|Year : 2011 | Volume
| Issue : 1 | Page : 26-29
Tympanomastoid obliteration for recalcitrant attico-antral chronic suppurative otitis media
C Preetam, Rohit Verma, Alok Thakar, Kapil Sikka
Department of Otorhinolaryngology and Head and Neck Surgery, AIIMS, New Delhi, India
|Date of Web Publication||11-Oct-2011|
Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi-110 029
Source of Support: None, Conflict of Interest: None
Though the standard canal wall up and canal wall down mastoidectomies provide for reliable disease removal and good functional outcome in most cases with atticoantral chronic suppurative otitis media (CSOM), few cases remain unresponsive to such treatment. This report describes the application of tympanomastoid obliteration with blind sac closure of the EAC as a surgical technique for recurrent CSOM persisting despite multiple previous surgical treatments. Though maximal conductive deafness is an inevitable consequence of this procedure, such morbidity may even otherwise be inevitable in this clinical situation, as scarring and destruction consequent to disease and previous surgical treatments often lead to clinical situations not amenable to tympanoplasty and hearing reconstruction. Further concerns of recurrent epithelial pearls and implantation cholesteatoma can be currently addressed by follow-up MR scanning.
Keywords: Recurrent chronic suppurative otitis media, Tympanomastoid obliteration, External auditory canal closure
|How to cite this article:|
Preetam C, Verma R, Thakar A, Sikka K. Tympanomastoid obliteration for recalcitrant attico-antral chronic suppurative otitis media. Indian J Otol 2011;17:26-9
|How to cite this URL:|
Preetam C, Verma R, Thakar A, Sikka K. Tympanomastoid obliteration for recalcitrant attico-antral chronic suppurative otitis media. Indian J Otol [serial online] 2011 [cited 2019 Apr 20];17:26-9. Available from: http://www.indianjotol.org/text.asp?2011/17/1/26/85798
| Introduction|| |
The standard treatment for the attico antral type of chronic suppurative otitis media (CSOM) remains a mastoidectomy. It provides for reliable and consistent eradication of disease and amelioration of symptoms. The choice between a canal wall up (CWU) or canal wall down (CWD) mastoidectomy is guided by both patient and surgeon factors. The CWD procedure creates a large cavity that takes longer to heal and produces an extensive anatomical modification to which the patient must adapt. However, the detection of recurrences is easily done through direct inspection of the cavity.  The CWU procedure has the advantages of preserving the external-ear and mastoid anatomy, and further requires a very short healing period.  However, the recurrence rates are much higher in the CWU procedure as compared with the CWU procedure 24-51% , VS 4-6%. ,,
The concept of mastoid obliteration was first introduced in 1911 by Mosher to promote the healing of a mastoidectomy defect after CWD mastoidectomy.  The vast majority of obliteration techniques consist of either local flaps (muscle, periosteum, or fascia) or free grafts (bone, cartilage, hydroxyapatite, etc.).  Obliteration of the mastoid segment ameliorated many of the problems of CWD mastoidectomy relating to recurrent retention of debris and subsequent infection and discharge, dizziness associated with thermal stimulation of the exposed lateral semicircular canal, and the need for water precautions and for periodic physician review and cleaning of the mastoid cavity. However, despite mastoid obliteration some cases still continue to get recurrent infections and to eliminate this problem, Rambo, in 1958, proposed a radical procedure consisting of canal wall down mastoidectomy, closure of the Eustachian tube More Details, obliteration of the tympanomastoid cavity with fat tissue and closure of the meatal orifice of the external-ear canal.  Such surgery may be proposed to those patients with ears retaining no useful hearing and for whom conventional treatments have not produced or maintained a dry and self-cleaning cavity. 
This report details a case of the troublesome open cavity with recurrent infection treated by radical disease clearance, eustachian tube opening obliteration, and the blind sac external auditory canal closure (Rambo operation). The advantages and limitations of such an approach in the context of modern imaging and the reconstructive techniques available are discussed, to formulate the probable indications and contraindications for the procedure.
| Case Report|| |
A 16-year-old female with history of left-ear discharge and impairment of hearing for 3 years was operated by her local ENT practitioner. She initially had a myringoplasty in April 2007 and subsequently a modified radical mastoidectomy with type2 tympanoplasty for persistent discharge in August 2007. Subsequent to this, the patient continued to have persistent discharge and also developed ipsilateral sensorineural hearing loss. In August 2008, she had another revision mastoidectomy and histological evaluation of the mastoid epithelium indicated chronic inflammatory granulation tissue. The otorrhea persisted and a further presumptive course of antitubercular therapy was prescribed but to no avail. The patient was then referred to our facility for further management of persistent ear discharge.
