Mastoid surgery

Initially, the ear may drain fluid with a foul odor. As the cholesteatoma pouch or sac enlarges, it can cause a feeling of fullness or pressure in the ear, along with hearing loss. An ache behind or in the ear, especially at night, may cause significant discomfort.
 
Dizziness, or muscle weakness on one side of the face (the side of the infected ear) can also occur. Any or all of these symptoms are good reasons to seek medical evaluation.

Cholesteatoma is a serious but treatable ear condition, which can be diagnosed only by medical examination. Bone erosion can cause the infection to spread into the surrounding areas, including the inner ear and brain. If untreated, deafness, brain abscess, meningitis, and, rarely, death can occur.


Teaching mastoid surgery with binocular operating microscope and KTP LASER Before antibiotics, mastoid surgery was commonly done in desperate circumstances for acute infection, a mastoid abscess. Our predecessors had nothing better than a hammer and gouge, and no magnification other than some spectacle loupes. It was counted a success if the patient – usually a young child – survived. No delicate work could be done, and most survivors were deafened. It was only after the introduction of the binocular operating microscope in the 1950’s that modern delicate controlled microsurgery of the ear became possible. Even with all the latest high powered microscopes, lasers and modern anaesthetics, mastoid surgery is very difficult. Surgeons have to train for years to get good at it. Like all ear surgeons trained since the 1960’s I did my basic training (in the 1980’s) on temporal bones from cadavers (dead bodies). Although some might find that macabre, I’d prefer the learning curve to be on my dead granny, rather than on my live child. The margin of error in mastoid surgery is measured in fractions of a millimetre. Anatomy varies considerably, and a surgeon needs to practice on lots of bones before embarking on live patients. Simulators and plastic bones just aren’t up to it. Unfortunately, in the UK, a public attitude has become established against the use of post-mortem tissues, which has led to a severe shortage of temporal bones for the next generation of ear surgeons to train on. I teach trainee surgeons ear surgery on live patients every week, sometimes two or three cases. The operations take anywhere between one to six hours. The average is around three hours.

With prompt treatment, it is possible to cure mastoiditis. Seeking medical care early is important. However, it is difficult for antibiotics to penetrate to the interior of the mastoid process and so it may not be easy to cure the infection; it also may recur. Mastoiditis has many possible complications, all connected to the infection spreading to surrounding structures. Hearing loss is likely, or inflammation of the labyrinth of the inner ear ( labyrinthitis ) may occur, producing vertigo and an ear ringing may develop along with the hearing loss, making it more difficult to communicate. The infection may also spread to the facial nerve (cranial nerve VII), causing facial-nerve palsy , producing weakness or paralysis of some muscles of facial expression, on the same side of the face. Other complications include Bezold's abscess , an abscess (a collection of pus surrounded by inflamed tissue) behind the sternocleidomastoid muscle in the neck, or a subperiosteal abscess , between the periosteum and mastoid bone (resulting in the typical appearance of a protruding ear). Serious complications result if the infection spreads to the brain. These include meningitis (inflammation of the protective membranes surrounding the brain), epidural abscess (abscess between the skull and outer membrane of the brain), dural venous thrombophlebitis (inflammation of the venous structures of the brain), or brain abscess . [2] [4]

Risks of the surgery are the same as if the cholesteatoma is not removed, but occur less frequently.  Hearing loss and dizziness may occur along with injury to the lining or dura of the brain.  The VII Nerve runs through the center of the middle ear and mastoid cavity and can be injured during surgery.  This may cause a facial paralysis.  However, from the picture on the right, one can see how this nerve can be easily damaged by the cholesteatoma .  Thus, once diagnosed, most cholesteatoma should be surgically removed.  Kos et al. reported on the results for canal wall down mastoidectomies .  He found the average pre-operative hearing loss was 52 dB.  Post-operatively the hearing was unchanged in 41%, improved in 31% and worse in 28%.  Other complications were persistent vertigo and one case of facial paralysis.  View Abstract

A long standing cholesteatoma can erode through the dura and into the brain or into the inner ear.  The horizontal semicircular canal is the inner ear structure most prone to damage.  Below is a link to a CT Scan of a cholesteatoma which produced a fistula of the horizontal semicircular canal.  The patient had a chronic history of hearing loss and ear drainage.  He recently, experienced a severe episode of vertigo from labyrinthitis .  

Mastoid surgery

mastoid surgery

Risks of the surgery are the same as if the cholesteatoma is not removed, but occur less frequently.  Hearing loss and dizziness may occur along with injury to the lining or dura of the brain.  The VII Nerve runs through the center of the middle ear and mastoid cavity and can be injured during surgery.  This may cause a facial paralysis.  However, from the picture on the right, one can see how this nerve can be easily damaged by the cholesteatoma .  Thus, once diagnosed, most cholesteatoma should be surgically removed.  Kos et al. reported on the results for canal wall down mastoidectomies .  He found the average pre-operative hearing loss was 52 dB.  Post-operatively the hearing was unchanged in 41%, improved in 31% and worse in 28%.  Other complications were persistent vertigo and one case of facial paralysis.  View Abstract

A long standing cholesteatoma can erode through the dura and into the brain or into the inner ear.  The horizontal semicircular canal is the inner ear structure most prone to damage.  Below is a link to a CT Scan of a cholesteatoma which produced a fistula of the horizontal semicircular canal.  The patient had a chronic history of hearing loss and ear drainage.  He recently, experienced a severe episode of vertigo from labyrinthitis .  

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