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Systematic Review/Meta-analysis

Otolaryngology–
Head and Neck Surgery

Therapeutic Mastoidectomy in the 2016, Vol. 155(6) 914–922


Ó American Academy of
Otolaryngology—Head and Neck
Management of Noncholesteatomatous Surgery Foundation 2016
Reprints and permission:
Chronic Otitis Media: Literature Review sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599816662438

and Cost Analysis http://otojournal.org

Aaron Trinidade, MD, FRCS1, Joshua C. Page, MD1, and


John L. Dornhoffer, MD1

No sponsorships or competing interests have been disclosed for this article. Received May 12, 2016; revised June 13, 2016; accepted July 13, 2016.

Abstract
Introduction
Objective. Despite evidence that therapeutic mastoidectomy
does not improve outcomes in noncholesteatomatous chronic Rationale
otitis media, it remains widely performed. An up-to-date sys- Mastoidectomy and its evolution have come to define modern
tematic review is undertaken and conclusions drawn regarding otological practice. Yet despite evidence that therapeutic mas-
the best evidence-based practice of its management. toidectomy does not improve outcomes in the management of
Data Sources. PubMed, Google Scholar, Medline Embase, noncholesteatomatous chronic otitis media, it remains a widely
Cochrane, and Web of Science. performed procedure in many centers.
The term chronic, noncholesteatomatous disease is applied
Review Method. A combination of the following words was here to encompass 3 types of chronic otitis media (COM)
used: chronic otitis media, chronic suppurative otitis media, (after Browning1; see Table 1): active mucosal (chronic sup-
COM, CSOM, mastoidectomy, tympanoplasty, atelectasis, retrac- purative otitis media, CSOM), inactive mucosal (dry tympanic
tion, tympanic perforation, and therapeutic. perforation or quiescent CSOM), and inactive squamous (tym-
Results. From 1742 studies, 7 were selected for full analysis with panic retraction or atelectasis).
respect to the benefit of mastoidectomy in the management of Active and inactive mucosal COM are considered part of a
active and inactive mucosal chronic otitis media. Most were ret- spectrum of otomastoiditis due to the anatomical connection of
rospective studies, with 1 prospective randomized controlled the middle ear cleft with the mastoid air cell system. This con-
trial available. Overall, there was no evidence to support routine cept is supported by histopathological evidence that diseased
mastoidectomy in conjunction with tympanoplasty in chronic mucosa, osteitis, and micro-abscess formation are commonly
otitis media. For ears with sclerotic mastoids, the evidence sug- observed in temporal bone specimens that have been severely
gested that there may be some benefit as a staged procedure. affected by chronic ear disease in life.2 Postoperative phenom-
Two studies were analyzed for the benefit of mastoidectomy in ena such as cholesterol granuloma and air cell effusions are
addition to tympanoplasty for the management of the atelectatic regularly encountered as well. Radiologically, severely dis-
ear (inactive squamous chronic otitis media). The conclusion eased chronic ears frequently demonstrate evidence of diffuse
was also that mastoidectomy added no benefit. mastoid air cell opacification and indicators of mastoiditis
even when the ear has been made dry and temporarily stable
Conclusions. Examination of the available literature supports clinically.3 These factors have led many otologists to perform
the notion that therapeutic mastoidectomy does not lend therapeutic mastoidectomy in addition to tympanic membrane
any additional benefit to the management of noncholestea- repair in an attempt to eliminate chronic tympanomastoid
tomatous chronic otitis media. This has implications for infection, and failure to thoroughly address mastoid air cell
patient care, both clinically and financially. Further research, disease and persistent mastoiditis has been frequently cited as
ideally in the form of a prospective, multi-institutional, geo-
graphically wide, ethnically diverse, randomized controlled
1
trial, is needed to further support this notion. University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Corresponding Author:
Keywords Aaron Trinidade MD, FRCS, Department of Otolaryngology, University of
Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, Arkansas
mastoidectomy, chronic otitis media, tympanic perforation, AR72207, USA.
atelectasis, retraction pocket, cost analysis Email: ATrinidade@uams.edu
Trinidade et al 915

