OTITIS MEDIA: SURGICAL PRINCIPLES

BASED ON PATHOGENESIS 0030-6665/99 $8.00 + .OO

FLEXIBLE APPROACH TO
TYMPANOMASTOIDECTOMY
Barry P. Kimberley, MD, PhD, and Oleg Fromovich, MD

The characterization of patients with chronic, recurring otitis media (OM)

encompasses a wide variety of underlying pathologic conditions and clinical pre-
sentations. For example, children who have recurrent acute otitis media but whose
middle ears clear in between individual bouts of acute illness likely have a differ-
ent underlying pathologic finding and optimal treatment options from those of
individuals who have chronically draining ears and perhaps sensorineuralhearing
loss induced by OM. Between these two extremes are many other variations,both
of underlying pathologic conditions and of appropriate surgical responses. Inter-
vention varies from prophylactic antibiotics to placement of ventilation tubes to
tympanoplasty with reconstruction of the middle ear and, ultimately, open-cavity
mastoid surgery. This article provides some guidance in the appropriate choice of
intervention based on assumptions about underlying pathologic tissues and anat-
omy. This variable surgical approach to chronic otitis media (COM) has been
termed the flexible surgical approach for treating OM.
Three important general considerationshave been observed in previous stud-
ies of the pathogenesis of OM. They are that (1)a continuum (including overlap
of types) of OM, including silent otitis media, exists; (2) pathologic conditions and
the location of the pathologic condition (i.e., localized or generalized) may vary;
and (3) often, pathologic and anatomic narrowings or obstructive sites exist along
the middle ear cleft. Understanding these principles allows surgeons to customize
the operation to correct the problems present and to help prevent future sequelae.

OBSTRUCTIVE SITES IN TEMPORAL BONE

AND THE PATHOGENESISOF OTITIS MEDIA

The role of dysfunction of the eustachian tube in the pathogenesis of OM is

well known. Perhaps less well known are the effects of anatomic obstruction in

From the Minnesota Ear, Head, and Neck Clinic, Minneapolis, Minnesota

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

VOLUME 32 NUMBER 3 *JUNE 1999 585

586 KIMBERLEY & FROMOVICH

the middle ear cleft in the protympanum, mesotympanum, attic, and antrum. Ob-
struction at these sites may also lead to intractable disease in the middle ear and
mastoid. For example, the promontory may be especially high riding, and the
handle of the malleus may be retracted, which together can lead to mesotympanic
obstruction. Similarly, inflammatory reactions associated with COM may lead to
obstructions in the attic and protympanum. Selective blockage of mastoid cells
may lead to formation of cholesterol granuloma at these sites.
Developmental anomalies in the temporal bone can include narrowing of the
meatus with obstruction of the external auditory canal. In addition the middle ear
cleft may be congenitally small, or a low-hanging tegmen tympani or a high-riding
jugular bulb may be present. These anomalies work in concert with pathologic
conditions to cause obstruction and OM. Therefore, to the extent possible, sur-
geons must not only remove pathologic tissue but also should focus on amelio-
rating underlying obstructive anatomy.

AN APPROACH TO SURGICAL INTERVENTION

If effusions do not resolve with good medical therapy within 3 months, usu-
ally tympanostomy tubes are placed. Occasionally, at the time of placement of
tubes, extensive granulation tissue is visualized in the middle ear cleft. Some of
these ears go on to have chronic drainage despite the placement of ventilation
tubes. For ears that have chronic drainage despite tube placement, the flexible
approach should be considered. Preoperative radiographic evaluation may sug-
gest significant mastoid disease, which not only provides some preoperative guid-
ance to surgeons but also appropriate counseling to patients preoperatively. This
surgery is, however, somewhat unique among surgical procedures in that the pre-
cise procedures to be undertaken are usually only fully defined at the time of
surgery after all of the pathologic and obstructive features have been determined.

