C'lin. Ololaryngol. 1992. 17, 280-283
Small cavity mastoidectomy G.D.L.SMYTH & D.S.BROOKER Eye and Ear Clinic, Royal Victoria Hospital, Bevast. Northern Ireland, U K Accepted for publication 7 January 1992 S M Y T H G . D . L . & RROOKER D . S .
(1992) C'lin. Otohryngol. 17, 280-283
Small cavity mastoidectomy Disappointment with thc long-term results of closed operations for ears with extensive cholesteatoma has led to a renewed preference for open techniques. Although the technical advantages provided by magnification and hypotensive anaesthesia have reduced the numbers of unstable post-operative open mastoidectomy cavities, when large, they are still frequently troublesome. Frequently, surgical cavities have been much larger than necessary because of adherence to a traditional approach to the pathologic lesion from its posterior aspect, and the inevitable removal of much normal bone. It is proposed herein that if, instead, bone removal were commenced from the area proximate to the origin of the disease and extended only as far as necessary in order to achieve adequate and effectivc exteriorization of the disease, fewer largc cavities would result and the proportion of stable postoperative ears would be increased. To test this, 100 patients have been treated by atticoantrotomy in which bone lateral to the cholesteatoma sac was removcd from anterior to posterior. The 5-year status of the first 43 patients thus treated supports the view that atticoantrotomy provides a logical, safe and successful means of treating extensive cholestcatoma. Kcywords
cholc.steatorna
small cavity
meutoplasty
Since the introduction of surgical treatment for cholesteatomatous middle ear disease 100 years ago, apart from a bricf period during the 1960s and 1970s when combined approach tympanoplasty (CAT) was preferred by a number of prestigious surgeons in the developed world, the bulk of otologic opinion has favoured techniques which provided permanent exteriorization of the mastoid segment of the tubotympanic cleft. However, although the various forms of open mastoidectomy which have been practised through the years when performed expertly have largely ensured freedom from life threatening complications from cholesteatoma, the propensity for instability in many open post-operative mastoidectomy cavities has given rise to much distress for both patients and surgeons. In the first half of the present century, patients typically found that, having come to hospital with a discharging deaf ear, having endured a major operation and then numerous treatments of the ear, they continue to experience their preoperative symptoms. In order to reduce the post-operative morbidity of open mastoideetomy, many techniques to improve cavity stability have been proposed. These centred on effective removal of irreversibly diseased Correspondence: Mr G.D.L.Smyth, Eye and Ear Clinic, Royal Victoria Hospital, Belfast BTI 2 6BA, Northern Ireland, UK.
280
tissue with a contoured cavity to facilitate epithelial migration, increasing cavity ventilation by meatal enlargement, reducing cavity volume by obliterating the retrofacial area with grafts and implanted materials, and separation of the mesotympanum from the mastoid bowl by means of tympanic membrane repair. Underlying all but the last of these strategies is an awareness of a direct relationship between cavity size and liability to epithelial instability. Increasingly it has been realized that traditional methods of open mastoid surgery frequently inflict patients with cavities much larger than those required to control their disease. Some surgeons, notably Sade,' have advocated a return to the method initially taught by Stacke and subsequently revived by Turnarkin: whereby, instead of approaching the cholesteatoma from its posterior aspect, necessitating the removal of much normal mastoid bone (posterior-anterior approach), the cholesteatoma sac is first exposed at its site of origin in the posterior mesotympanum or epitympanum and followed posteriorly with the removal of only that amount of bone which is necessary for its complete exteriorization (anterior-posterior approach). Thus, because the mastoid process in many cholesteatomatous ears is sclerotic, the resultant cavity is likely to be much smaller than that which is inevitable with standard methods which include first opening the antrum and removing the osseous canal wall.
