Mastoidectomy: Surgical Techniques

History

The first scholarly treatise on mastoid surgery for suppurative disease was written by Schwartze in 1873. This described a cortical mastoidectomy with limited air cell exenteration. For acute and coalescent mastoiditis, both prevalent in the preantibiotic era, this procedure proved remarkably efficacious but rarely curative for the causative disease. In 1890, Zaufa described removing the superior and posterior canal wall, tympanic membrane, and lateral ossicular chain—a procedure now known as the radical mastoidectomy. It was modified by Bondy, who recognized that disease limited to the pars flaccida could simply be exteriorized, leaving the uninvolved middle ear alone. His description of the modified radical mastoidectomy or Bondy procedure in 1910 represented one of the first reports to address hearing function. Interest in hearing preservation and restoration gained further attention after Lempert introduced the fenestration operation in 1938 and Zollner and Wullstein described tympanoplasty techniques in the early 1950s. During the next decade, Jansen and Sheehy and Patterson extended these principles of restoring function and maintaining normal anatomy with the introduction of the intact canal wall mastoidectomy.

Relevant Anatomy

As reviewed in Chapter 126 , the temporal bone is composed of squamous, tympanic, mastoid, and petrous regions ( Figs. 143.1 and 143.2 ). This chapter focuses primarily on the mastoid portion, which articulates with the parietal and occipital bones. It typically houses the mastoid air cell system, which is in continuity with all other pneumatized portions of the petrous pyramid. Other important structures housed within the mastoid include the facial nerve, jugular bulb, and labyrinth. There are a few important surface landmarks on the mastoid. The temporal line, which extends posteriorly from the zygomatic root, helps denote the approximate location of the middle fossa's floor. The suprameatal spine, or spine of Henle, is a small bony protuberance that extends superficially from the posterior and superior bony external auditory canal (EAC). Just posterior to this spine is a cribriform area, which approximates the location of the underlying mastoid antrum.

All major components of the temporal bone are present in infants, but one notable difference has surgical implications. In infants, the mastoid tip has yet to develop, and the stylomastoid foramen is located more superficially, which makes the facial nerve vulnerable to surgical trauma.

Nomenclature

The nomenclature for mastoid surgery is often confusing and may describe a variety of approaches and techniques. Concomitant surgery that involves the middle ear requires additional terminology, such as tympanoplasty or ossiculoplasty . Box 143.2 lists the standard mastoid procedures for addressing chronic ear disease.