Table 1. Clinicopathological Classification of Chronic Otitis Media (COM).a


COM Classification Synonyms Otoscopic Findings

Inactive mucosal Perforation Permanent perforation of pars tensa, inactive middle ear mucosa
Active mucosal Chronic suppurative otitis media Permanent perforation of pars tensa, inflamed middle ear
mucosa, mucus discharge
Inactive squamous Retraction Retracted pars tensa/flaccid usually at posterosuperior segment,
with potential of becoming active with retained debris
Active squamous Cholesteatoma Retraction of pars tensa/flaccida, retained squamous epithelium,
debris and pus
Healed Healed perforation/tympanosclerosis Thinning and/or local or generalized opacification of the pars
tensa without perforation or retraction
a
From Browning GG. Condition of middle ear-classification. In: Kerr AG, ed. Scott-Brown’s Otolaryngology. 7th ed. Vol 3. London, UK: Arnold; 2008:3396.

a reason for surgical failure, both in canal wall-up and canal were therefore eliminated to maintain scientific integrity. For
wall-down scenarios. Particular air cell tracts have even been studies concerned with mastoidectomy in inactive squamous
identified as being most commonly associated with surgical COM, since these were much less in quantity, the review was
failure.4,5 extended to the past 25 years (1991 to present) instead, but
With respect to the atelectasis encountered in inactive eligibility criteria remained the same.
squamous COM, the physiologic role of the mastoid air cell
system in the regulation of gas pressure within the mastoid Information Sources
and the middle ear cleft is still poorly understood. There is
still debate as to whether a healthy mucosa of the mastoid PubMed, Google Scholar, Medline Embase, Cochrane, and
and epitympanum is vital in maintaining postoperative tym- Web of Science were used for the literature search.
panic gas homeostasis or whether mucosal gas absorption in
these areas is partially responsible for negative middle ear Search
pressure, subsequent recurrent tympanic membrane retraction, This was undertaken independently by 2 authors (A.T. and
and ultimately active squamous COM (cholesteatoma).6-9 J.C.P.). A combination of the following terms was used for
Canal wall-up with or without posterior tympanotomy has each search: chronic otitis media, chronic suppurative otitis
been advocated as a means of counteracting such middle ear media, COM, CSOM, mastoidectomy, tympanoplasty, atelec-
underventilation.10 tasis, retraction pocket, tympanic membrane perforation,
and therapeutic.
Objective
This article serves to objectively review the literature and Data Collection Process
draw conclusions about the role of mastoidectomy in non- Studies were independently selected by each author based
cholesteatomatous COM and its clinical and financial impli- on inclusion and exclusion criteria. They were then ana-
cations for patient care. lyzed and data extracted independently and inserted onto a
predetermined proforma of data items. A consensus was
Methods then reached. It was decided that when there was a conflict,
For this review, PRISMA guidelines were followed. a study would be rejected according to majority vote. Strict
adherence to the inclusion and exclusion criteria prevented
Eligibility Criteria major conflicts about which studies were eventually
For studies concerned with mastoidectomy in active and inac- included in the review.
tive mucosal COM, a literature review of the past 20 years
Data Items
(1996 to present) was undertaken. Exclusion criteria included
studies published prior to 1996, case reports, non-English- Data items included author, year published, population size,
language studies, and studies on mastoidectomy for choles- type of study performed, pathology studied, interventions
teatoma. Studies that did not directly compare management used, graft types, outcome measures, statistical results, and
of noncholesteatomatous COM with and without mastoidect- author conclusions.
omy were also excluded. Of the studies yielded, particular
attention was paid to the quality of the study, concentrating on Synthesis of Results
those with sufficient numbers and a long enough follow-up The data items used formed the basis of Table 2 and Table
period. All studies with a mean follow-up period of less than 3, with Table 2 representing a summary of studies con-
12 months and/or a total of fewer than 50 patients or ears cerned with mastoidectomy in active and inactive mucosal
Table 2. Summary of Studies Comparing the Success Rate of Tympanoplastya with and without Concurrent Cortical Mastoidectomy in Active Mucosal (CSOM) and Inactive Mucosal (Dry