Small cavity mastoidectomy
Not only does the anterior-posterior technique usually produce a smaller cavity but it is logical in following the disease in the direction of its own progress, and safer because the vital structures, including the ossicles, are encountered early. There is less chance of missing a small antrum altogether because of Korner’s septum, and depth is easier to judge in relation to the tympanic sulcus. It is therefore a safer method to teach.’ An additional advantage of the reversed direction method is that it allows for the repair of a surgical defect in the medial osseous canal wall with tragal or concha1 cartilage when a cholesteatoma sac is found to be limited to the epitympanum. During the past 30 years, in the Eye and Ear Clinic, Royal Victoria Hospital, Belfast, thcrc has been an open-minded attitude to methods of cholesteatoma management. From the results of 10-15 years audits of series of patients in this Clinic having combined approach tympanoplasty, mastoid obliteration with tympanoplasty, and open mastoidectomy with tympanoplasty4 our increasing interest in small cavity mastoidectomy has developed. We were stimulated to evaluate atticoantrotomy as an alternative to closed techniques such as CAT and open mastoidectomy with obliteration and tympanic reconstruction, by discussions with Dr David Austin and Dr Jacob Sade whose published report in 1982 provided an excellent description of the technical details of the procedure attributed to Stacke.’ We found this so helpful that we make no apology for quoting it at length. The operation can be performed through an endaural as well as a post-auricular incision, creating in either case as large as possible a tympano-meatal flap, similar to the one Lempert devised for fenestration. After disinsertion of the annular ligament and the Shrapnel1 membrane, the midddle ear is exposed and cholesteatoma, hypertrophic mucosa, polyps or part of the macerated and infiltrated drum are removed as necessary. It is mostly in the presence of a retraction pocket that parts of the drum have to be sacrificed. Shrapnell’s membrane perforations are at times very small and may need little repair. The bony part of the middle-ear framework, behind which retraction pockets are inclined to reform, is now removed. For this purpose the classical approach, which consists of drilling through the outer mastoid plate, finding the mastoid antrum, enlarging it, creating a bridge and finally removing it-has been abandoned. Instead, we begin by removing the scutum and the would-be bridge or part of the facial ridge, starring in the middle ear, going upwards and posteriorly, as one would d o for an extensive atticotomy. This differs from a regular atticotomy in that here the atticotomy is total, and the whole outer (lateral) attic wall is removed. The antrum (or even the mastoid) is exposed from the tympanic cavity. This approach leaves the smallest mastoid cavity possible, as vision is obtained from the middle ear and there is hardly any need to drill and enlarge the outer mastoid walls.
28 1
Quite often the surgeon is pleasantly surprised to find only a rudimentary antrum. These ears give the best results, as they end in the smallest cavity. Here the tympanomeatal flap, with or without an additional fascia1 underlay, can be replaced over the exposed tegmen and posterior wall, so as to cover much of them. At times I leave a grommet in the drum, but I have never used Silastic. Any ossiculoplasty may be performed right then. Sometimes it is best done in a second stage when, for example, one is not sure of the state of the mucosa or of the stapes itself-or when the surgeon is not sure as to whether every bit of cholesteatoma has been removed from the intra-aural space. Ossiculoplasty is especially important or practical if the stapes is intact. which unfortunately is the case in only 60 percent of the ears. Indeed, in 29 percent only the footplate is left. The remaining 1 1 percent show part of the stapes. There is more than one satisfactory way to bridge the gap from the stapes to the drum or to the malleus. Personally, I like, if possible, to nip off the malleus head and rotate it over the stapes. Finally, hearing results are as good as when the middleear framework is conserved. Epithelialization is rapid, little immediate postoperative care is needed, and the cavity formed when the antrum is rudimentary is finally so small as to be at times hardly recognizable. It is because of this that I have looked upon such ideal cases of very small conservative radicals (modirefraining fied) as “total” or large atticotomies-often from a meatoplasty. One is, of course, not always so fortunate as to encounter a rudimentary antrum. Mastoid sizes vary from hardly any antrum at all to a large-cell or small-cell system extending from the tegmen down to the mastoid tip. Whenever an antrum is present, the facial ridge