Fascioperiosteal flap and neo-osteogenesis in radical mastoidectomy: Long-term results.

Abstract

We performed an analysis of long-term outcomes data on 60 patients with chronic otitis media with cholesteatoma who had undergone a surgical procedure based on an improved radical mastoidectomy and an inferiorly based fascioperiosteal flap. We found that at the 2-, 7-, 10-, and 13-year postoperative followup visits, all mastoid cavities were healthy and reduced in volume. At the final examination, the mean cavity volume was found to be decreased by 39% of the mean volume measured 1 month postoperatively. This reduction in volume is attributable to the neo-osteogenic activity of the flap, which was confirmed by histopathologic and radiologic findings. No recurrences took place.

Introduction

A method of mastoidectomy called improved radical mastoidectomy with flap (IRMF) consists of the saucerization of all bony buttresses, the excision of the mastoid apex, the dissection of all diseased tissues, the alignment of the mastoid cavity by an inferiorly based fascioperiosteal flap, and the creation of a large meatoconchoplasty. [1] In this article, we report the long-term clinical results and radiologic and histopathologic findings with regard to 60 patients who had undergone this procedure.

Materials and methods

We identified 80 patients who had undergone IRMF at the Gulhane Military Medical Academy between 1982 and 1992. These patients were not good candidates for conservative surgery. Their primary complaint had been a longstanding (2-30 yr) otorrhea. All patients had varying degrees of cholesteatoma, osteitis, and granulation. Some patients also had a postauricular fistula, meningitis, one or more intracranial abscesses, Bezold's abscess, parapharyngeal abscess, spontaneous mastoid excavitation, erosion of the facial canal at various levels, destruction of dural or sigmoid plates, or sigmoid sinus hernia. The ossicular chains were largely destroyed in all patients, and many of them had no stapedial suprastructure.

The surgical method, postoperative care, and volume measurements of the cavities were carefully noted. [1,2] Some patients underwent computed tomography (CT) of the temporal bone in addition to the classic radiologic studies in Schuller's position. For some patients, we were able to obtain a biopsy specimen of the tissue that formed under the fascioperiosteal flap on postoperative day 21. Some of these patients had undergone a simultaneous and successful reconstruction of the tympanum.

All 80 patients were invited to return to our institution for followup in 1987, 1989, 1992, and 1995. Of that group, 60 patients--52 males and 8 females, aged 9 to 56 years--appeared for the final followup in 1995. Each of them underwent physical and radiologic examinations and volume measurements of the cavities.

Results

IRMF had proved to be successful in all cases. Only six patients had experienced an immediate postoperative complication: two patients had an inadequate meatoconchoplasty, one had perichondritis, one had spontaneous nystagmus, one had transient facial paresis, and one developed a total sensorineural hearing loss. In general, all patients had trouble-free cavities. Although epithelialization had still been in progress 1 month postoperatively, all cavities had become dry and fully epithelialized by 2 months.

At 3 to 13 years postoperatively, all patients were found to have healthy and small mastoid cavities (figure 1). The meatoconchoplasties were sufficiently large, the postauricular areas were smooth and taut, and there was no anterior displacement of the pinna. Most important, there was no recurrence of cholesteatoma or osteitis. The mean cavity volume had decreased by 39% of the volume measured 1 month postoperatively.

X-rays and CT scans obtained 1 month and 10 years postoperatively showed that the osseous lines over the sigmoid sinus had thickened. CT of the temporal bone obtained at various times postoperatively revealed a slow building of neo-osteogenic tissue right under the flap (table). This was documented by measuring the density of the bone-flap contact area on the CT sections.

Discussion

One of the goals of surgery for chronic otitis media and cholesteatoma is to preserve or reconstruct the posterior wall of the ear canal. Many methods of doing so have been introduced during the past 40 years, but classic radical mastoidectomy with an open cavity is still the most common technique. The primary reasons for its popularity are its simplicity, efficiency, and safety.

The most common long-term problem with this procedure is a putrid drainage from the cavity. Therefore, the maintenance of a healthy cavity is important, and many graft, flap, and obliteration techniques have been introduced for this purpose. Within this framework, the principal author (M.K.) previously introduced the IRMF technique. Analysis of its outcomes confirmed that neo-osteogenesis reduces the volume of the operated cavity. [1-3]

With the IRMF method, perioperative volume reduction of the mastoid cavity is secured by the circumferential saucerization of all bony buttresses and the removal of the mastoid tip and all diseased tissues. [4-8] To obtain an even smaller and less problematic cavity, the inferiorly based fascioperiosteal flap is used to align the cavity. [1] The rationale behind this technique, which is not an obliteration method, is to facilitate new bone formation underneath and epithelialization over the surface of the fascioperiosteal flap. Although some surgeons have claimed that the flaps wither away in time, we have found that they do not. Over the course of a decade, our patients exhibited an average 39% decrease in cavity volume compared with the volume 1 month postoperatively.

The reduction in the size of these open mastoid cavities is the result of the neo-osteogenic activity of the periosteal layer of the flap, which remains in contact with the denuded bony walls of the cavity. Temporal bone CT of our patients obtained at various intervals showed an increase in this activity over time. At postoperative year 4, the density of the bone-flap contact zone increased from 65 to 210 Haunsfield units. It is interesting that there were variations in the density of the underlying bone, which could have occurred as a result of a simultaneous and temporary bone decalcification and recalcification. In addition, histopathologic study of a biopsy specimen of the subflap tissue taken from one patient demonstrated an obvious new bone formation and an increase in osteoblasts therein (figure 2).

Meatoconchoplasty is indispensable for obtaining sufficient aeration and self-cleansing. [3-6,9-12] Only one of our patients developed postoperative perichondritis, and the reason for that was unsatisfactory surgical management of the meatoconchoplasty, which had to be reoperated. Two patients had very narrow meatoconchoplasties, which required enlargement under local anesthesia. Even the largest meatoconchoplasties became narrower over time, but they provided adequate aeration of and access to the cavity.

Inevitably, there were some complications of surgery, but they were not the result of the particular method used. One of our patients developed a spontaneous nystagmus that was caused by irritation of the vestibule, which was entirely encompassed by the cholesteatoma. Another patient experienced a total sensorineural hearing loss for the same reason. Finally, one patient developed a slight facial peripheral paresis, but it resolved spontaneously within several days.

Generally speaking, within 2 months of surgery, all flaps and epithelial layers had become smooth and healthy and had covered all surfaces. At the various followups, we observed that all patients had dry and small mastoid cavities. A few patients had a slightly wet tympanic portion of the cavity, but this was easily managed.

From the Department of Otorhinolaryngology--Head and Neck Surgery (Dr. Kahramanyol and Dr. Ozunlu) and the Department of Radiology (Dr. Pabuscu), the Gulhane Military Medical Academy, Ankara, Turkey.

References

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