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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 24  |  Issue : 3  |  Page : 194-198

Mastoid cavity obliteration using bone pate and ribbon-like temporalis muscle flap: Our experience


Department of ENT, Shri Guru Ram Rai Institute of Medical Sciences, Dehradun, Uttarakhand, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. V P Singh
Department of ENT, Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_36_18

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  Abstract 


Objective: The aim of this study was to elucidate a mix of bone pate with ribbon-like temporalis muscle flap for mastoid cavity obliteration after mastoid surgery to avoid mastoid cavity problems. Materials and Methods: In 54 patients of unsafe chronic suppurative otitis media, canal wall down mastoidectomy was done, size of the cavity assessed and ribbon-like temporalis muscle flap with bone pate used for mastoid cavity obliteration. Follow-up was done at 3 weeks, 3 months and then at 6 months. Results: Dry cavity with success rate of 83% is achieved with temporalis muscle flap technique of mastoid cavity obliteration. Conclusion: A mix of bone pate to obliterate the small spaces in the mastoid cavity along with a ribbon-like temporalis muscle flap is effective method of mastoid cavity obliteration as it gives a dry ear, is not bulky and most importantly maintains the canal.

Keywords: Cavity obliteration, chronic suppurative otitis media, temporalis muscle flap


How to cite this article:
Bansal C, Singh V P, Varma A. Mastoid cavity obliteration using bone pate and ribbon-like temporalis muscle flap: Our experience. Indian J Otol 2018;24:194-8

How to cite this URL:
Bansal C, Singh V P, Varma A. Mastoid cavity obliteration using bone pate and ribbon-like temporalis muscle flap: Our experience. Indian J Otol [serial online] 2018 [cited 2019 Mar 22];24:194-8. Available from: http://www.indianjotol.org/text.asp?2018/24/3/194/249872




  Introduction Top


Unsafe chronic suppurative otitis media (CSOM) is traditionally treated with surgery. The surgery is usually an open cavity mastoidectomy (Modified Radical Mastoidectomy [MRM]) or canal wall down surgery. At a conservative estimate, 20% of postoperative ears stay wet. To create a good self-cleansing, dry cavity apart from the low facial ridge, the secret is the match between the cavity size and the meatoplasty. However, there is a cosmetic limit to the size of the meatoplasty that can be done. At times, it is felt that the meatoplasty will be actually inadequate in a very large postoperative mastoid cavity. The only answer is to decrease the size of the postoperative mastoid cavity. This is done by cavity obliteration.

Obliteration is a technique which obliterates the cavity and promotes healing by decreasing the surface area to be epithelialized. Materials and flaps are usually used for the obliteration. The materials which have been tried are blood clot, cartilage, bone chips, bone pate, inert glass beads, bone wax, and hydroxyapatite among other materials. The variety of flaps devised for obliteration are also numerous. However, all the flaps which are required for adequate obliteration are usually too bulky, or they are unable to reach the depths of the cavity including the mastoid tip. This study is aimed to describe a ribbon-like temporalis muscle flap for mastoid cavity obliteration and its results discussed.


  Materials and Methods Top


A total 54 patients underwent mainly revision mastoidectomy using postaural approach from July 2011 to Jun 2014. Inclusion criteria were patients undergoing MRM for unsafe disease with or without complication, facial nerve decompressions, and in revision cases (discharging ears post-MRM). Exclusion criteria were safe CSOM. Using a retroauricular approach, an extended retroauricular incision in shape of lazy S extending into the temporal region is given [Figure 1]. Temporalis fascia is widely exposed and graft taken [Figure 2]. Starting with the mastoid cortex bone removed with a drill, the bone dust is collected from the initial drilling. Canal wall down mastoidectomy is done and the size of the cavity assessed. Area or extent of obliteration is assessed. Small deep cells or pockets are eradicated or obliterated using the bone paste [Figure 3]. A ribbon-like temporalis flap is created whose length is as per the requirement [Figure 4], [Figure 5], [Figure 6]. The ribbon-like flap is placed into the cavity as required [Figure 7]. Fascia is placed in the middle ear and extending over the muscle flap. Meatoplasty is done and ensured that the skin flaps cover the fascia. An antibiotic pack is placed in the canal. A normal mastoid dressing done which is removed after 48 h. Sutures are removed after 7 days. The ear pack is removed after 3 weeks. Follow-up is done at 3 weeks, 3 months, and then at 6 months [Figure 8] and results analyzed.
Figure 1: An extended retroauricular incision in shape of lazy S

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Figure 2: Temporalis fascia with muscle is widely exposed and graft taken

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Figure 3: Small deep cells or pockets are obliterated using the bone paste

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Figure 4: Incision outline

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Figure 5: Incision outlined on patient

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Figure 6: Raised temporalis muscle flap

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Figure 7: Flap being placed into the cavity

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Figure 8: Postoperative result

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Statistical analysis

The data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences package version 21.0 (IBM Inc., Chicago, IL, USA) for relevant statistical comparisons. Results are presented in the form of tables and graphs. The categorical variables are summarized as frequencies and percentages. Inferential statistics were done using the Chi-square test for the categorical variables. Level of statistical significance was set at P ≤ 0.05.

