Treatment for Attico-antral disease

Rohan Sharma 128/08

Investigations
1.Examination under microscope 2.Tuning fork tests and audiogram 3.X-ray and ct scan temporal bone 4.Culture and sensitivity of discharge

Surgical Treatment
Canal Wall down:

Attico-antrostomy
Modified Radical Mastoidectomy (MRM) Radical Mastoidectomy Canal Wall up: Combined Approach through the meatus and mastoid

Medical Treatment
Topical ear drops + frequent suction clearance Indications: 1. Early disease with shallow retraction pocket 2.Elderly patients 3.Pts who are not fit for surgery under G.A. 4.Pts who can regularly come for follow up
The treatment of choice is surgical only. Surgery is done even in a wet ear unlike safe csom

Mac Ewans triangle

Canal Wall Up Mastoidectomy

Canal Wall Down Mastoidectomy

Canal wall up

Canal wall down Meatus-widely open Doctor dependant cleaning twice a year Low rate of reccurence Second look surgery not required Swimming not allowed Problems in using hearing aid due to large meatus

Meatus-normal Depence-not required

High reccurence Requires second look surgery No limitations Easy to wear a hearing aid

Middle ear cleft

Attico-antrostomy

Schwartzes Cortical Mastoidectomy

Middle ear cleft (Right)

Cortical Mastoidectomy

Boundaries of cavity
Superior: Dural or Tegmen plate Anterior: Posterior wall of external auditory canal Inferior: Digastric ridge Posterior: Sigmoid sinus plate

Medially: Lateral semicircular canal

Normal temporal bone (right)

Cortical Mastoidectomy

1. mastoiditis 2. CSOM , active refractory to antibiotics 3. Secretory otitis media refractory to antibiotics

Antiseptic dressing

Draping

Infiltration with Lignocaine

Marking of incision

Wildes post-aural incision

Incision deepened till periosteum

Musculo-periosteal flap elevated

Cortical mastoidectomy begun

Exposure of mastoid antrum

Widening of aditus

Aditus widened

Final Cavity (right)

Final Cavity (left)

Drain put in mastoid cavity

Mastoid dressing

Healed post-aural scar

Modified Radical Mastoidectomy

It is a modification of radical mastoidectomy where much of the hearing mechanism as possible is preserved

Pre-operative Anatomy

Cortical Mastoidectomy done

Modified Radical Mastoidectomy

Surgical Steps

 Perform cortical mastoidectomy

Lower facial ridge & break facial bridge

Remove cholesteatoma & granulations from

mastoid air cells & middle ear cavity

Preserve healthy mucosa, T.M. remnant &

ossicles Mastoid cavity & E.A.C. become a single cavity seperated by middle ear cavity Perform tympanoplasty. Do meatoplasty.

Cortical mastoidectomy begun

Exposure of mastoid antrum

Widening of aditus

Facial ridge lowering started

Healed Concho-meatoplasty

Post-aural incision closed

Radical Mastoidectomy

Radical Mastoidectomy

Surgical Steps

 Perform cortical mastoidectomy. Lower facial ridge

& break facial bridge. Remove cholesteatoma & granulations from mastoid air cells & middle ear. Remove normal middle ear mucosa, T.M. remnant & ossicles (except stapes footplate). Close Eustachian tube opening. No tympanoplasty done. Concho-meatoplasty performed. Mastoid, E.A.C. & middle ear become single cavity.

Indications
1. CSOM attico-antral disease with Intra-cranial complication Recurrence after modified radical mastoidectomy 2. Limited malignancy of middle ear 3. Osteomyelitis of temporal bone

Reconstructive surgery
Hearing can be restored by myringoplasty or tympanoplasty

Tympanoplasty

Thank You