916
Perforation) Chronic Otitis Media.
Follow-up, Study Pathology by Outcome
Author Year n mo Type Group Intervention (n) Measure Results Conclusion

Albu et al11 2012 282 12 Single blinded RCT A, B: CSOM A: TWOM Graft success Graft—Success rates: No difference
without B: TWM Mean A: TM perforationa1
cholesteatoma Graft type: postoperative TWOM (76%)
temporalis fascia ABG B: TM perforation 1
TWM (82.8%)
ABG closure (both
groups) good
(P \.0001)
Toros et al12 2010 92 .12 Retrospective A, B: CSOM A: TWOM Graft success Graft—success rates No difference
review without B: TWM Mean between groups not
cholesteatoma Graft type: not postoperative significant (P . .05):
stated ABG A: CSOM 1 TWOM
(90.5%)
B: CSOM 1 TWM
(85.7%)
ABG closure—
difference between
groups not
significant (P . .05)
McGrew et al13 2004 428 ~32 Retrospective A, B: Dry TM A: TWOM (320) Graft success Graft—success rates Cortical
review perforation B: TWM (144) Mean between groups mastoidectomy
Graft type: fascia, postoperative not significant: reduces need for
cartilage ABG A: TM perforation 1 subsequent
Need for TWOM (90.6%) procedure
subsequent B: TM perforation 1
ipsilateral TWM (91.6%)
procedure ABG closure—
difference overall
between groups not
significant (P . .05)
Subsequent procedures
more likely in the
TWOM group
(14.1% vs 6.1%;
P \.05)

(continued)
Table 2. (continued)
Follow-up, Study Pathology by Outcome
Author Year n mo Type Group Intervention (n) Measure Results Conclusion

Mishiro et al14 2009 213 60 Retrospective A: CSOM without A, B: TWOM Graft success Graft—success rates No difference
review with cholesteatoma (179) Mean between groups not
logistic regression B: Dry TM A, B: TWM (34) postoperative significant (P = .913)
analysis perforation Graft type: not ABG and overall success
stated rate was 95.8%
ABG closure—overall
success rate was
81.7%
Mishiro et al15 2001 251 Mean, 31.7 Retrospective A: CSOM without A1: TWOM (14) Graft success Graft—success rates No difference
review cholesteatoma A2: TWM (40) Mean among groups not
B: Dry TM B1: TWOM (90) postoperative significant (P = .441):
perforation B2: TWM (107) ABG A1: CSOM 1 TWOM
Graft type: not (85.7%)
stated A2: CSOM 1 TWM
(90%)
A1 vs A2: P = .661
B1: TM perforation 1
TWOM (94.4%)
B2: TM perforation 1
TWM (90.7%)
B1 vs B2: P = .318
ABG closure—
difference among
groups not
significant (P = .056)
Balyan et al16 1997 323 Mean, 34 Retrospective A, B: CSOM A,C: TWOM Graft success Graft—success rates No difference
review without B: TWM Mean among groups not
cholesteatoma Graft type: fascia, postoperative significant
C: Dry TM vein, other ABG (P . .05):
perforation A: CSOM 1 TWOM
(90.5%)
B: CSOM 1 TWM
(85.7%)
C: TM perforation 1
TWOM (89.2%)

(continued)

917
918
Table 2. (continued)
Follow-up, Study Pathology by Outcome
Author Year n mo Type Group Intervention (n) Measure Results Conclusion

ABG closure—
difference among
groups not
significant (P . .05)
Krishnan et al17 2002 123 24 Case-control study A: Dry TM A1: TWOM (36) Graft success Graft—Success: No difference
perforation A2: TWM (40) (intact, A1: TM perforation 1
B: Quiescent B1: TWOM (8) mobile) TWOM (55%)
CSOM without B2: TWM (36) Mean A2: TM perforation 1
cholesteatoma Graft type: postoperative TWM (80%)
temporalis fascia ABG B1: CSOM 1 TWOM
(50%)
B2: CSOM 1 TWM
(89%)
ABG closure—
difference among
groups not
significant
Abbreviations: ABG, air-bone gap; CSOM, chronic suppurative otitis media; RCT, randomized controlled trial; TM, tympanic membrane; TWM, tympanoplasty with mastoidectomy; TWOM, tympanoplasty without
mastoidectomy.
a
The term tympanoplasty is used to also include myringoplasty (syn. type 1 tympanoplasty).
Trinidade et al 919