has to be dealt with, aiming at shaving or removing it. The purpose is to achieve as small as possible, and as round as possible, a self-cleansing cavity. In the presence of a small antrum, this is achieved by shaving part of the upper facial ridge. Initially it was intended that in ears with a sclerotic mastoid (predicted by radiology) the procedure would be performed through a speculum. Because experience showed that the limited access inherent in this method could prevent sufficient removal of laterally located bone, following the 27th operation in the series, an endaural incision was usually employed. However, in spite of the better exposure thus obtained, it was found that in ears with greater than expected pneumatization, ease of removal of the mastoid tip was compromised. As a result a post-aural incision has become routine for all ears. Throughout the series the basic premise to commence bone removal anteriorly at the sulcus tympanicus and proceed posteriorly has been adhered to. Although the method we have used varies little from that of Sade, it does differ in the management of cholesteatoma
282 G.D.L.Smyth und D.S.Brooker
Table 1. Cavity/external auditory meatus status
Excessive wax
Moist accumulation ("0
1
("0)
Atticoantrotomy (n - 43, follow-up 5 years)
Modified radical mastoidectorny (n follow-up mean 7.6 years)
=
4.65
7
4.05
8
74,
of the outer epitympanic wall, cspccially anteriorly lateral to the supratubal region. Our experience tcachcs that rclative to the size of the final cavity and meatus, enlargement of the meatus is often of value and that omission of this stcp may result in a meatoplasty being required subsequently as a further procedure. Because we believe that meatoplasty techniques are often inexpertly performed, we make mention of two we have found successful and easily carried out (Figure 1). The volume of the meatus and cavity (and also the diameter of the meatal orifice) were measured in a randomly selected group of paticnts at thcir 5-year follow-up in order to evaluate the ability or otherwise of atticoantrotomy to provide smaller cavities than modified radical mastoid operations, in which bone removal was performed in a forward direction from a surgically enlarged antrum, previously studied by us!
Results
Figure 1. Meatoplasty incisions. The posterior margin of the meatal orifice is incised down to concha1 cartilage. A skin flap@)is developed by extending this incision posteriorly for 1.O-1.5 cm, either as in (a) Schuknecht' or in (b) Fisch6.After flap elevation, underlying cartilage and soft tissue are widely excised (c). The skin flap@)is rotated medially and held in place with a pack. Suturing is rarely necessary.
matrix. Although we always attempt to remove all keratinizing epithelium from the mesotympanum, either excising it or replacing it on the lateral aspect of the tympanic membrane graft, we do attempt to preserve as much matrix as possible on the medial wall of the epitympanum, aditus and antrum in the expectation that this will accelerate healing. We concur with Sadc on the importance of creating a roundly contoured cavity with smooth outwardly sloping boundaries and attach particular importance to lowering the facial ridge to the level of the meatal floor and removing all
The first 43 in this series of 100 patients have been examined regularly at between 6 and 12-monthly intervals for a minimum of 5 years. Their 5-year status of cavity and external auditory meatus in regard to epithelial instability and excessive wax accumulation is shown in Table 1. Revision operations to correct technical errors at the initial procedure, due to the limited access imposed by the use of a speculum and to a lesser extent with an endaural incision, have been necessary in 8 patients. In 3 ears, lateral osseous overhangs causing keratin accumulations were removed (in 2 ears a meatoplasty was also performed). Also, in 2 ears, a larger than intended surgical cavity with excessive keratin formation required further surgery to lower the facial ridge. Subsequently, these ears have remained stable. In one other ear a secondary meatoplasty was performed to improve cavity epithelial instability (without success), and in another an attic epithelial pearl was removed as an outpatient procedure. The measurements of cavity volume are summarized in Table 2 and compared with those previously reported by us for modified radical operations in this clinic.4 These confirm our expectation of small cavities in ears treated by atticoantrotomy.
Small cavitji mastoidectomy
Table 2. Mean volume (cm’)
A tt icoan t rotomy
Modified radical mastoidectomy
Operated ear
Control ear
1.4 2.4
0.96
0.91
283
sigmoid area and mastoid tip, and to facilitate lowering the facial ridge and removal of the mastoid tip in ears with less than the predicted degree of sclerosis, a post-aural incision has proved its superiority to other means of access.
