CHRONIC MASTOIDITIS 339
cavity liable to infection and requiring supervision. Additionally good
functional results are difficult to achieve later by tympanoplasty. (6) Closed
techniques—combined approach mastoidectomy avoids the formation of a
cavity and provides better conditions for functional restoration but exposure
of all disease is technically difficult and may on occasion be impossible.
The recurrence rate of cholesteatoma is higher and less easily detected.
The object of this operation is to remove chronic infection, especially chole-
steatoma, from the mastoid cavity and middle ear, and, by creating a window
in the posterior meatal wall, to allow of toilet of the cavity until healing
takes place. The steps of the operation are shown in Fig. 174, and the
incisions in the posterior meatal wall to create a flap of soft tissue to turn
outwards and effect a window are illustrated in Fig. 175.
Once the mastoid cavity has been entered all cholesteatoma is meticulously
removed because any that is overlooked will result in regrowth and a recur-
rence of symptoms. This entails dissection forwards through the mastoid
antrum into the attic. Removal of the outer attic wall and the lateral wall
(bridge) of the aditus exposes the attic and ossicles'. Cholesteatoma and
granulations are removed from this area, and necrosis of the ossicles may
necessitate the removal of the incus and the amputation of the head of the
When the ossicles and tympanic membrane can safely be retained the
operation is one of modified radical mastoid, but when the malleus, incus
and drumhead are sacrificed the operation is called a radical mastoidectomy.
The plastic flap to create a window in the posterior meatal wall is fashioned
in both these operations. The cavity is packed via the external meatus, and
the incision is completely closed. The sutures and pack are removed 1 week
later, and thereafter the cavity is dressed regularly until squamous epithelium
grows into it from the meatal skin, and healing is complete. This takes an
average of 2 months although the patient may be discharged from hospital
in 2 or 3 weeks, and will attend as an outpatient. Healing occurs more
quickly in an adult with an acellular cavity than in a child with a cellular
The aim of the operation is to make the ear safe in that cholesteatoma is
not shut off from inspection via the meatus. Should it recur it may be removed
at a suction clearance using an operating microscope, usually under anaes-
thesia although it may be done in the outpatient department in a suitable
patient. The resulting hearing level depends upon whether the ossicles have
been removed or not. Removal of the incus will cause a loss of at least 50 dB.
ny patients are left with a moist ear, which disappoints them as it requires
cleaning. Some of this catarrh is of Eustachian origin, but some is
• a low-grade infection in the cavity, and it may continue throughout
atal Operation. Many surgeons favour an incision through the
I meatus rather than a postaural one. The operation is then conducted
L the same manner. This approach is particularly useful in those patients
ho have a limited cholesteatoma in an acellular mastoid, but is less satis-
factory in an extensive infection.