On clinical evaluation, the patient's left external auditory canal was completely filled with granulation tissue and purulent discharge. Hearing evaluation indicated left sided profound sensori-neural hearing loss, with normal right sided hearing. Examination of the nasopharynx and nasal cavity was normal, as was the rest of the otorhinolaryngological evaluation. Specific attention was focused at all the listed causes of recurrent-ear discharge following mastoidectomy as enumerated in [Table 1].
|Table 1: Causes of recurrent ear discharge following canal wall down mastoidectomy|
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Further evaluation included histological and radiological evaluations. Biopsy from the mastoid tissue demonstrated acute inflammatory granulation tissue with no suggestion of granulomas. High resolution CT (HRCT) of the temporal bone showed a postoperative cavity with no ossicles and a possible lateral semicircular canal fistula along with soft tissue in the middle ear [Figure 1] and [Figure 2]. The petrous apex was normal and symmetrical and further no erosion was noted at the dural plate, sinus plate, and Fallopian canal More Details.
|Figure 1: High-resolution CT (HRCT- coronal section) of the temporal bone showing a postoperative cavity with no ossicles and a possible lateral semicircular canal fistula along with soft tissue in the middle ear|
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|Figure 2: High-resolution CT (HRCT- axial section) of the temporal bone showing a postoperative cavity with no ossicles and a possible lateral semicircular canal fistula along with soft tissue in the middle ear|
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A revision mastoid exploration was planned. Since clinical, laboratory, and radiological evaluation had not pinpointed a specific cause, the major differential diagnosis at the time of undertaking surgery included deep bony osteitis, tuberculosis, or a tendency toward inadequate healing (ie, exuberant granulations/exuberant fibrosis and keloid formation).
The patient underwent left-ear radical mastoidectomy with complete tympanomastoid obliteration, along with closure of external auditory canal in August 2009. A postauricular incision was used and overhanging edges of cavity were smoothened, the dural and sinus plate were delineated, the facial ridge was partly lowered and granulations were cleared from the mastoid cavity, attic and middle ear after identifying the tympanic segment of facial nerve with the help of a facial nerve monitor. The tympanic segment was found to be dehiscent anteriorly and was enclosed by granulations all along its course, which were cleared carefully avoiding trauma to the nerve. With the help of the nerve stimulator, the vertical segment was also identified and cleared of granulations. A complete radical mastoidectomy was performed and eustachian tube was obliterated with bone dust and the mastoid cavity with abdominal fat. The external auditory canal was sectioned and its skin everted and closed in a blind sac, along with reinforcement by a periosteal flap.
The patient had an uneventful postoperative recovery with rapid healing of the postauricular and EAC suture lines. Histological evaluation of the surgical tissue excised from the tympanomastoid cavity indicated only inflammatory granulation tissue with no evidence of any chonic granulomatous disease. No further episodes of discharge have been noted over a follow up period of 1 year. A radiological evaluation (MRI - delayed gadolinium enhanced, T1- weighted sequence in combination with nonecho planar imaging, diffusion weighted sequences) at 1 year of follow up showed no evidence of recurrence and the patient is further scheduled after 18 months for a repeat scan.
| Discussion|| |
A CWD mastoidectomy remains the standard surgical procedure for cases with attico-antral chronic suppurative otitis media. Recurrent or persistent-ear discharge following a mastoidectomy is however not uncommon. This can be consequent to the nature of the disease process (granulomatous inflammation/osteitis/osteomyelitis), or consequent to the anatomical limitations to complete disease clearance and mucosal clearance posed by the crowded vital structures in the temporal bone. Technical inadequacies in the surgical procedure, and the vagaries of healing in the postoperative period, are probably the most frequent causes of persistent discharge. [Table 1] lists the common causes of persistent discharge following mastoid surgery. However, despite attention to all the technical factors as listed, there continues to remain cases wherein a dry ear is not achieved with the usual treatment administered.