Conclusions Discussion The results with atticoantrotomy are clearly very similar at 5 years in terms of cavity stability to those we previously reported for 74 patients with modified radical mastoidectomy operations with mean follow-up of 7-6 years, in spite of smaller mean cavity volume. However, it must be said that some revision operations were necessary in order to improve the results to the extent that at 5 years the percentage of intermittently moist ears is similar. Although, for aesthetic reasons. we were influenced by Tumarkin’s description of performing the operation entirely through a speculum, this approach was soon abandoned because of some early failures. Equally, the access provided by an endaural incision may be inadequate if an unexpectedly extensive cellular system is encountered. Clinical observation and the findings at revision operations have convinced us that failure to achieve a stable cavity is usually due to poor surgical technique and can usually be avoided by attention to radical removal of all bone lateral to the cavity combined with adequate ventilation by meatal enlargement. To this end, in order to have sufficient access to unexpected cell extensions in the sinodural angle, retro-
We believe that atticoantrotomy is the most logical current method of treating extensive cholesteatoma in poorly pneumatized ears, provided a post-aural incision is used and bone removal is carried out in an anterior to posterior direction. It has proved to be an elegant procedure and as successful as modified radical mastoidectomy in providing patients with stable ears and offers the added advantages of increased safety and much reduced operating times.
References I SADE J.
2 3
4 5 6
(1982) Treatment of retraction pockets and cholesteatoma. J . Laryngol. Otol. 96, 685-704 TUMARKIN A. (1953) A discussion of the management of chronic otitis media. Proc. R. Soc. Med. 46, 379-384 RICHARDSON A.E.S. (1991) Avoiding a large cavity. Communication to Section of Otology, Royal Society of Medicine, March 1991 TONEKJ.G. & SMYTHG.D.L. (1990) Surgical treatment of cholesteatoma: a comparison of three techniques. Am. J . O/o/. 11, 241-249 SCHUKNECHT H.F. (1964) Tympanoplasty videotape. Richards Manufacturing Co. Inc., No. 2413, file V.A. 208 FISCHU. (1980) Tympanoplasty and Srapedectomy. ThiemeStratton Inc., New York
Small cavity mastoidectomy G.D.L.SMYTH & D.S.BROOKER Eye and Ear Clinic, Royal Victoria Hospital, Bevast. Northern Ireland, U K Accepted for publication 7 January 1992 S M Y T H G . D . L . & RROOKER D . S .
(1992) C'lin. Otohryngol. 17, 280-283
Small cavity mastoidectomy Disappointment with thc long-term results of closed operations for ears with extensive cholesteatoma has led to a renewed preference for open techniques. Although the technical advantages provided by magnification and hypotensive anaesthesia have reduced the numbers of unstable post-operative open mastoidectomy cavities, when large, they are still frequently troublesome. Frequently, surgical cavities have been much larger than necessary because of adherence to a traditional approach to the pathologic lesion from its posterior aspect, and the inevitable removal of much normal bone. It is proposed herein that if, instead, bone removal were commenced from the area proximate to the origin of the disease and extended only as far as necessary in order to achieve adequate and effectivc exteriorization of the disease, fewer largc cavities would result and the proportion of stable postoperative ears would be increased. To test this, 100 patients have been treated by atticoantrotomy in which bone lateral to the cholesteatoma sac was removcd from anterior to posterior. The 5-year status of the first 43 patients thus treated supports the view that atticoantrotomy provides a logical, safe and successful means of treating extensive cholestcatoma. Kcywords
cholc.steatorna
small cavity
meutoplasty
Since the introduction of surgical treatment for cholesteatomatous middle ear disease 100 years ago, apart from a bricf period during the 1960s and 1970s when combined approach tympanoplasty (CAT) was preferred by a number of prestigious surgeons in the developed world, the bulk of otologic opinion has favoured techniques which provided permanent exteriorization of the mastoid segment of the tubotympanic cleft. However, although the various forms of open mastoidectomy which have been practised through the years when performed expertly have largely ensured freedom from life threatening complications from cholesteatoma, the propensity for instability in many open post-operative mastoidectomy cavities has given rise to much distress for both patients and surgeons. In the first half of the present century, patients typically found that, having come to hospital with a discharging deaf ear, having endured a major operation and then numerous treatments of the ear, they continue to experience their preoperative symptoms. In order to reduce the post-operative morbidity of open mastoideetomy, many techniques to improve cavity stability have been proposed. These centred on effective removal of irreversibly diseased Correspondence: Mr G.D.L.Smyth, Eye and Ear Clinic, Royal Victoria Hospital, Belfast BTI 2 6BA, Northern Ireland, UK.