COM and Table 3 representing a summary of those con- groups. In contrast, Avraham et al19 reviewed 111 ears, with
cerned with mastoidectomy in inactive squamous COM. those undergoing tympanoplasty only having follow-up of
an average of 52.8 months and those undergoing an addi-
Ethical Approval tional mastoidectomy having follow-up of an average of 54
This study was given full approval by the local Institutional months. Their outcome measure was the state of atelectasis
Review Board Committee of the University of Arkansas for postoperatively. Their conclusion was that the addition of
Medical Sciences hospital. mastoidectomy was related to a worse postoperative
outcome.
Results
Study Selection Discussion
Search criteria returned a total of 1742 studies, which were Comparison with Other Studies
reduced to 602 after removal of duplicates. These were Of the studies examining the role of mastoidectomy in
screened and a further 576 were excluded, resulting in 26 active and inactive COM, the prospective randomized con-
studies for full review. Of these, a total of 9 were chosen trolled trial by Albu et al11 in 2012 was the most statisti-
for this systematic review, 7 relating to mastoidectomy in cally robust. In this, they compared type 1 tympanoplasty
active and inactive COM and 2 relating to inactive squa- (myringoplasty) with temporalis fascia graft alone with tym-
mous COM (Figure 1). panoplasty and canal wall-up (cortical) mastoidectomy in
282 cases. Both treatment arms were equally stratified
Mastoidectomy in active and inactive mucosal COM. A total of
according to the Middle Ear Risk Index (MERI) and were
7 papers were deemed suitable for analysis at consensus
equally matched for perforation size and location, preopera-
(Table 2). There was 1 single-blinded randomized controlled
tive hearing, age, and sex. Cases were followed up for 12
trial of 282 ears with noncholesteatomatous CSOM, with a
months, at the end of which no statistically significant dif-
follow-up period of 12 months.11 Five studies were retrospec-
ference was found from the addition of mastoidectomy to
tive reviews.12-16 Toros et al12 reviewed their series of 92
the tympanic membrane repair. Nor was there any statistical
ears with CSOM without cholesteatoma that were followed
difference in postoperative hearing improvement.
up for at least 12 months. McGrew et al13 reviewed 428
In 2002, Krishnan et al17 carried out a case-control study
patients with dry perforations only and who had follow-up an
in which cases of dry tympanic perforation (controls) were
average of 32 months. The remaining 3 retrospective reviews
compared with cases of CSOM (cases). Both groups under-
dealt with a combination of both CSOM without cholestea-
went temporalis fascia repair of the tympanic membrane
toma and dry perforations. Mishiro et al14 reviewed 213 ears
with or without additional mastoidectomy and were fol-
with a follow-up of 60 months. This represented a follow-up
lowed up for 24 moinths. In their study, they found a direct
of their original study of 251 ears at a mean of 31.7
correlation between middle ear mucosal disease and the
months,15 with 38 ears having been lost to follow-up. Their
concurrent presence of mastoid antral disease. They con-
2009 review14 included a logistical regression analysis of the
cluded that in the presence of healthy mucosa, mastoidect-
role of middle ear factors on success rates. Balyan et al16
omy added no additional benefit to surgical outcome, but in
reviewed 323 ears with follow-up of a mean of 34 months.
the presence of unhealthy middle ear mucosa, opening of
Finally, in the case-control study by Krishnan et al,17 the authors
the mastoid antrum and air cells could be deemed good
divided 2 groups of ears (one with dry perforations and one
practice. However, they were not able to statistically ana-
with quiescent CSOM without cholesteatoma) into those who
lyze their results due to the small numbers in some of the
would undergo tympanoplasty with mastoidectomy and those
treatment groups.
who would undergo tympanoplasty alone. A total of 123
Of the retrospective studies, that by McGrew et al13 was
ears were treated and followed up for 24 months. In all 7
the largest with a cohort of 428 cases. In this study, they
studies, graft success and mean postoperative air-bone gap
compared the role of additional mastoidectomy in simple
(ABG) were used as outcome measures. McGrew et al13
tympanic membrane perforation repair (no otorrhea).
also used the need for a subsequent procedure as an out-
Cartilage tympanoplasty was used in 55 (12.9%) of their
come measure. In all but 1 study (McGrew et al13), no dif-
patients and temporalis fascia in the rest. Cases were fol-
ference was seen in outcomes between ears treated with an
lowed up for an average of 32 months. No statistical differ-
additional therapeutic mastoidectomy and those who
ence was found between the groups with respect to graft
underwent tympanoplasty alone.
healing or hearing outcomes, as with all other studies.
Mastoidectomy in inactive squamous COM. A total of 2 studies However, theirs was the only study to suggest that long-
were deemed suitable for analysis at consensus (Table 3). term clinical outcomes were worse in the tympanoplasty-
Both were retrospective reviews. Ozbek et al18 reviewed 56 only group, with 2 developing atelectasis and 4 developing
ears with dry retraction pockets with follow-up of an aver- cholesteatoma. Subsequent tube placement was necessary in
age of 44.5 months. Their outcome measures were graft suc- 10 of the tympanoplasty-only group compared with 5 in the
cess and mean postoperative ABG. They found no mastoidectomy group, but this result did not reach statistical
difference between mastoidectomy and nonmastoidectomy significance. Of note, of the cases requiring subsequent
920 Otolaryngology–Head and Neck Surgery 155(6)