The mere performance of a CWD mastoidectomy, and exteriorization of the mastoid bowl does not lead to the achievement of a "safe" ear.  Complications consequent to CSOM are not necessarily related to the type of CSOM- tubotympanic or attico-antral, but primarily to the presence or absence of ear discharge. Persistent ear discharge following mastoidectomy continues to pose risks of intracranial complications and therefore needs aggressive treatment. ,
This report presents the successful utilization of complete mastoid obliteration for a case with recurrent otitis media and persistent-ear discharge despite three previous surgical operations. This surgical option is demonstrated to be successful in achieving a dry ear in the majority of cases with none of the vagaries of healing of secondary intention as are inevitable in conventional CWD mastoidectomy. The obliteration option however runs the risk of embedding epithelium or mucosa, or infection in the closed mastoid space so created, with a potential for delayed complications. Therefore, it is not used as a first line option, but is indicated in situations where in the conventional options like radical or modified radical mastoidectomy have not proved successful in providing a dry ear.
At the time when this operation was initially proposed (1958), there was significant concerns about the residual epithelium or mucosa which would be buried in the mastoid cavity and could lead to subsequent complications and suppuration, particularly in a well-pneumatized temporal bone, wherein it may be impossible to remove mucosal or epithelial invaginations in the peripheral cells insinuated in the perilabyrinthine or retrofacial cell tracts. Current surgical techniques and surgical armamentarium such as magnification and high-speed drills do ensure better disease excision, but concerns of residual mucosal or epithelial disease being left behind do remain.
The recent development of imaging techniques (MRI: delayed gadolinium enhanced, T1: weighted sequence in combination with non-echo planar imaging, diffusion weighted sequences) as development for the detection of cholesteatoma following CWU techniques, can however also be applied in this situation for early detection of residual epithelium progression to cholesteatoma. In this, particular patient being reported, an MR evaluation at 1-year postsurgery demonstrated no residual/recurrent cholesteatoma. A repeat MR is planned after another 18 months or earlier if indicated.
Further the surgical option of cavity obliteration and sealing of the ET and EAC necessarily leads to a maximal conductive hearing loss. In this particular case under report, this was not of consequence due to the associated sensori-neural hearing loss, but this can be consequential in other situations and especially if the other ear too has subnormal hearing. However, in the setting of cases with recurrent otorrhea persisting despite multiple-ear surgeries, it is often the case that the local pathology and the poor eustachian tube function render the situation to be less than ideal for a reconstructive tympanoplasty, and a significant degree of conductive deafness may have to be accepted even with other surgical options.
Though many materials have been proposed for obliteration, fat has been of particular interest due its inherent properties, which may be the cause for low complication rate associated with use of fat. Fat tissue is not inert; it stores macrophages, which participate in inflammation and the immune reaction. Fat tissue also stores a high proportion of lymphocytes which, along with macrophages, can lead to immune regulation. ,,, Also fat provides a ready contrast medium in postoperative fat suppression and diffusion sequences on the MRI scan, which provides a very adequate method to detect recurrence.  An initial scan is usually done 1-year postoperatively, followed by 3, 5, and 10 years. 
Kos et al.,  have reported the long-term surgical results of 46 such operations undertaken in their institution, whose data were evaluated retrospectively. On follow up (mean 8 years) 7/46 had abscess formation and 4 had recurrent cholesteatoma requiring surgical management. Sanna et al.,  however noted a much lower rate of complications in a series of 53 cases, and noted recurrence, postaural fistula and complete SNHL in only one patient each. These authors have attributed their success to good antibiotic prophylaxis and the meticulous surgical technique. It has been hypothesized that the surgeon performing the Rambo operation does not have to preserve hearing and therefore can be as radical as necessary. Another explanation for the low incidence of complications is the obliteration of the cavity with fat tissue, which may act as an antiseptic agent and may also impede the growth of epithelial and mucous linings.  Kos et al.,  have also noted that 13% patients were unsatisfied with the surgery despite good relief of otorrhea, suggesting that a proper selection of patients is also of prime importance. The causes of dissatisfaction were attributed to the poor understanding of the disease which necessitated the operation, unrealistic expectations regarding surgical results, and the impossibility of recovering a useful hearing level. 
| Conclusion|| |
Though most cases of CSOM are managed by conventional measures, some patients have recurrent infection of the cavity warranting multiple treatment episodes. In such cases complete tympanomastoid obliteration with fat obliteration and EAC blind sac closure (Rambo operation) is a surgical option with a high success rate. Concerns of burying epithelium, and of subsequent silent and buried recurrent/residual cholesteatoma can be currently addressed by specific MR scanning for follow-up evaluations. Informed counseling of the patient with regard to significant conductive hearing loss and also the need for follow-up MR evaluations is however imperative.
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[Figure 1], [Figure 2]