280
tissue with a contoured cavity to facilitate epithelial migration, increasing cavity ventilation by meatal enlargement, reducing cavity volume by obliterating the retrofacial area with grafts and implanted materials, and separation of the mesotympanum from the mastoid bowl by means of tympanic membrane repair. Underlying all but the last of these strategies is an awareness of a direct relationship between cavity size and liability to epithelial instability. Increasingly it has been realized that traditional methods of open mastoid surgery frequently inflict patients with cavities much larger than those required to control their disease. Some surgeons, notably Sade,' have advocated a return to the method initially taught by Stacke and subsequently revived by Turnarkin: whereby, instead of approaching the cholesteatoma from its posterior aspect, necessitating the removal of much normal mastoid bone (posterior-anterior approach), the cholesteatoma sac is first exposed at its site of origin in the posterior mesotympanum or epitympanum and followed posteriorly with the removal of only that amount of bone which is necessary for its complete exteriorization (anterior-posterior approach). Thus, because the mastoid process in many cholesteatomatous ears is sclerotic, the resultant cavity is likely to be much smaller than that which is inevitable with standard methods which include first opening the antrum and removing the osseous canal wall.
Small cavity mastoidectomy
Not only does the anterior-posterior technique usually produce a smaller cavity but it is logical in following the disease in the direction of its own progress, and safer because the vital structures, including the ossicles, are encountered early. There is less chance of missing a small antrum altogether because of Korner’s septum, and depth is easier to judge in relation to the tympanic sulcus. It is therefore a safer method to teach.’ An additional advantage of the reversed direction method is that it allows for the repair of a surgical defect in the medial osseous canal wall with tragal or concha1 cartilage when a cholesteatoma sac is found to be limited to the epitympanum. During the past 30 years, in the Eye and Ear Clinic, Royal Victoria Hospital, Belfast, thcrc has been an open-minded attitude to methods of cholesteatoma management. From the results of 10-15 years audits of series of patients in this Clinic having combined approach tympanoplasty, mastoid obliteration with tympanoplasty, and open mastoidectomy with tympanoplasty4 our increasing interest in small cavity mastoidectomy has developed. We were stimulated to evaluate atticoantrotomy as an alternative to closed techniques such as CAT and open mastoidectomy with obliteration and tympanic reconstruction, by discussions with Dr David Austin and Dr Jacob Sade whose published report in 1982 provided an excellent description of the technical details of the procedure attributed to Stacke.’ We found this so helpful that we make no apology for quoting it at length. The operation can be performed through an endaural as well as a post-auricular incision, creating in either case as large as possible a tympano-meatal flap, similar to the one Lempert devised for fenestration. After disinsertion of the annular ligament and the Shrapnel1 membrane, the midddle ear is exposed and cholesteatoma, hypertrophic mucosa, polyps or part of the macerated and infiltrated drum are removed as necessary. It is mostly in the presence of a retraction pocket that parts of the drum have to be sacrificed. Shrapnell’s membrane perforations are at times very small and may need little repair. The bony part of the middle-ear framework, behind which retraction pockets are inclined to reform, is now removed. For this purpose the classical approach, which consists of drilling through the outer mastoid plate, finding the mastoid antrum, enlarging it, creating a bridge and finally removing it-has been abandoned. Instead, we begin by removing the scutum and the would-be bridge or part of the facial ridge, starring in the middle ear, going upwards and posteriorly, as one would d o for an extensive atticotomy. This differs from a regular atticotomy in that here the atticotomy is total, and the whole outer (lateral) attic wall is removed. The antrum (or even the mastoid) is exposed from the tympanic cavity. This approach leaves the smallest mastoid cavity possible, as vision is obtained from the middle ear and there is hardly any need to drill and enlarge the outer mastoid walls.