Outcome worse
Table 3. Summary of Studies Comparing the Success Rate of Tympanoplasty with and without Concurrent Cortical Mastoidectomy in Inactive Squamous Chronic Otitis Media (Tympanic

procedures, only 3 underwent cartilage tympanoplasty,

Conclusion

No difference

after TWM
reinforcing the concept of the superiority of cartilage as the
graft of choice in tympanoplasty.20
The longest follow-up was afforded by Mishiro et al14
in 2009 and represented a 60-month data of their cohort
that they first reported in 2001.15 In the original cohort,
ABG closure—difference among groups
251 cases with both dry perforations and CSOM were ret-
Graft—success rates between groups

Overall success rate (A1B) = 91%


rospectively reviewed after a mean follow-up period of
State of atelectasis—full aeration or

A: Atelectasis 1 TWOM = 79.7%


B: Atelectasis 1 TWM = 55.5%
improvement between groups
31.7 months following perforation repair with or without
mastoidectomy. In both analyses, they found no statistical
not significant (P . .05)

difference in either graft or audiological outcome. In the


significant (P = .0048):
Results

60-month data, multivariate analysis was used to examine


any prognostic factors and to determine whether mastoi-
not significant:

dectomy was useful in tympanoplasty for perforated COM.


They concluded that a normal ossicular chain was the only
factor shown to have a significantly favorable influence on
long-term hearing outcomes after tympanoplasty for perfo-
rated COM; there were no significant predictors of long-
term successful graft outcomes after tympanoplasty for per-
Mean postoperative
Outcome Measure

forated COM; mastoidectomy was not a significant predic-


State of atelectasis
postoperatively

tor and could be avoided even for infected ears.14


Abbreviations: TM, tympanic membrane; TWM, tympanoplasty with mastoidectomy; TWOM, tympanoplasty without mastoidectomy.
Graft success

One study not included in Table 2 but worthy of men-


tion is the prospective case series by Rhul and Pensak21 in
ABG

1999. In this study, they selected 135 patients who had all
underwent at least 1 attempt at tympanoplasty alone in the
past for active mucosal COM. All patients underwent tym-
Graft type: not stated

panoplasty and mastoidectomy using a variety of materials


Graft type: cartilage
Intervention (n)

for the repair depending on availability (areolar tissue,


A: TWOM (27)