CHOOSING THE BEST MASTOID PROCEDURE

Mastoid procedures are generally classified into three broad categories:

(1)intact canal wall mastoid, also known as closed-cavity mastoidectomy; (2)canal
wall-down or open-cavity mastoidectomy; and (3)a hybrid version, or the intact-
bridge tympanomastoidectomy (IBM) (Fig. 1).In practice, each mastoidectomyis
different and depends on the underlying anatomy and pathologic conditions.The
three categories of mastoid procedures, however, each carry different functional
outcomes in hearing, in physical and cosmetic appearance, and in expected post-
operative care. The closed-cavity technique may result in multiple operations to
eradicate disease. The open-cavity technique often, however, carries reduced func-
tional outcome, both in postoperative hearing and in the need for postoperative
mastoid care. The hybrid technique, namely the IBM, combines features of both
the open-cavity and closed-cavity techniques. The details of this procedure have
been described elsewhere.'
In the flexible approach, the choice among the options for the cavity is deter-
mined by the underlying anatomy and pathologic conditions.Specifically, in small,
sclerotic cavities, closed-cavity mastoidectomy may yield no advantage. In fact,
closed-cavity mastoidectomy may be technically challenging in a small mastoid
cavity. Conversely, a large, well-pneumatized mastoid cavity with modest mastoid
disease is much better treated with a closed-cavity technique to avoid postoper-
Figure 1. Types of mastoidectomy. A, Closed-cavity mastoidectomy, also known as the intact-
wall mastoid technique. B, Open-cavity mastoidectomy, also known as the canal-wall-down
mastoid technique. C, Hybrid rnastoidectomy technique, known as the intact-bridgemastoid
technique (IBM).
587
588 KIMBERLEY & FROMOVICH

ative cosmetic issues and cleaning of the cavity. In between these two extremes,
the IBM fills a role for many forms of chronic mastoid disease in which surgeons
reaIize a significant amount of granulation tissue or other intractable disease in
the mastoid cavity, warranting concern that to leave the cavity closed would be
to invite subsequent recurrence of mastoid disease. The IBM allows for excellent
postoperative hearing results and minimizes the risk for recurrent chronic disease
in the mastoid cavity or middle ear space.

CONTINUUM OF PATHOLOGIC CONDITIONS IN OTITIS MEDIA

The pathology of OM can be conceived as occurring along a continuum, from

effusions in the middle ear characterized as serous at one end of the continuum
to intractably pathologic tissue in the mastoid, such as granulation tissue and
cholesteatoma, at the other end of the continuum. Studies of human temporal
bones and animal models suggest that a progression in severity of OM occurs
from one end of the pathologic continuum to the other. In the case of effusions in
the middle ear, three types are usually described (I) serous, (2) purulent, and
(3) mucoid. Individual ears often contain a combination of these types, but usually
one type dominates.
Such pathologic conditions as type of effusion in the middle ear and presence
or absence of granulation tissue or cholesteatoma are easily identified accurately
by the operating surgeon at the time of surgery. Findings of mucoid effusion with-
out granulation tissue and without significantly thickened mucosa in the middle
ear represent a less severe infectious state compared with the middle ear that has
excessive granulation tissue in it, and these probably suggest different surgical
approaches. For example, a finding of extensive granulation tissue in the middle
ear may warrant a mastoidotomy at the time of surgery to rule out intractable
disease in the mastoid and hence the need for a mastoid procedure. On the other
hand, the absence of thickened mucosa or granulation tissue in the middle ear, in
most cases, suggests that a mastoidotomy or mastoidectomy is unnecessary. The
continuum of pathologic conditions in OM has been described extensively else-
where.*~~

SURGICAL STEPS IN THE FLEXIBLE APPROACH

TO TYMPANOMASTOIDECTOMY

Endaural Incisions

For all variations of the flexible approach to tympanomastoidectomy, the au-

thors use the endaural approach and Lempert I, 11, and I11 endaural incisions as
illustrated in Figure 2A. The Lempert endaural incisions, especially the Lempert
I1 and I11 incisions, offer great flexibility in degree of extension. The sizes of the
incisions are customized for anticipated pathologic conditions.These incisionscan
easily be extended intraoperatively, and, therefore, they let one ensure at the outset
that if a large mastoid cavity is encountered, requiring wide exposure, the size of
the incision can be adjusted.
The Lempert I1 incision does not cut into the cartilage but rather divides the
t r a p s and the helix at the incisura. Through this extended second incision, tem-
poralis fascia is harvested for grafting. (The Lempert I11 incision is not always
necessary for tympanoplastic approaches but usually is for mastoid operations.)
Figure 2. Endaural incisions and expo-
sure. A, Lemperl I, II, and 111 incisions.
These are symbolized by L1, L2,and L3.
B, Endaural exposure obtained with a
periosteal elevator. C, Maintenance of
exposure with self-retaining retractors.
0,Sites of injectionfor local anestheticfor
the endaural approach.
590 KIMBERLEY & FROMOVICH

Exposure of the bony ear canal and mastoid cortex is facilitated with the use of
large periosteal elevators, and exposure is maintained with large, usually three-
pronged, self-retaining retractors, as illustrated in Figures 2B and C. Figure 2 0
illustrates the sites for injection of local anesthetic before accomplishment of the
endaural incisions.