Informed written consent

Informed written consent was taken from all the patients involved both for treatment as well as for any documentation/presentation/publication/data analysis.

Institutional ethics committee clearance

The study is done as per the clearance and guidelines of our Institutional Ethics Committee (letter enclosed).


  Results Top


A total of 54 cases of mastoid cavity obliteration were done in the past 3 years using ribbon-like temporalis muscle flap. The distributions of these cases are as below:

Primary obliteration in unsafe CSOM 03

Revision surgery and obliteration in a wet ear 28

Unsafe CSOM with erosion of the tegmen tympani 08

Unsafe CSOM with lateral sinus thrombosis 06

VII nerve exploration with Canal Wall Down approach 04

Cerebrospinal spinal fluid otorrhoea and brain fungus 03

Mastoid tip obliteration (Bezold abscess) 02

Total 54

At the end of 3 months, 45 ears were dry [Table 1]. 9 had persistent discharging ear which had to be revised. The cause was an inadequate meatoplasty. At the end of 6 months, only one ear was wet. Two cases had a narrow meatus with a bulky posterior wall 2 (though dry). In addition to these, 7 cases had granulations near the meatoplasty which required repeated sittings of chemical cautery. On assessment, after 3 months, 52 cases had mild-to-moderate deafness. Two cases had developed sensory neural hearing loss (caused by? drilling).
Table 1: Postoperative results

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  Discussion Top


Canal wall down mastoidectomy has been the backbone in the treatment of unsafe ear disease. None the less this surgery leads to the creation of a mastoid cavity which is abnormal and anatomically and physiologically unacceptable. The causes of persistent otorrhea was given by Sade in his article as high facial ridge, large cavity, small meatus causing incomplete drainage, tympanic membrane perforation leaving middle ear mucosa, and  Eustachian tube More Details opening open to the discharging cavity and inadequate clearance of the disease. In addition, an open cavity[1],[2] also leads to chronic ear discharge with incidence being 20%–53%, regular hospital visits for ear cleaning, vertigo due to exposure of semicircular canals to direct caloric stimulation by air/water entering the cavity, ugly appearance due to large meatoplasty and hindrance in fitting the hearing aids. This is the long-term results in patient dissatisfaction. An ideal mastoid cavity should be

  • Small
  • Well saucerized
  • With no sumps and ridges
  • With adequately lowered facial ridge
  • With adequate meatus for drainage
  • With intact tympanic membrane or closed air-filled middle ear which isolates eustachian tube opening from the canal and the mastoid cavity.


This is difficult to do in all the primary surgeries as removal of the disease is the primary aim. However, as a secondary surgery, it can be achieved by mastoid cavity obliteration. Obliteration of the mastoid cavity is usually done in

  • A large mastoid cavity resulting from disease in a well-pneumatized ear, resulting in a very large cavity. In these cases, an adequate meatoplasty would result in an unsightly cymba concha
  • Dura exposed in the tegmen tympani
  • In CSF otorrhea with a dural defect
  • A chronically discharging ear for revision surgery
  • Sigmoid sinus exposed in the sinus plate
  • Obliteration of the mastoid tip
  • To avoid the formation of a sump
  • To decrease the volume of the ear for fitting of a hearing aid.


Raising of the muscle flap was initially used to close postauricular fistulas, but subsequently used to obliterate the mastoid cavity. In 1911, Musher was the first to conceptualize the technique of mastoid cavity obliteration to enhance early healing of mastoid defect.[3] Over the past 2–3 decades, various materials, flaps, and techniques have evolved for mastoid cavity obliteration. These flaps are can be pedicled muscle flaps which are largely superiorly based, inferiorly based or anteriorly based. Most of these flaps are bulky and cannot obliterate in depth, i.e., the attic or the mastoid tip especially anterior and inferior flaps. At times, these also leave a very narrow canal wall which is not self-cleaning. Materials ranging from biological as well as alloplastic have been used for mastoid cavity obliteration.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] Each of the methods has advantages and disadvantages. Biological materials, including cartilage,[13] bone, fat, and various flaps, are resistant to infection but have the disadvantage of resorption, atrophy, curvature, difficulty in sculpturing, and donor site morbidity. The most popular of these all is the muscle flap and various flaps have been devised over the years. A few examples are the Palva flap, Korner flap, and Guilford flap for the mastoid tip among others whereas alloplastic materials, including hydroxyapatite and bone wax, have the advantages of being easily available, no resorption and no donor site morbidity; Out of all the alloplastic materials used, hydroxyapatite has been the most successfully used, but has been associated with the risk of infection and exposure.[10] Some of the materials used result in a foreign body reaction which requires reoperation and removal of the material.

Requirement of an ideal muscular flap is as follows:

  • Conveniently accessible from the surgical site
  • Which is versatile
  • Is reasonably robust
  • Can be adjusted to the situation
  • It should have a good long-term prospect
  • Easily harvestable
  • With a good blood supply
  • With adequate material present
  • Is not too bulky.


A thin temporalis muscle flap is usually based on the superficial temporal artery, is ribbon-like and has a more than adequate length. It is versatile and flexible. Donor area is close to the receptor area; therefore, blood supply is apparently not really an issue. We are yet to see complete fibrosis or necrosis of the flap. In similar studies conducted by Palva et al., an anteriorly based musculoperiosteal flap was used with success rate of 80%[11] and by N B Solomon using bone pate for mastoid cavity obliteration was 78%.[12] This study shows similar results with success rate of 83%. Epithelization is early in obliterated cavity due to smaller surface area. Chances of granulation and discharge decreases as exposed bone are covered by flap. Moreover, because of smaller cavity size, it is expected to retain its epithelial migration and self-cleaning and thus remains dry.[15] The patient can also swim without complications because of small cavity size and protection of lateral wall by obliterated material. Hearing aids if required are better tolerated in an obliterated cavity than an open cavity. On the basis of all above observations, we infer that cavity obliteration is a useful method of reducing postoperative morbidity of patients. Especially, useful is the combined use of bone dust for obliteration of small cavities and the muscle flaps for the larger outline of the cavity. It lessens the postoperative cavity problems, thereby reducing the patients' reliance on the doctor thus improving the quality of life.

Irrespective of the method used, principles to follow include creating a mastoid cavity with an oval shape, leaving a low facial ridge, and creating an adequate-sized meatoplasty for easy toileting and inspection. Overall, the surgical method used should be appropriate to the patients diagnosis, defect size and surgeon experience as the result obtained is dependent not only on the type of obliteration or reconstruction method but also surgeon expertise.


  Conclusion Top


  • A mix of bone pate to obliterate the small spaces in the mastoid cavity along with a ribbon-like temporalis muscle flap is effective method of mastoid cavity obliteration
  • It gives a dry ear, which is not bulky and most importantly maintains the canal.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kinney SE. The problem mastoid cavity: Medical and surgical management. Laryngoscope 1977;87:1853-60.  Back to cited text no. 1
    
2.
Males AG, Gray RF. Mastoid surgery: Quantifying the distress in a radical cavity. Clin Otolaryngol 1994;19:194-8.  Back to cited text no. 2
    
3.
Ojala K, Palva A. Results of obliterative cholesteatoma surgery. Arch Otolaryngol Head Neck Surg 1982;108:1-3.  Back to cited text no. 3
    
4.
Ringenberg JC, Fornatto EJ. The fat graft in middle ear surgery. Arch Otolaryngol 1962;75:329-34.  Back to cited text no. 4
    
5.
Moffat DA, Gray RF, Irving RM. Mastoid obliteration using bone pâté. Clin Otolaryngol Allied Sci 1994;19:149-57.  Back to cited text no. 5
    
6.
East CA, Brough MD, Grant HR. Mastoid obliteration with the temporoparietal fascia flap. J Laryngol Otol 1991;105:417-20.  Back to cited text no. 6
    
7.
Cheney ML, Megerian CA, Brown MT, McKenna MJ. Mastoid obliteration and lining using the temporoparietal fascial flap. Laryngoscope 1995;105 (9 Pt 1):1010-3.  Back to cited text no. 7
    
8.
Mahendran S, Yung MW. Mastoid obliteration with hydroxyapatite cement: The Ipswich experience. Otol Neurotol 2004;25:19-21.  Back to cited text no. 8
    
9.
Kakigi A, Taguchi D, Takeda T. Mastoid obliteration using calcium phosphate bone paste with an artificial dermis soaked with basic fibroblast growth factor: Preliminary clinical report. Auris Nasus Larynx 2009;36:15-9.  Back to cited text no. 9
    
10.
Ridenour JS, Poe DS, Roberson DW. Complications with hydroxyapatite cement in mastoid cavity obliteration. Otolaryngol Head Neck Surg 2008;139:641-5.  Back to cited text no. 10
    
11.
Palva T, Palva A, Salmivalli A. Radical mastoidectomy with cavity obliteration. Arch Otolayngol 1968;88:27-81.  Back to cited text no. 11
    
12.
Solomons NB, Robinson JM. Obliteration of mastoid cavities using bone pâté. J Laryngol Otol 1988;102:783-4.  Back to cited text no. 12
    
13.
Lee HJ, Chao JR, Yeon YK, Kumar V, Park CH, Kim HJ, et al. Canal reconstruction and mastoid obliteration using floating cartilages and musculo-periosteal flaps. Laryngoscope 2017;127:1153-60.  Back to cited text no. 13
    
14.
Ghiasi S. Mastoid cavity obliteration with combined Palva flapand bone pâté. Iran J Otorhinolaryngol 2015;27:23-8.  Back to cited text no. 14
    
15.
Harun A, Clark J, Semenov YR, Francis HW. The role of obliteration in the achievement of a dry mastoid bowl. Otol Neurotol 2015;36:1510-7.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]



 

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