Surgery for chronic ear disease.
When surgically treating chronic ear disease, the physician strives to accomplish several surgical objectives. Chief among them is to achieve a safe ear. This article discusses specific techniques that the surgeon can employ to reach these goals, whether he or she is performing tympanoplasty, atticotomy, intact canal wall mastoidectomy, or an open-cavity procedure. The author has found that the techniques discussed in this article are useful, and sometimes even essential, to achieving surgical objectives and maximizing outcomes.
The term chronic ear disease encompasses a wide range of clinical entities, including chronic otitis media, chronic suppurative otitis media (with and without cholesteatoma), chronic mastoiditis, tympanosclerosis, and cholesterol granuloma. The medical treatment of chronic ear disease has been reviewed in the other articles in this supplement; this article discusses surgical treatment. Its purpose is not to present a comprehensive review of surgery for chronic ear disease, but rather to emphasize specific surgical techniques and to provide clinical pearls that can help achieve successful surgical outcomes.
Definition of terms
Tympanoplasty. In 1965, the American Academy of Ophthalmology and Otolaryngology's Committee on Conservation of Hearing defined tympanoplasty without mastoidectomy as "an operation to eradicate disease in the middle ear and to reconstruct the hearing mechanism without mastoid surgery, with or without tympanic membrane grafting." 
The committee defined tympanoplasty with mastoidectomy as "an operation to eradicate disease in both the mastoid process and middle ear cavity and to reconstruct the middle ear conducting mechanism, with or without tympanic membrane grafting." 
The indications for grafting a tympanic membrane perforation include (1) control of mucoid or purulent otorrhea, (2) stabilization or improvement in hearing by the reconstruction of the sound-conducting mechanism, (3) control or prevention of secondary acquired cholesteatoma, and (4) removal of severe atelectatic or adhesive areas of the tympanic membrane.
Atticotomy. Atticotomy involves removal of the lateral epitympanic wall (scutum). This exposure allows for eradication of middle ear and attic cholesteatoma and attic retraction pockets, as well as for reconstruction of the ossicular chain while preserving the posterior canal wall. The scutum defect is generally repaired with cartilage to prevent further attic retraction.
Intact canal wall mastoidectomy. Intact canal wall mastoidectomy, also known as canal-wall-up mastoidectomy, involves removal of the mastoid cortex and dissection of the middle fossa tegmen, sigmoid sinus, antrum, and attic. As disease and anatomy permit, this approach allows for resection of disease while preserving (as the name implies) the bony posterior canal wall.  A facial recess approach might or might not be required, depending on the particular individual characteristics of the patient's disease.
Open-cavity procedures. Radical mastoidectomy and modified radical mastoidectomy are both examples of an open-cavity procedure, otherwise known as canal-walldown mastoidectomy. To achieve their objectives, these procedures involve removal of the posterior canal wall. Indications for these procedures fall into absolute and relative categories. Absolute indications are (1) unresectable disease, (2) unreconstructable posterior canal wall erosion, and (3) unavailability of followup. Relative indications are (1) disease in an only-hearing ear, (2) disease in the medically infirmed, (3) severe otologic or central nervous system complications, and (4) neoplasms. 
Modified radical mastoidectomy. In this procedure, the posterior canal wall is removed and meatoplasty is generally performed to create an open cavity. By definition, modified radical mastoidectomy involves the grafting of the middle ear space, which (when disease permits) allows for the sealing of the eustachian tube and prevents the middle ear mucosa from draining into the epithelialized mastoid bowl.
Radical mastoidectomy. As with the modified procedure, radical mastoidectomy involves removal of the canal wall, the performance of meatoplasty, and the formation of a mastoid cavity. The primary difference between the two procedures is that during radical mastoidectomy, the middle ear is not grafted. The primary indications for radical mastoidectomy are the presence of unresectable disease involving the facial nerve, ossicular chain (stapes suprastructure or footplate), sinus tympani, jugular bulb, or labyrinth.
Persistent cholesteatoma in the middle ear obviously prevents grafting and necessitates the creation of an open middle ear or radical cavity (figure 1). A labyrinthine fistula in which cholesteatoma is unresectable does not reflexively imply that a radical procedure is needed. The middle ear can be grafted in such a way as to incorporate the cholesteatoma into the graft, which places the graft medial to the elevated cholesteatoma without disturbing or manipulating the fistula.
