SURGICAL APPROACHES TO THE MIDDLE EAR AND MASTOID

DR.MAAMON AMEEN

• The three most commonly used surgical approaches to the middle ear and mastoid are:

• Transcanal, • Endaural, • Postaural

• The decision as to perform any of these approaches should be based on preoperative evaluation .

• The expected extent of surgery, the necessity of opening the mastoid, the given anatomical findings, all have to be considered.

TRANSCANAL APPROACH

TRANSCANAL APPROACH

• Not commonly used in children • Contraindicated in diffuse or localized otitis

externa • Used when the mesotympanum and

hypotympanum are the surgical sites

Indications• Tympanoplasty• Ossiculoplasty• stapedectomy • Removal of glomus tympanicum • Exploratory tympanotomy • Second look” tympanotomy• Repair of round window after rupture

TRANSCANAL APPROACH

Preparation • Done G/A and L/A• Wax is cleared from EAC • Hairs clipped from EAC• If a temporalis graft is to be used, a

small portion of hair is shaved just above the pinna.

TRANSCANAL APPROACH

• position • Canal is cleaned with pyodine

and draped applied • Canal is cleard by genlte suction

TRANSCANAL APPROACH

LA (lignocain with adrenalin)

TRANSCANAL APPROACH

Procedure

• Incision is made

TRANSCANAL APPROACH

• Reflection of the tympanomeatal flap

TRANSCANAL APPROACH

TRANSCANAL APPROACH

• The superior portion of the tympanomeatal flap is completed

• Curettage of the posterosuperior canal wall scutum

• The tympanomeatal flap is completed when the posterior edge of the long process of the malleus, the long process of the incus, the stapes, the stapedius tendon, and the round window are visible, and the flap is reflected anteriorly without tension

TRANSCANAL APPROACH

Closure of wound

• Flap is replaced • Incision line sealed with gelatin

sponge • Light pack in EAC placed

TRANSCANAL APPROACH

ENDAURAL APPROACH

• Commonly used in infants and young children• Accessibility to epitympanum and postero-

superior part of mesotympanum• Temporalis fascia and tragal cartillage graft can

be easily obtained• faster and less traumatic compared to the

postaural approach• Difficult to gain access to mastoid tip cells

• Tympanoplasty• Atticotomy and atticoantrostomy • Congenital and acquired cholesteatoma in the

epitympanum • meatal stenosis • Excision of osteomas and exostoses of ear canal• Large tympanic membrane perforation• Modified radical mastoidectomy

ENDAURAL APPROACH

Indications

Anaesthesia • additional injections are placed in

the incisura of the pinna

ENDAURAL APPROACH

The incision

ENDAURAL APPROACH

Flap elevation

ENDAURAL APPROACH

Middle ear cavity opened

ENDAURAL APPROACH

• Exposure of mastoid and temporalis fascia

ENDAURAL APPROACH

• Exposure of mastoid antrum

ENDAURAL APPROACH

• Exposure of attic and mastoid bowl

ENDAURAL APPROACH

• Atticotomy

ENDAURAL APPROACH

Closure of the wound • Bipp pack is commonly used • Vicryl stitches to approximate

edges • Skin is closed with silk • Firm mastoid bandage is applied

ENDAURAL APPROACH

• frequently used in children.• fascia graft can be readily

obtained from the temporalis muscle

• Excellent approach to mastoid

POSTAURAL APPROACH

• Cortical mastoidectomy • MRM and radical mastoidectomy • Combined approach tympanoplasty • Cochlear implantation• Facial nerve surgery • Translabyrinthine removal of acoustic tumour• Retrolabyrinthine approach to CP angle

POSTAURAL APPROACH Indications

Indications • Carcinoma of the middle ear • Extensive glomus jugulare tumours • Rarely ,thrombophlibitis arising from

lateral sinus thrombosis • Some cases of congenital atresia

POSTAURAL APPROACH

• The anesthesia is the same as that described for the transcanal approach,

• Additional injection sites are required in the postauricular area

POSTAURAL APPROACH

Incision• A transcanal incision is made from the 6 to 12

o’clock position about one third of the distance from the annulus to the meatus to create a tympanomeatal flap

POSTAURAL APPROACH

INCISION

POSTAURAL APPROACH

INCISION IN CHILDREN

POSTAURAL APPROACH

Elevation of Skin Flap

POSTAURAL APPROACH

Incising Periosteum

POSTAURAL APPROACH

Elevation of Periosteal Flap

POSTAURAL APPROACH

POSTAURAL APPROACH

Mac Ewen’s Triangle

POSTAURAL APPROACH

POSTAURAL APPROACH

Closure of the wound • Periosteal edges are

approximated • Skin closed with interrupted silk• Firm mastoid bandage applied

POSTAURAL APPROACH

Complications Immediate Facial nerve paralysisAcute SOM vertigoTM perforation Dead earDistortion or lost of taste Persistent bleeding Perichondritis

Complications Delayed Dead earPersistent vertigoPersistent perforationMeatal stenosis

Thank you