A: TWOM (84)
B: TWM (29)

B: TWM (27)

fascia, cartilage, pericranium) and were followed up at 18


palisades

months. The success rate was 90.4%. They concluded that


for patients with noncholesteatomatous COM who have
failed prior tympanoplastic reconstruction, an aerating mas-
toidectomy may be indicated and may improve the success
rate of the surgery.21
retraction

retraction
Pathology
by Group

A, B: TM

A, B: TM

Finally, with respect to inactive squamous COM, Ozbek


et al18 conducted a relatively small retrospective study of 56
cases undergoing a cartilage palisade technique to prevent
recurrent tympanic membrane retractions. After a mean
Retrospective

Retrospective

follow-up period of 44.5 months, closure of the tympanic


membrane was achieved in 91% of ears. Otomicroscopic
Study
Type

review

review

evaluation revealed 9 (16%) mild and 5 (8%) moderate


retractions, none of which they felt necessitated tube place-
ment. Air-bone gap closure was found to be less than 20 dB
in 71% of cases. They concluded that mastoidectomy made
(TWOM)
Mean, 44.5

Mean, 52.8
Follow-up,

54 (TWM)

no difference to their outcomes. Similarly, Avraham et al19


mo

reviewed 111 atelectatic ears in which tympanoplasty was


performed with mastoidectomy in 84 cases and without mas-
toidectomy in 27 cases. They found a statistically significant
111

difference between the 2 operation groups with respect to


n

56

presence of postoperative atelectasis, with normal aeration


Membrane Retraction).

2010

1991

or at least improvement more likely in the tympanoplasty-


Year

only group (P = .0048).

Synopsis of Key Findings


Avraham

A review of the current literature thus suggests that with


et al18

et al19
Author

Ozbek

respect to active and inactive COM, therapeutic mastoi-


dectomy is most likely only useful in selected complicated
Trinidade et al 921

Records idenfied through Addional records idenfied


database searching through other sources
(n = 1742) (n = 0)

Records aer duplicates removed


(n = 602)

Records screened Records excluded


(n = 602) (n = 576)

Full-text arcles assessed Full-text arcles excluded,


for eligibility with reasons
(n = 26) (n = 17)

Studies included in
qualitave synthesis
(n = 9)

Figure 1. Flowchart outlining the study selection process of the systematic review (based on PRISMA guidelines).

cases, while most cases seem to respond to closure of the middle Clinical Applicability of This Study
ear space via tympanoplasty in combination with culture-directed The cost of a potentially unnecessary mastoidectomy can be
systemic and/or topical antibiotics. Mastoidectomy may be useful viewed from both a clinical and financial standpoint.
in cases of refractory infection with evidence of antimicrobial Clinically, while mastoidectomy is relatively safe in the
resistance, past surgical failures with radiological evidence of hands of an experienced otologist, it still carries inherent
extensive mastoid disease, or cases involving an infectious com- risks, such as facial nerve palsy, worsened hearing, vertigo,
plication. There is as yet still insufficient evidence, however, to and tinnitus, and at higher rates than with tympanoplasty
make a strong recommendation for mastoidectomy in any of alone. Conversely, the financial cost must also be consid-
these situations. The findings of this review are in keeping with ered. The senior author (J.L.D.) does not routinely perform
those found in a similar review performed by Eliades and Limb22 therapeutic mastoidectomy for the chronic noncholesteato-
in 2013. matous ear. In 2015, 153 cartilage tympanoplasties without
With respect to inactive squamous COM, while the cre- mastoidectomy were performed on such ears. If it is pre-
ation of a volumetric pressure buffer seems a sound theory sumed that the average cortical mastoidectomy takes
in concept, evidence supporting therapeutic mastoidectomy approximately 15 to 30 minutes to perform, then at a current
in this instance is also lacking. This lack of evidence may local 1-day surgery operating room cost of $486.38 for
be in part due to an inherently flawed theory regarding the every extra 15 minutes past the first 30 minutes of operat-
volumetric buffer effect. ing, having routinely performed mastoidectomies for these
cases would have cost an additional $74,416.14 to
Limitations of This Study $148,832.28 of operating room time at our institution in
The impetus of this article was our own belief that therapeu- 2015 alone. This cost represents a sizable additional finan-
tic mastoidectomy is not beneficial in the management of cial burden on the health care system and still has not yet
the noncholesteatomatous ear. This can be seen as a bias. taken into account the further additional costs of anesthesia,
However, we feel that this belief is founded in the long supplies, medications, devices, or implants.
experience of the senior author (J.L.D.) and the evidence
that is currently available. Conclusion
Only the English literature was analyzed, but necessarily The current literature supports an evidence-based practice of
so, given that none of the reviewers are fluent in other lan- not routinely performing therapeutic mastoidectomy in the
guages. Therefore, relevant non-English articles may have chronic noncholesteatomatous ear but instead considering it
been omitted and likewise with respect to excluding studies only in cases where prior tympanoplasty has failed, antimi-
prior to 1996 (1991 in the case of inactive squamous COM). crobial resistance has been found, middle ear environment
922 Otolaryngology–Head and Neck Surgery 155(6)

