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EDITORIAL
Year : 2013  |  Volume : 19  |  Issue : 2  |  Page : 49-50

Current trend in mastoid surgery: A vascular consideration


Chief, Indian Institute of Ear Diseases, Resident, Department of E.N.T., Subharti Medical College and University, Meerut, Uttar Pradesh, India

Date of Web Publication15-Jun-2013

Correspondence Address:
Mahendra K Taneja
Chief, Indian Institute of Ear Diseases, Resident, Department of E.N.T., Subharti Medical College and University, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.113499

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How to cite this article:
Taneja MK, Taneja V. Current trend in mastoid surgery: A vascular consideration. Indian J Otol 2013;19:49-50

How to cite this URL:
Taneja MK, Taneja V. Current trend in mastoid surgery: A vascular consideration. Indian J Otol [serial online] 2013 [cited 2018 Nov 20];19:49-50. Available from: http://www.indianjotol.org/text.asp?2013/19/2/49/113499

Otologic surgery can be performed either by postaural, endaural, or permeatal routes. The aim is to provide the patient with a dry, hearing, and trouble free ear; we can achieve our goal by any approach or technique but what about morbidity or success rate of your surgery. Does the retaining of blood supply and lymphatic drainage makes a difference for this we have to understand the blood supply and different incision in ear surgery and what may be the best for our patient.

Three factors contribute to wound healing:

  1. Sterilization or prevention of infection and selecting a suitable antibiotic. One must go for vigorous sterilization and always get a culture sensitivity done in preoperative period. The most susceptible antibiotics recently reported are: Cefoperazon, salbactum, and ciprofloxacin. [1]

    We may not need an antibiotic if we have adequately taken out the disease but augmentation of antibiotic is worth considering. A preoperative antibiotic prevents infection.
  2. Body's immunity to say host defense is important in postoperative period, in general, anemia and factors responsible for Eustachian Catarrah including deficiency of vitamin D should be considered. [2]


The ear gets its blood supply from three vessels: (1) Post auricular artery which is the main feeder and accounts for two-third of its blood supply, hence a post aural incision will lead to hampered blood supply and delayed wound healing. (2) Superficial temporal artery which is going to provide blood supply from anterior side, hence endaural incision to be avoided. These two vessels are going to make a plexus and take care of the vascularity of Pinna. (3) Deep auricular artery which is a branch from external carotid artery enters the ear in deep anterior inferior auditory bony canal wall. We can take its advantage by preserving and utilizing the canal skin as a flap (meatal skin flap) to cover the raw bone postoperatively specially the mastoid cavity.

We need a good access and wide exposure to work deep into the middle ear and mastoid cleft with ease. For attaining this wide exposure, we can do a meatoplasty and/or a conchoplasty at the beginning of surgery and if required we can give a release incision at 12 O'clock position in external auditory canal. After retracting the pinna a horizontal incision is given at cartilage and bony junction beginning from 2°C position to posteriorly 12°C and going up to 5°C position in the right ear, second horizontal incision is given parallel to it, 2 mm lateral to annulus. These two incisions join anteriorly by third incision. Flap created is raised from posterior bony canal wall. This flap is one of the most important steps in vascularization and early wound healing of mastoid cavity.

I am not going to discuss the steps of minimum access mastoidectomy, but certainly I will like to emphasize that superior and posterior wall canaloplasty making the bony auditory canal into an inverted trunk cone is going to make deep working a much easier job. I can say the procedures we do at the end of surgery, that is, canaloplasty and meatoplasty; we can do at the initial stage and access may be much easier without giving any incision or jeopardizing the blood supply and obliteration to lymphatic drainage.

Edema is another factor which can lead to delayed healing and postoperative morbidity. In tympanoplasty, while raising the tympanomeatal flap usually we give an incision from 12°C to 6°C position at place of this we can give incision from 10°C position to 2°C position providing a vascular strip intact leading to early healing. While elevating the tympanomeatal flap annulus we can peal of the fibrous flap from endothelium, this endothelial bed will provide optimum placement of graft and better blood supply. At the time of repositioning the tympanomeatal flap, one should take extra precaution that no blood clot or air is left in between the graft and bone by repeated gentle pressure within outwardly placed gel foam on the bony canal wall. Remember if there is no air or blood between graft, and a meatal bone graft gets a good blood supply resulting in early and better healing. Temporal fascia is a loose connective tissue which requires minimum blood supply; hence acceptance rate may be better.

One may be reluctant to operate in a middle-aged or old person having a mixed deafness, not expecting good results in terms of hearing. I assure if one can take care of the associated factors we can complement him with some improvement in hearing. These associated factors are treating anemia and cessation of smoking which leads to poor mucociliary flow resulting in Eustachian catarrh and mild negative pressure in the middle ear amounting to 5-10 dB hearing loss. Again tobacco chewing is neurotoxic; a withdrawal with supporting treatment of neurotropics must be kept in mind.

Cervical spondyliosis is one of the factor which leads to partial occlusion of vertebral artery; hence shoulder and cervical exercises improve the labyrinthine blood flow.

Vitamin D deficiency is attributed to predisposition of recurrent Upper respiratory tract infection ( urti0 ),  Eustachian tube More Details dysfunction, and osteoporosis of cochlea. It also disturbs calcium channel in cochlear microphonies resulting in decreased generation of action potential, hence cochlear deafness. [3],[4],[5] Finally, I will like to emphasize that if overall care is taken up; Vitamin D deficiency, cessation of smoking, and tobacco chewing, obesity, correction of nasal pathology, and hypothyroidism; the ear surgery specifically tympanoplasty may be as rewarding as cataract surgery.

I conclude; in cholesteatoma cases during surgery if we do a meatoplasty and superior, posterior, and inferior canal wall canaloplasty at the initial stage what we do at the end of surgery, retaining its blood supply by avoiding post aural or endaural incision and creating a post canal wall skin flap to line the mastoid cavity; we are going to provide an early healed, self-draining, trouble free cavity requiring minimum postoperative care and follow-up even in the hands of budding otologist. Also, I like to emphasize the role of systemic factors like anemia, smoking, and vitamin D deficiency in wound healing and need to be addressed seriously.

 
  References Top

1.Kumar S, Sharma R, Saxena A, Pandey A, Gautan G, Taneja V. Bacterial flora of infected unsafe CSOM. Indian J Otol 2012;18:208-11.  Back to cited text no. 1
  Medknow Journal  
2.Taneja MK, Taneja V. Vitamin D deficiency in E.N.T. patients. Indian J Otolaryngol Head Neck Surg 2013;65:57-60.  Back to cited text no. 2
    
3.Taneja MK, Taneja V. Role of ENT surgeons in the National Deafness Program for Prevention and Control of Deafness. Indian J Otol 2012;18:119-21.  Back to cited text no. 3
  Medknow Journal  
4.Taneja MK, Taneja V. Role of vitamin D in prevention of deafness. Indian J Otol 2012;18:55-7.  Back to cited text no. 4
  Medknow Journal  
5.Weir N. Sensorineural deafness associated with recessive hypophosphataemic rickets. J Laryngol Otol 1977;91:717-22.  Back to cited text no. 5
    




 

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