.
Ten patients (13%) underwent second-stage surgery for hearing rehabilitation. In these patients, sharp dissection with micro-scissors was used to elevate the flap sharply. None of these cases had flap-related complications. Among patients undergoing ossicular reconstruction, 80% had successful hearing improvement (15 dB decrease in air-bone-gap at least).
Discussion
Concerns regarding post-op problems of the canal-wall-down procedure are the main issue resulting in debates about choosing canal-wall-up or -down procedures. Canal-wall-up mastoidectomy, although it eliminates CWD post-op problems, has a higher rate of recurrent or residual disease.7 The mastoid-obliteration technique helps the surgeon to benefit from both procedures: a more efficient removal of cholesteatoma and a small post-op external ear canal.
Our results show that the mastoid-obliteration technique by excluding the mastoid cavity from the external ear canal can really help to achieve a self-cleaning, smaller ear canal.
Meatoplasty is performed for patients undergoing canal-wall-down mastoidectomy in order to achieve better ventilation of the cavity (which decreases fungal infections) and makes cavity care and wax removal easier and feasible.7 However, it does not look natural and patients complain of its cosmetic results. One of benefits of our technique is that it eliminates the need for meatoplasty and has better cosmetic results.
Vertigo due to caloric stimulation of lateral semi-circular canal is not unusual in canal-wall-down patients, especially those who had a LSCC fistula.8 None of our patients had vertigo during swimming, or equally caloric stimulation. This was because the muscle had covered the LSCC area efficiently.
One of the negative points of our technique is dependance on flap vasculature. In revision cases fibrosis and sacrified perfusion of the flap may lead to flap necrosis. majority of our patients with post-op flap necrosis were revision cases. In conclusion, obliteration of mastoid cavity with a long palva flap seems to be a good option for radical cavity procedures. The main benefits are that meatoplasty is not needed, it provides a better cosmetic result, it does not limit physical activities such as swimming, there is no risk of vertigo due to labyrinthine stimulation by cold water in the cavity, and most importantly, it eliminates the need for long-term cavity care. The negative point is that by using this flap, second-stage surgeries are technically demanding or should be done by the retro-auricular approach, but it is feasible in most of patients.
References
1.Brackmann D. Mastoid cavity management: operative techniques. Otolaryngol Head Neck Surg 3:8–14, 1992
2.O’Sullivan P, Atlas M. Use of soft tissue vascular flaps for mastoid cavity obliteration. Laryngoscope 114: 957–959, 2004
3.Linthicum F. The fate of mastoid obliteration tissue: a histopathological study. Laryngoscope 112:1777–1781, 2002
4.Ridenour J, Poe D, Roberson D. Complications with hydroxyapatite cement in mastoid cavity obliteration. Otolaryngol Head Neck Surg 139:641–645, 2008
5.Wong R, Gandolfi B, St-Hilaire H. Complications of hydroxyapatite bone cement in secondary pediatric craniofacial reconstruction. J Craniofac Surg 22:247–251, 2011
6.Mokbel KM, Khafagy YW. Single flap with three pedicles, bone pate´ and split-thickness skin graft for immediate mastoid obliteration after canal wall down mastoidectomy. Eur Arch Otorhinolaryngol 269(9):2037–2041, 2012
7.Karmarkar S, Bhatia S, Saleh E, DeDonato G, Taibah A, Russo A, Sanna M. Cholesteatoma surgery: the individualized technique. Ann Otol Rhinol Laryngol 104:591–595, 1995
Beutner D, Helmstaedter V, Stumpf R, Beleites T, Zahnert T, Luers JC, Huttenbrink KB. Impact of partial mastoid obliteration on caloric vestibular function in canal wall down mastoidectomy. Otol Neurotol 31(9):1399–1403, 2010
Address for correspondence: Martin Fernandez, MD, Otorrinolaringologia, Otologia & Neurotologia, Centro de Especialidades Clinica de Marly, Calle 50 # 7–36 piso 5, Bogota DC, Colombia. clinicadeloido@marly.com.co
Cholesteatoma and Ear Surgery – An Update, pp. 313–316
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands