The Laryngoscope
Lippincott Williams & Wilkins, Inc.
© 2003 The American Laryngological,
Rhinological and Otological Society, Inc.
How I Do It
A Targeted Problem and Its Solution
Modified Bondy’s Technique for
Epitympanic Cholesteatoma
Mario Sanna, MD; Manoj Agarwal, DLO RCS, DLO(Cal); Tarek Khrais, FRCS(I), HSDM;
Giuseppe Di Trapani, MD
INTRODUCTION
Localized epitympanic cholesteatoma with normal or
near normal hearing gives the otologist an opportunity to
achieve both aims of otologic surgery: a dry, safe ear and
preservation of hearing. Clinical acumen coupled with the
availability of modern radiologic technology allows the
surgeon to recognize this group of cholesteatoma early.
This clinical scenario is an ideal setting to perform a
modified Bondy’s technique, the steps of which are de-
scribed in the following paragraphs.
INDICATIONS
1. Epitympanic cholesteatoma in normal or good
hearing ear with an intact tympanic membrane
and ossicular chain (Fig. 1).
2. Epitympanic cholesteatoma in the better or only
hearing ear with slightly compromised ossicular
chain.
An important prerequisite for performing modified
Bondy’s technique is that the preoperative air-bone gap
should not exceed 25 dB (calculated as the difference be-
tween the average of the air and bone-conduction thresh-
olds at 0.5, 1, 2, and 4 kHz).1
SURGICAL STEPS
1. A standard postauricular incision is made, and
the soft tissues are handled in regular fashion.
A large piece of temporalis fascia is harvested
for grafting.
2. A transcortical mastoidectomy is performed to
This article supported by a grant from Associazione Studio Aggior-
namento Basicranio.
From the Gruppo Otologico, Piacenza, Italy.
Editor’s Note: This Manuscript was accepted for publication July 23,
2003.
Send Correspondence to Dr. Mario Sanna, Gruppo Otologico, Via
Emmanueli 42, 29100 Piacenza, Italy. E-mail: mario.sanna@
gruppootologico.com
Laryngoscope 113: December 2003
2218
widely expose the sinodural angle and mastoid
tip (Fig. 2).
3. Once the mastoidectomy is completed, poste-
rior epitympanotomy is performed. Care is
taken not to touch the ossicles with the rotat-
ing burr during this step. This is imperative to
avoid any postoperative sensorineural hearing
loss because the ossicular chain is intact. To
identify the ossicles as early as possible, the
operating table is rotated away from the
surgeon.
4. Next, attention is directed toward the canal
wall, which may need a canaloplasty. The
meatal skin is elevated, folded medially, and
protected using an aluminum strip while dril-
ling the canal walls.
5. The facial ridge must be lowered to the level of
the tympanic annulus. The most medial part of
the facial bridge is removed using a curette
(Fig. 3). The use of a curette reduces the
chances of dislocating the intact ossicular
chain as compared with use of a rotating burr.
The same instrument is used for removing the
anterior and posterior buttresses. Care is
taken to open the anterior epitympanum as far
anterior as possible.
6. Once adequate exposure of the mastoid and
epitympanum is obtained, removal of cho-
lesteatoma is initiated. Again, care is taken to
avoid excessive manipulation of the ossicular
chain for the reasons mentioned above.
7. The posterosuperior annulus is partially de-
tached from the tympanic sulcus, and the tym-
panic cavity is inspected for the presence of any
cholesteatomatous extension that can be
removed.
8. Once the cholesteatoma is removed completely,
a wide conchomeatoplasty is performed. The
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma
www.medicsindex.com
Fig. 1. Coronal computed tomography scan of the right temporal
bone without contrast showing presence of localized epitympanic
cholesteatoma lateral to the ossicles: an ideal case for modified
Bondy’s technique.

conchal cartilage obtained is used for the

following steps.
9. A piece of cartilage is place in the attic and
pushed as far anteriorly as possible, medial to
the body of the incus and the head of the mal-
leus (Fig. 4). If the anterior epitympanum is
widely exposed, the cartilage is pushed as far
as the orifice of the eustachian tube. The car-
tilage is placed to avoid any possible retrac-
tions in this area in the future. Another piece
of cartilage may be placed lateral to the long
process of the incus and medial to the handle of
the malleus (Fig. 5). This cartilage prevents
retraction in the posterosuperior quadrant of
the grafted tympanic membrane.
10. A longitudinal cut is made in the temporalis
fascia. One tongue is inserted medial to the
Fig. 3. Operative sketch of the right side demonstrating removal of
the most medial part of the facial bridge, with use of a curette to
minimize the chances of ossicular disruption. Note the movement of
the curette is directed away from the ossicles.
body of the incus and the head of the malleus
over the previously placed cartilage. The other
tongue is inserted lateral to the long process
of the incus and medial to the handle of the
malleus by pushing it under the tympanic
membrane.

Fig. 2. Operative sketch of the right side demonstrating transcor-

tical mastoidectomy with the cholesteatoma visible in the epitym- Fig. 4. Operative sketch of the right side demonstrating the place-
panum. Note the wide exposure of the mastoid tip and sinodural ment of cartilage in the attic medial to the incudomalleolar joint as
angle. far anterior as possible.

Laryngoscope 113: December 2003 Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma
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Fig. 5. Operative sketch of the right side demonstrating the place-
ment of cartilage between the long process of incus and the handle
of the malleus.
11. The remaining part of the fascia covers the
exposed bony surface of the mastoid cavity as
far as possible. If necessary, another piece of
fascia may be harvested to cover the same.
12. The tympanomeatal flap is replaced over the
fascia, and the cavity is packed with an absorb-
able gelatin sponge (Spongostan, Johnson &
Johnson, Skipton, UK).
13. The wound is closed in layers, and pressure
bandage is applied.
HINTS AND PITFALLS
1. Adequate exposure of the sinodural angle and
the mastoid tip is necessary to avoid recurrence.
2. A very deep sinodural angle should be obliterated
using bone patè, cartilage, and temporalis fascia.
3. A extensively pneumatized mastoid tip should
be amputated to reduce the volume of the mas-
toid cavity.
4. As mentioned earlier, handling of the intact os-
sicles should be avoided lest the surgeon cause a
sensorineural hearing loss. Extreme care should
be exercised in this region, and the direction of
the drilling and curetting should be away from
the ossicles.
5. The anterior buttress should be removed com-
pletely to obtain a smooth continuation with the
anterior wall of the external canal. This is nec-
essary to avoid any bony overhang in this region
that could hamper the self-cleansing property of
the cavity.
6. Caution is advisable while drilling the anterior
external canal wall during the canaloplasty to
Laryngoscope 113: December 2003 Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma
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avoid inadvertent opening of the temporoman-
dibular joint.2 Similarly, caution is necessary
while drilling the posterior external canal wall
to avoid any injury to the facial nerve, which is
particularly vulnerable to injury in the postero-
inferior quadrant.3
7. Inspection of the tympanic cavity is mandatory to
ensure complete removal of the disease process.
8. Modified Bondy’s technique is mainly indicated
for localized epitympanic cholesteatoma and not
recommended for more extensive cholesteatoma.
RESULTS
During the period between December 1983 and De-
cember 2002, we performed a total of 153 surgeries using
the surgical technique described above. Some of these
cases have been reported previously.4,5 Of these, 57 cases
had a follow-up of 3 years (36 months) or more. The mean
follow-up was 86.6 (range 36 –196)months. Dry cavity was
achieved in 54 (94.7%) cases. The remaining three (5.3%)
cases had an occasional episode of otorrhea, which was
controlled with local medication. There was no single in-
stance of recurrence or reoperation. The air-bone gap was
preserved or improved in comparison with the preopera-
tive level in 43 (75.4%) cases. Nine (15.8%) cases showed a
drop of air-bone gap of more than 10 dB but less than 20
dB in comparison with the preoperative level, whereas
five (8.8%) cases showed a drop of more than 20 dB but
less than 30 dB. This small group of patients (n ⫽ 14)
exhibited the deterioration on long-term follow-up. There-
fore, this deterioration is probably attributable to tubal
dysfunction or ossicular fixation but definitely not to any
intra-operative factor. The bone conduction was measured
just before discharging the patient to assess the incidence
of iatrogenic sensorineural hearing loss. It was main-
tained within 10 dB of the preoperative level in 55 (96.5%)
cases. Two (3.5%) cases showed a deterioration of bone
conduction of more than 10 dB but less than 20 dB.
DISCUSSION
In 1910, Gustave Bondy described a technique that
attempted to provide a better outcome for his patients
suffering from cholesteatomatous otitis media. He treated
patients having epitympanic cholesteatoma with intact
pars tensa and intact ossicular chain using a modified
form of radical mastoidectomy wherein he removed the
lateral attic wall and the posterior osseous wall.6 This
enabled him to remove the pathology without disturbing
the intact ossicular chain, thus providing the patient with
a safe, dry ear and preserved hearing. However, his tech-
nique was not without pitfalls. The high facial ridge and
incomplete removal of mastoid tip favored debris collec-
tion, which meant repeated visits to the otologist for the
patients. There was also a possibility of leaving behind the
pathology because of the restricted access. Moreover, he
did not perform any meatoplasty.
We, at the Gruppo Otologico, have been using the
modified Bondy’s technique described above since 1983.
We call it the modified Bondy’s technique because of the
following reasons:
 1. We put cartilage in the vicinity of the ossicles as
described above to reduce the chances of retraction.
2. We inspect the middle ear to rule out any extension
of the cholesteatoma in the mesotympanum.
3. Special attention is paid to the adequate lowering
of the facial ridge up to the level of the tympanic
annulus, which plays an important role in ensur-
ing complete disease removal. Leaving the facial
ridge high is an important cause of persistently
discharging mastoid cavity.7
4. A wide conchomeatoplasty is performed for ade-
quate aeration of the resultant cavity.
5. Treatment of the deep sinodural angle and
highly pneumatized mastoid tip as outlined
above is of paramount importance to achieve
good results.
By following these principles, the surgeon can ex-
pect to provide the patient with a dry, safe ear with
preserved hearing in cases of localized epitympanic cho-
lesteatoma in a single stage. Any procedure that
Laryngoscope 113: December 2003 Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma
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achieves this end result in one stage is worth trying and
therefore strongly recommendable.
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