CHRONIC MASTOIDITIS 341
Modifications of the Standard Operation. Dissatisfaction with the prolonged
care of an open mastoid cavity which is exposed to the ravages from external
sources such as washing, hair shampoo, swimming, meatal infection, etc.
has led surgeons to explore means of avoiding this. One of the early methods
was to fill the mastoid cavity with a muscle graft swung on a pedicle from
the temporalis muscle. No meatal flap was cut. This was satisfactory only if
every minute particle of disease had been removed, and it has largely been
Fig, 175. Radical mastoid operation. Korner's meatal plastic. The sharp-pointed tenotomy knife has
been passed through the external meatus and is making the upper cut of the tongue-shaped flap. The
lower cut is indicated by dotted lines.
More recently the combined approach technique has been evolved. At this
operation, performed under the operating microscope, the middle ear is
entered, after mastoid disease has been eradicated, through the bony pos-
terior meatus instead of removing the outer attic wall and the bridge over
the aditus. The posterior meatal wall is left intact and no flap is cut. The
operation is a lengthy one and the facial nerve is at greater risk. Visualiza-
tion of all parts of the middle ear cavity may not readily be made, especially
by those who have not performed many operations by this technique.
Cholesteatoma may not be completely removed around the ossicles, and
it will recur. Such recurrence is more difficult to detect in its early stage
than if the mastoid cavity is fully exposed to view through the window,
and thus is not easily removed without converting the operation to a standard