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C.S.O.M.: Mastoidectomy Dr. Vishal Sharma. Schwartze’s Cortical Mastoidectomy.

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Presentation on theme: "C.S.O.M.: Mastoidectomy Dr. Vishal Sharma. Schwartze’s Cortical Mastoidectomy."— Presentation transcript:

1 C.S.O.M.: Mastoidectomy Dr. Vishal Sharma

2 Schwartze’s Cortical Mastoidectomy

3 Middle ear cleft (Right)

4 Cortical Mastoidectomy

5 Boundaries of cavity Superior: Dural or Tegmen plate Anterior: Posterior wall of external auditory canal Inferior: Digastric ridge Posterior: Sigmoid sinus plate Medially: Lateral semicircular canal

6 Normal temporal bone (right)

7 Cortical Mastoidectomy

8 Indications

9 1.Coalescent mastoiditis & Masked mastoiditis 2.CSOM T.T.D. active refractory to antibiotics 3.Secretory otitis media refractory to antibiotics 4.Approach to:  Endolymphatic sac surgery  Facial nerve decompression  Vestibulo-cochlear nerve section  Translabyrinthine approach for C.P. angle  Cochlear implant surgery  Combined approach tympanoplasty

10 Antiseptic dressing

11 Draping

12 Infiltration with Lignocaine

13 Marking of incision

14 Wilde’s post-aural incision

15 Incision deepened till periosteum

16 Musculo-periosteal flap elevated

17 Bezold’s abscess

18 Aspiration of pus

19 Drainage of abscess

20

21 Corical mastoidectomy begun

22 Exposure of mastoid antrum

23 Widening of aditus

24 Aditus widened

25 Final Cavity (right)

26 Final Cavity (left)

27 Drain put in mastoid cavity

28 Mastoid dressing

29 Healed post-aural scar

30 Treatment for Attico-antral disease

31 Topical ear drops + frequent suction clearance Indications: 1.Early disease with shallow retraction pocket 2.Only hearing ear with cholesteatoma 3.Elderly patients 4.Pts who are not fit for surgery under G.A. 5.Pts who can regularly come for follow up Medical Treatment

32 Canal Wall down: Attico-antrostomy Modified Radical Mastoidectomy (MRM) Radical Mastoidectomy Canal Wall up: Combined Approach Tympanoplasty (CAT) Surgical Treatment

33 Mac Ewan’s triangle

34 Canal Wall Up Mastoidectomy

35 Canal Wall Down Mastoidectomy

36 Middle ear cleft

37 Attico-antrostomy

38 Modified Radical Mastoidectomy

39 Pre-operative Anatomy

40 Cortical Mastoidectomy done

41 Modified Radical Mastoidectomy

42 Surgical Steps

43 Perform cortical mastoidectomy Lower facial ridge & break facial bridge Remove cholesteatoma & granulations from mastoid air cells & middle ear cavity Preserve healthy mucosa, T.M. remnant & ossicles Mastoid cavity & E.A.C. become a single cavity seperated by middle ear cavity Perform tympanoplasty. Do concho-meatoplasty.

44 Antiseptic dressing

45 Draping

46 Infiltration

47

48 Marking of incision

49 Wilde’s post-aural incision

50

51 End-aural incision

52 Incision deepened till periosteum

53

54 Temporalis fascia graft

55 Periosteum incised

56 Periosteal flap elevated

57 Mastoid cortex exposed

58 Posterior canal wall incision

59 Posterior canal wall vascular strip

60 Vascular strip retracted laterally

61 Drill cuts on mastoid cortex

62 Corical mastoidectomy begun

63 Cholesteatoma in mastoid cavity

64 Exposure of mastoid antrum

65 Widening of aditus

66 Aditus widened

67 Cortical mastoidectomy cavity

68

69 Facial ridge lowering started

70 Breaking of facial bridge

71 Elevation of tympanomeatal flap

72

73 Removal of cholesteatoma over lateral SCC

74 Retrofacial & labyrinthine cells removed

75 Incudo-stapedial joint separated

76 Malleus head nipped off

77 Tensor tympani tendon cut

78 Cholesteatoma removal from attic

79 Exposure of sinus tympani

80 ET orifice plugged with malleus head

81 MRM cavity

82 MRM cavity (ossicles preserved)

83 Sites of facial nerve injury

84 Korner’s meatoplasty incision

85 Flap elevated

86 Conchal cartilage cut

87 Flap sutured posteriorly

88 Healed Concho-meatoplasty

89 Post-aural incision closed

90 Radical Mastoidectomy

91

92 Surgical Steps

93 Perform cortical mastoidectomy. Lower facial ridge & break facial bridge. Remove cholesteatoma & granulations from mastoid air cells & middle ear. Remove normal middle ear mucosa, T.M. remnant & ossicles (except stapes footplate). Close Eustachian tube opening. No tympanoplasty done. Concho-meatoplasty performed. Mastoid, E.A.C. & middle ear become single cavity.

94 Indications 1. CSOM attico-antral disease with  Intra-cranial complication  Recurrence after modified radical mastoidectomy  Profound sensori-neural hearing loss (?) 2. Limited malignancy of middle ear 3. Glomus jugulare 4. Osteomyelitis of temporal bone

95 Causes of discharging mastoid cavity

96 1. Inadequate concho-meatoplasty 2. Recurrence of cholesteatoma 3. Residual cholesteatoma: facial ridge, facial bridge, anterior + posterior buttress, mastoid tip, sinus tympani, anterior epitympanum 4. Persistent infection: petrositis, T.B., sinusitis 5. Persistent allergy 6. Retained foreign body: cotton ball 7. Persistent extra-dural abscess 8. Wrong indication

97 Combined Approach Tympanoplasty

98 Surgical Steps 1.Cortical Mastoidectomy 2.Anterior tympanotomy: via tympano-meatal flap 3.Posterior tympanotomy: via facial recess 4.Tympanoplasty

99 Cortical Mastoidectomy

100 Anterior Tympanotomy

101 Posterior Tympanotomy

102 Tympanoplasty

103 Thank You


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