Essentially all surgical procedures for chronic ear disease are designed to attain the same general goals.  These goals are to:
* achieve a safe ear
* eradicate disease
* achieve a dry ear free of otorrhea
* prevent the need for further surgery
* stabilize or improve hearing by reconstructing the sound-conduction mechanism (tympanic membrane and ossicular chain)
* close any tympanic membrane perforations (when indicated)
* prevent the future development of disease
Both residual cholesteatoma (cholesteatoma left behind by the surgeon at the time of the original surgery) and recurrent cholesteatoma (cholesteatoma that results from graft retraction as a consequence of adhesions or poor ventilation) are obvious causes of surgical failure. [5,6] It has been proposed that residual cholesteatoma can be prevented by employing either a more diligent surgical technique or more radical procedures.  The incidence of recurrent cholesteatoma is reported to range from 5% to as much as 71%. 
With the exception of achieving a safe ear, not all of the surgical objectives are necessarily absolute. For example, following radical mastoidectomy, a middle ear that is not grafted might continue to drain secondary to exposed middle ear mucosa (failure to achieve a dry ear); even so, the procedure might still accomplish the primary objective of achieving a safe ear. Likewise, a canal-wall-down procedure in which surgical excision is contraindicated might leave cholesteatoma in place (failure to eradicate disease), but still achieve the goal of a safe ear.
Tympanoplasty. As mentioned earlier, the primary indications for tympanoplasty are (1) prevention of otorrhea, (2) stabilization or improvement of hearing, (3) removal or prevention of secondary acquired cholesteatoma, and (4) removal of atelectatic or diseased areas of the tympanic membrane.  Fat, fascia, perichondrium, periosteum, cartilage, vein, and AlloDerm have all been used as grafting materials. [8,9]
When indicated, mastoidectomy might improve tympanoplasty results and prevent graft failure. Relative indications for mastoidectomy during tympanoplasty are (1) a history of profuse otorrhea, especially purulent otorrhea, (2) a previous tympanoplasty failure, (3) secondary acquired cholesteatoma, and (4) severe tympanic membrane retraction that is not resectable without further exposure provided by mastoidectomy.
Atticotomy. Atticotomy is often indicated for certain clinical situations, such as the presence of attic cholesteatoma, adhesive middle ear disease, or attic retraction. Removal of the scutum can improve access to the attic and facilitate removal of cholesteatoma or retracted tympanic membrane. Removal of the middle or inferior portion of the posterior canal wall can increase the amount of exposure to the hypotympanum and to the region of the sinus tympani. The degree of additional exposure is, of course, limited by the complex anatomy of this region and by other anatomic features (e.g., the facial nerve). Nevertheless, just a few millimeters of additional exposure can often provide access to the leading edge of a retracted tympanic membrane or cholesteatoma and thus facilitate complete removal. The introduction of new high-speed surgical drills has improved our ability to perform these techniques. Cartilage can be used to reconstruct any significant bony defect that might exist either as a result of the dise ase process or secondary to surgical removal to improve exposure (figure 2). Cartilage also prevents the placed graft from further retraction secondary to postoperative adhesions.
Intact canal wall mastoidectomy. When clinically indicated, intact canal wall mastoidectomy is the author's preferred technique for treating both children and adults. [10,11] The keys to the success of this procedure are meticulous microsurgical technique and adequate exposure. Adequate exposure is critical to achieving complete excision of cholesteatoma and successful tympanoplasty. Complete eradication of all diseased mastoid air cells is, of course, also essential.
During mastoidectomy, two techniques can help improve exposure to the antrum and attic: thinning the tegmen of the middle fossa dura and thinning the posterior canal wall. Anatomy permitting, excellent attic exposure can generally be achieved by following the middle fossa dura tegmen anteriorly with a small cutting or diamond burr. Thinning the posterior and superior bony canal wall also enhances exposure. With diligent dissection, the surgeon can generally achieve much more attic exposure than expected. As anatomy allows, this technique can provide exposure even anterior to the malleus head (figure 3). An enlarged Henle's spine or any other significant bony canal obstruction should be thinned to increase exposure. As noted earlier, atticotomy techniques can also be performed during intact canal wall mastoidectomy when additional exposure is needed to eradicate disease. Good attic exposure, either via atticotomy or with the described posterior approach, is essential to disease eradication. A facial recess exp osure might or might not be required.