28 1
Quite often the surgeon is pleasantly surprised to find only a rudimentary antrum. These ears give the best results, as they end in the smallest cavity. Here the tympanomeatal flap, with or without an additional fascia1 underlay, can be replaced over the exposed tegmen and posterior wall, so as to cover much of them. At times I leave a grommet in the drum, but I have never used Silastic. Any ossiculoplasty may be performed right then. Sometimes it is best done in a second stage when, for example, one is not sure of the state of the mucosa or of the stapes itself-or when the surgeon is not sure as to whether every bit of cholesteatoma has been removed from the intra-aural space. Ossiculoplasty is especially important or practical if the stapes is intact. which unfortunately is the case in only 60 percent of the ears. Indeed, in 29 percent only the footplate is left. The remaining 1 1 percent show part of the stapes. There is more than one satisfactory way to bridge the gap from the stapes to the drum or to the malleus. Personally, I like, if possible, to nip off the malleus head and rotate it over the stapes. Finally, hearing results are as good as when the middleear framework is conserved. Epithelialization is rapid, little immediate postoperative care is needed, and the cavity formed when the antrum is rudimentary is finally so small as to be at times hardly recognizable. It is because of this that I have looked upon such ideal cases of very small conservative radicals (modirefraining fied) as “total” or large atticotomies-often from a meatoplasty. One is, of course, not always so fortunate as to encounter a rudimentary antrum. Mastoid sizes vary from hardly any antrum at all to a large-cell or small-cell system extending from the tegmen down to the mastoid tip. Whenever an antrum is present, the facial ridge has to be dealt with, aiming at shaving or removing it. The purpose is to achieve as small as possible, and as round as possible, a self-cleansing cavity. In the presence of a small antrum, this is achieved by shaving part of the upper facial ridge. Initially it was intended that in ears with a sclerotic mastoid (predicted by radiology) the procedure would be performed through a speculum. Because experience showed that the limited access inherent in this method could prevent sufficient removal of laterally located bone, following the 27th operation in the series, an endaural incision was usually employed. However, in spite of the better exposure thus obtained, it was found that in ears with greater than expected pneumatization, ease of removal of the mastoid tip was compromised. As a result a post-aural incision has become routine for all ears. Throughout the series the basic premise to commence bone removal anteriorly at the sulcus tympanicus and proceed posteriorly has been adhered to. Although the method we have used varies little from that of Sade, it does differ in the management of cholesteatoma
282 G.D.L.Smyth und D.S.Brooker
Table 1. Cavity/external auditory meatus status
Excessive wax
Moist accumulation ("0
1
("0)
Atticoantrotomy (n - 43, follow-up 5 years)
Modified radical mastoidectorny (n follow-up mean 7.6 years)
=
4.65
7
4.05
8
74,
of the outer epitympanic wall, cspccially anteriorly lateral to the supratubal region. Our experience tcachcs that rclative to the size of the final cavity and meatus, enlargement of the meatus is often of value and that omission of this stcp may result in a meatoplasty being required subsequently as a further procedure. Because we believe that meatoplasty techniques are often inexpertly performed, we make mention of two we have found successful and easily carried out (Figure 1). The volume of the meatus and cavity (and also the diameter of the meatal orifice) were measured in a randomly selected group of paticnts at thcir 5-year follow-up in order to evaluate the ability or otherwise of atticoantrotomy to provide smaller cavities than modified radical mastoid operations, in which bone removal was performed in a forward direction from a surgically enlarged antrum, previously studied by us!
