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Reversible Canal Wall Down Surgery and Mastoid Obliteration
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
10 sections · 92 slides
The problem and the concept
- Goal of cholesteatoma surgery
- Canal wall up and canal wall down defined
- Canal wall reconstruction: the concept
- Three approaches compared
How the technique developed
- Origins of mastoid obliteration
- Autologous versus biocompatible materials
- Mercke technique and its outcomes
- Modifications to the Mercke technique
Rationale for canal wall reconstruction
- Advantages of canal wall down surgery
- Disadvantages of canal wall down surgery
- Advantages of preserving the posterior canal wall
- Recidivism after canal wall up surgery
- Causes of recidivism: limited exposure
- Nitrogen-absorbing mucosa and re-retraction
- Rationale for the CWR approach
- Preserved anatomy after reconstruction
Patient selection
- Indications for canal wall reconstruction
- Prior surgery and anatomical considerations
- Conditions that do not contraindicate CWR
- Contraindications
- Preoperative management of active infection
Operative technique
- Operative sequence
- Patient positioning and preparation
- Skin preparation and draping
- Postauricular incision and Palva flap
- Bone pate harvest
- Mastoid tip harvest
- Intact canal wall mastoidectomy
- Exenteration of air cell tracts
- Facial recess and ossicular steps
- Canal wall up mastoidectomy with proposed canal wall cuts
- Elevating the canal skin as an intact sleeve
- Superior canal wall cuts
- Bone cuts for ear canal removal
- Inferior canal wall cut and bevel
- Removal and inspection of the canal wall segment
- Exposure of cholesteatoma after canal wall removal
- Cholesteatoma dissection with enhanced exposure
Reconstruction
- Reconstruction sequence
- Silastic sheeting in the middle ear
- Silastic wedge without stapes superstructure
- Temporalis fascia underlay graft
- Middle ear reconstruction after cholesteatoma removal
- Attic block with mastoid tip cortical bone
- Extent of the attic bone block
- Bone chip blocking the attic
- Replacement of the posterior canal wall
- Replaced canal wall with facial recess bone block
- Obliteration with bone pate
- Mastoid and antrum obliterated with bone pate
- Repositioning the canal skin
- Canal packing and closure
- Canal skin replacement and iodoform packing
Postoperative care
- Perioperative antibiotic management
- Discharge antibiotics and packing removal
- Outpatient follow-up
- Second-look tympanoplasty with ossiculoplasty
Outcomes
- Reported recurrence rates by technique
- Surgical steps critical to disease eradication
- Initial eight-year CWR series
- Long-term series findings
- Management of recidivism in the series
- Five-year follow-up subgroup
- Outcomes in pediatric patients
- Evolution of the attic reconstruction
- Concerns about mastoid obliteration
- Hearing results after CWR
- Secretory otitis media after CWR
Complications
- Graft and prosthesis complications
- Exposed bone in the external auditory canal
- Cerebrospinal fluid leak
- Facial nerve injury
- Wound infection risk
- Measures to prevent wound infection
Summary
- Key principles of CWR tympanomastoidectomy
- Determinants of success
- References
- References (continued)
- References (continued)
- References (continued)
- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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