Canalplasty

Canalplasty is the next step, and it is important in allowing for adequate

visualization, both intraoperatively and postoperatively, of the tympanic mem-
brane and its anulus. Often, pathologic ears have associated overhang in the an-
terior canal wall that obstructs the anterior portions of the tympanic membrane.
Anterior canalplasty is accomplished after a laterally based flap of skin from the
canal is elevated in a retrograde fashion. This allows drilling of the bony wall of
the anterior canal. Care must be used to avoid violating the capsule of the tem-
poromandibular joint.
Anterior canalplasty is illustrated in Figure 3. Anterior canalplasty may be
done either before or after posterior canalplasty. The advantage of doing anterior
canalplasty before posterior canalplasty in some instances is that it provides im-
proved protection to the tympanomeatal flap. It is accomplished after elevation of
the tympanomeatal flap in a standard fashion. Posterior canalplasty then affords
much improved visualization of the middle ear intraoperatively and postopera-
tively.

Meatoplasty

Meatoplasty may occasionally be done at this step in the flexible approach to

tympanomastoidectomy. Performing meatoplasty at this stage facilitates intra-

Figure 3.Anterior canalplasty in an ear with a large overhanging anterior canal wall.
 FLEXIBLE APPROACH TO TYMPANOMASTOIDECTOMY 591

operative surgical exposure, but it is more usually done at the end of surgical
treatment because then the size of the meatus is tailored to the size of the mastoid
cavity or bony ear canal. An adequately performed meatoplasty facilitates future
examinations and debridement of the cavity in the office.

Atticotomy

The authors perform atticotomy routinely. Atticotomy comes in various sizes,

depending on pathologic conditions in the middle ear. In diseased ears, it must
be sufficiently large to remove disease adequately from both the ossicular chain
and the facial recess. Preservation of the chorda tympani nerve should always be
a goal during this process. Figure 4 illustrates various sizes of atticotomy.

Reconstructionof the Middle Ear

Endaural exposure, canalplasty, exploratory tympanotomy, and atticotomy

have now provided surgeons with an ability to evaluate clearly the state of path-
ologic conditions in the middle ear. At this point, reconstruction of the middle ear
can be accomplished or, alternatively, it follows mastoid surgery. Reconstruction
of the middle ear is highly variable, as are pathologic conditions in the middle
ear. The first step is to examine carefully the state of the middle ear, specifically
the mucosa, presence or absence of granulation tissue, and its location, especially
in relationship to the ossicles and the possible presence of a retracted malleus and
subsequent obstruction of the middle ear. The orifice of the Eustachian tube, facial
recess, and sinus tympani are carefully evaluated for disease.
Disease around the round window niche and the oval window may have
particular relationship to sensorineural hearing loss in patients with COM. A find-
ing of cholesteatoma in the middle ear is a special case, but many of the principles

Figure 4. Various sizes of atticotomy are illustrated by the superimposed dashed arcs. The
posterior inferior anulus can also be removed with a drill, to enlarge the middle ear space, as
illustrated with a separate dashed arc.
592 KIMBERLEY & FROMOVICH

of the flexible approach to tympanomastoidectomy still apply. As a part of the

process of inspection of the pathologic state of the middle ear, some physicians
use rigid telescopes intraoperatively to examine such areas as the facial recess and
sinus tympani. Reconstructing of the middle ear often involves cutting of the ten-
sor tympani tendon and lateralizing of the malleus while stabilizing the incudo-
stapedial joint (Fig. 5). Judicious removal of granulation tissue from the middle
ear follows, but care is used not to disrupt the ossicular chain and especially not
to sublux the footplate of the stapes. The use of topical adrenalin, 1:lOOO concen-
tration, is helpful to achieve hemostasis and to improve intraoperative visualiza-
tion of the middle ear. The processes of lateralizing the malleus and performing
atticotomy and canalplasty all achieve improvement in the volume of the middle
ear space, which consequently improves natural ventilation.