is found to be particularly unsuitable, or in the case of 8. Magnuson B. Functions of the mastoid cell system: auto-
patients with sclerotic mastoids. Even then, tympanoplasty regulation of temperature and gas pressure. J Laryngol Otol.
alone may still suffice. Such practice will lead to reduced 2003;117:99-103.
cost to the patient both clinically and financially. Further 9. Gantz BJ, Wilkinson EP, Hansen MR. Canal wall reconstruction
research, ideally in the form of a prospective, multi-institu- tympanomastoidectomy with mastoid obliteration. Laryngoscope.
tional, geographically wide, ethnically diverse, randomized 2005;115:1734-1740.
controlled trial, is needed to further support this notion. 10. Cinamon U, Sade J. Mastoid and tympanic membrane as pres-
sure buffers: a quantitative study in a middle ear cleft model.
Author Contributions Otol Neurotol. 2003;24:839-842.
Aaron Trinidade, substantial contributions to the conception and 11. Albu S, Trabalzini F, Amadori M. Usefulness of cortical mas-
design of the work, acquisition/analysis/interpretation of data for toidectomy in myringoplasty. Otol Neurotol. 2012;33:604-609.
the work, drafting the work and revising it critically for important 12. Toros SZ, Habesoglu TE, Habesoglu M, et al. Do patients
intellectual content, final approval of the version to be published; with sclerotic mastoids require aeration to improve success of
Joshua C. Page, substantial contributions to the conception and tympanoplasty? Acta Otolaryngol. 2010;130:909-912.
design of the work, acquisition/analysis/interpretation of data for 13. McGrew BM, Jackson CG, Glasscock ME III. Impact of mas-
the work, drafting the work and revising it critically for important toidectomy on simple tympanic membrane perforation repair.
intellectual content, final approval of the version to be published;
Laryngoscope. 2004;114:506-511.
John L. Dornhoffer, substantial contributions to the conception
14. Mishiro Y, Sakagami M, Kondoh K, Kitahara T, Kakutani C.
and design of the work, acquisition/analysis/interpretation of data
for the work, drafting the work and revising it critically for impor- Long-term outcomes after tympanoplasty with and without
tant intellectual content, final approval of the version to be mastoidectomy for perforated chronic otitis media. Eur Arch
published. Otorhinolaryngol. 2009;266:819-822.
15. Mishiro Y, Sakagami M, Takahashi Y, Kitahara T, Kajikawa
Disclosures H, Kubo T. Tympanoplasty with and without mastoidectomy
Competing interests: None. for non-cholesteatomatous chronic otitis media. Eur Arch
Sponsorships: None. Otorhinolaryngol. 2001;258:13-15.
Funding source: None. 16. Balyan FR, Celikkanat S, Aslan A, Taibah A, Russo A, Sanna
M. Mastoidectomy in noncholesteatomatous chronic suppura-
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