Second-look procedures are scheduled as the clinical situation demands. The
decision to perform a second-look procedure is made at the time of surgery at the discretion of the surgeon. Indications for a second-look procedure include (1) excessive bleeding or inflammation that prevents full visualization of cholesteatoma, (2) a suspicion that cholesteatoma has been only incompletely excised, especially in the sinus tympani, on the facial nerve, or on the ossicular chain, and (3) reconstruction of the ossicular chain in a less-inflamed environment.
Cartilage, usually tragal cartilage, is liberally employed as an adjunct to fascia tympanoplasty, regardless of whether there is a bony defect. Cartilage can support the placed graft and thereby aid in achieving successful tympanoplasty, and it can prevent extrusion of the prosthesis and future graft retraction. [12-15] The thickness of the graft has not been shown to have any adverse effect on hearing thresholds. 
Endoscopes are used in a variety of otolaryngologic procedures, including tympanomastoidectomy. Endoscopes can be used for both primary and second-look procedures to facilitate visibility into the sinus tympani and attic. [17,18] Endoscopes are especially beneficial during second-look procedures, as less bleeding and edema are encountered, improving visibility. The use of endoscopes can allow for some second-look procedures to be performed via a transcanal approach. The middle ear, attic, sinus tympani, facial nerve, ossicular chain, and hypotympanum are areas of high risk for recurrent disease. With the 0[degrees], 30[degrees], and 70[degrees] endoscopes, these high-risk areas can be visualized endoscopically in certain clinical situations via a transcanal approach.
Before all procedures, lidocaine with epinephrine is injected into the postauricular and peritragal regions at a concentration of 1:100,000. The skin of the posterior canal wall is injected with a concentration of 1:50,000. Topical lidocaine/epinephrine (1:1,000) is used to control bleeding, primarily in the middle ear mucosa. The vasoconstrictive properties of epinephrine help improve visibility and therefore facilitate disease eradication.
Small amounts of Gelfoam are used to secure the graft, and mupirocin ointment is used to fill most of the external canal, thereby further securing the graft and vascular strip.
Open-cavity procedures. Purulent otorrhea and recurrent cholesteatoma following a canal-wall-down procedure can usually be attributed to inadequate surgical technique, such as a small meatoplasty, a high facial ridge, an incomplete removal of the posterior or superior canal wall, a deep dependent mastoid tip, or a missing or perforated tympanic membrane. [3,19] A dependent mastoid tip can lead to an accumulation of squamous debris. Whenever possible, the middle ear should be grafted so that it effectively seals the middle ear mucosa and eustachian tube from the mastoid cavity. Large pieces of Gelfoam can be used to line the cavity and prevent any undue adhesions that can result in stenosis. Postoperative webbing or adhesions can trap squamous debris and lead to recurrent cholesteatoma. The rest of the cavity is filled with mupirocin ointment.
Antibiotics are usually employed perioperatively. Cefazolin is given prior to making the skin incision in most cases. If an obvious Pseudomonas aeruginosa infection is present, antipseudomonal antibiotics, such as ciprofloxacin, ceftazidime, or ticarcillin/clavulanic acid are administered. Bacitracin at 50,000 U (one-half an ampule per liter of saline) is added to the sterile saline that is used for intermittent irrigation (not in the hanging saline that is used for suction/irrigation).
Most patients are seen for their first postoperative followup 2 to 3 weeks after surgery. Thereafter, they should make periodic visits at regular intervals so the surgeon can monitor and guide healing (figure 4). Following the initial postoperative visit, canal-wall-down patients are seen on a weekly basis for 6 to 8 weeks, depending on the clinical picture. Gentian violet is often used in liberal fashion as a drying agent on granulation tissue. Silver nitrate should be used sparingly because it can impair epithelialization; it should be reserved for abundant, heaped-up granulation tissue orpolyps. Elevated areas of granulation tissue or polyps must be lowered to allow for epithelialization.
Antibiotic drops are prescribed during the postoperative period. Ciprofloxacin/hydrocortisone drops and ofloxacin drops are commonly used to treat infection and/or reduce inflammation in the postoperative period. Any granulation tissue, edema, or polyps that arise can usually be treated successfully with topical therapy.
From the Department of Otolaryngology, Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences, Vanderbilt University Medical Center, Nashville, Tenn.
Adapted from an educational seminar sponsored by Alcon Laboratories and presented during the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Washington, D.C., Sept. 26, 2000.
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|Author:||Haynes, David S.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Jun 1, 2001|
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