Use of Silicone

The authors routinely use thin (0.013 cm silicone), cut into the shape of a
plump banana, that fits across the promontory and serves as a spacer between the

Figure 5. Reconstruction of the middle ear. A, Cutting of the tensor tympani tendon, after an
endaural approach and atticotomy. B, Lateralization of the malleus.
 FLEXIBLE APPROACH TO TYMFANOMASTOIDECTOMY 593

overlying tympanic membrane and its graft and the underlying promontory of
the inner ear. In the event of subsequent retraction of the tympanic membrane,
the silicone serves a useful purpose as a spacer and is particularly helpful in the
event of reoperation in preventing adhesion between the tympanic membrane and
the promontory.

Ossiculoplasty
The many forms of ossiculoplasty are fit to the specific pathologic condition
of the ossicles, as are the choice of type I, 11, or I11 tympanoplasty and the choice
of partial or total ossicular replacement prostheses; these options are discussed
elsewhere. Whether to remove ossicles engulfed in granulation tissue can be a
difficult decision.

Mastoidectomy

In the event of significant disease in the middle ear, a mastoidotomy may be

accomplished simply through the same endaural incision (Fig. 6 ) . If mastoid dis-
ease is discovered in the antrum, then a mastoidectomy should follow. Any of the
three types of mastoidectomy can result from use of the flexible approach. Figure
1 illustrates the closed-cavity tympanomastoidectomy, also known as canal wall-
up mastoidectomy; the open-cavity tympanomastoidectomy, or canal wall-down
mastoidectomy; and the IBM.

Figure 6. Endaural approach to tympanoplasty-rnastoidotorny.

594 KIMBERLEY & FROMOVICH

Saucerization of Cortical Bone

Saucerization of the mastoid defect essentially reduces its volume. Such sau-
cerization is particularly important for the IBM and the open-cavity mastoidec-
tomy.

Thiersch Grafting

If significant unhealed areas remain 2 to 4 weeks after canalplasty or mas-

toidectomy, Thiersch grafting (an outpatient procedure) ensures epithelialization.

Figure 7. Thiersch grafting techniques. A, Harvesting of thin, split-thickness skin from the
inner arm, using a razor blade. B,Sandwich fashioned of skin-graft and Owens silk gauze.
 FLEXIBLE APPROACH TO TYMPANOMASTOIDECTOMY 595

This transparent graft is taken, using a freehand technique, from the inner aspect
of the upper arm with the patient under local anesthesia, using 2%lidocaine with
1:100,000 epinephrine. The grafts are placed, subepithelial side up, on Owens silk
gauze coated with gentamicin ointment (Fig. 7B).Granulation tissue is removed
from the exposed bone after topical 4% cocaine has been applied. Additional he-
mostasis in most cases is obtained with topical epinephrine in 1:lOOO dilution; care
is exercised not t o exceed toxic levels. When hemostasis is obtained, the grafts are
carefully placed over all exposed bone. The Owens silk gauze is removed 10 to
14 days later.

SUMMARY

The flexible approach to tympanomastoid surgery is driven largely by the fact

that appropriate surgical intervention depends on underlying anatomy and path-
ologic conditions. Furthermore, such underlying pathologic conditions and anat-
omy can rarely be determined precisely preoperatively. The flexible approach is
guided by the principle of created surgical aggressiveness appropriate to the path-
ologic conditions and anatomy determined at the time of surgery. The authors
have had extensive personal experience with this approach and are convinced of
its efficacy.

References
1. Alleva M, Paparella MM, Morris M, et a 1 The flexible/intact-bridge tympanomastoidec-
tomy technique. Otolaryngol Clin North Am 22:41-49,1989
2. Guo M, Paparella MM, Lamey S, et al: A histopathological study of the relationship be-
tween otitis media and mastoiditis. Laryngoscope 101:1050-1055,1991
3. Paparella MM, Kimberley B, Alleva M: The concept of silent otitis media: Its importance
and implications. Otolaryngol Clin North Am 24:763-774,1991

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Barry P. Kimberley, MD, PhD
Minnesota Ear, Head, and Neck Clinic
701 25th Avenue South, Suite 200
Minneapolis, MN 55454