Results
Figure 1. Meatoplasty incisions. The posterior margin of the meatal orifice is incised down to concha1 cartilage. A skin flap@)is developed by extending this incision posteriorly for 1.O-1.5 cm, either as in (a) Schuknecht' or in (b) Fisch6.After flap elevation, underlying cartilage and soft tissue are widely excised (c). The skin flap@)is rotated medially and held in place with a pack. Suturing is rarely necessary.
matrix. Although we always attempt to remove all keratinizing epithelium from the mesotympanum, either excising it or replacing it on the lateral aspect of the tympanic membrane graft, we do attempt to preserve as much matrix as possible on the medial wall of the epitympanum, aditus and antrum in the expectation that this will accelerate healing. We concur with Sadc on the importance of creating a roundly contoured cavity with smooth outwardly sloping boundaries and attach particular importance to lowering the facial ridge to the level of the meatal floor and removing all
The first 43 in this series of 100 patients have been examined regularly at between 6 and 12-monthly intervals for a minimum of 5 years. Their 5-year status of cavity and external auditory meatus in regard to epithelial instability and excessive wax accumulation is shown in Table 1. Revision operations to correct technical errors at the initial procedure, due to the limited access imposed by the use of a speculum and to a lesser extent with an endaural incision, have been necessary in 8 patients. In 3 ears, lateral osseous overhangs causing keratin accumulations were removed (in 2 ears a meatoplasty was also performed). Also, in 2 ears, a larger than intended surgical cavity with excessive keratin formation required further surgery to lower the facial ridge. Subsequently, these ears have remained stable. In one other ear a secondary meatoplasty was performed to improve cavity epithelial instability (without success), and in another an attic epithelial pearl was removed as an outpatient procedure. The measurements of cavity volume are summarized in Table 2 and compared with those previously reported by us for modified radical operations in this clinic.4 These confirm our expectation of small cavities in ears treated by atticoantrotomy.
Small cavitji mastoidectomy
Table 2. Mean volume (cm’)
A tt icoan t rotomy
Modified radical mastoidectomy
Operated ear
Control ear
1.4 2.4
0.96
0.91
283
sigmoid area and mastoid tip, and to facilitate lowering the facial ridge and removal of the mastoid tip in ears with less than the predicted degree of sclerosis, a post-aural incision has proved its superiority to other means of access.
Conclusions Discussion The results with atticoantrotomy are clearly very similar at 5 years in terms of cavity stability to those we previously reported for 74 patients with modified radical mastoidectomy operations with mean follow-up of 7-6 years, in spite of smaller mean cavity volume. However, it must be said that some revision operations were necessary in order to improve the results to the extent that at 5 years the percentage of intermittently moist ears is similar. Although, for aesthetic reasons. we were influenced by Tumarkin’s description of performing the operation entirely through a speculum, this approach was soon abandoned because of some early failures. Equally, the access provided by an endaural incision may be inadequate if an unexpectedly extensive cellular system is encountered. Clinical observation and the findings at revision operations have convinced us that failure to achieve a stable cavity is usually due to poor surgical technique and can usually be avoided by attention to radical removal of all bone lateral to the cavity combined with adequate ventilation by meatal enlargement. To this end, in order to have sufficient access to unexpected cell extensions in the sinodural angle, retro-
We believe that atticoantrotomy is the most logical current method of treating extensive cholesteatoma in poorly pneumatized ears, provided a post-aural incision is used and bone removal is carried out in an anterior to posterior direction. It has proved to be an elegant procedure and as successful as modified radical mastoidectomy in providing patients with stable ears and offers the added advantages of increased safety and much reduced operating times.
References I SADE J.
2 3
4 5 6
(1982) Treatment of retraction pockets and cholesteatoma. J . Laryngol. Otol. 96, 685-704 TUMARKIN A. (1953) A discussion of the management of chronic otitis media. Proc. R. Soc. Med. 46, 379-384 RICHARDSON A.E.S. (1991) Avoiding a large cavity. Communication to Section of Otology, Royal Society of Medicine, March 1991 TONEKJ.G. & SMYTHG.D.L. (1990) Surgical treatment of cholesteatoma: a comparison of three techniques. Am. J . O/o/. 11, 241-249 SCHUKNECHT H.F. (1964) Tympanoplasty videotape. Richards Manufacturing Co. Inc., No. 2413, file V.A. 208 FISCHU. (1980) Tympanoplasty and Srapedectomy. ThiemeStratton Inc., New York
