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Fig. 21.5 Subdural empyema in temporal region
S. Şerier et al.
treatment is started to treat the main cause of the condition. If the empyema is due to AOM, myringotomy is included in the treatment plan. In cases associated with COM, mastoidectomy is performed. In appropriate clinical circumstances, mastoid­ectomy and craniotomy may be performed simultaneously [59].

21.4 Conclusion

The use of antibiotics has reduced the incidence of complications. Early diagnosis is a critical element in preventing these potential complications and requires sound clinical knowledge. Although some fatal complications are unavoidable, timely diagnosis and appropriate treatment can reduce or even prevent the damage that can result from such complications.

References

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21 Complications ofOtitis Media
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443

Basic Otological Surgical Techniques

22
HakanBayraktar, MeteIseri, andMarcoMandala

22.1 Introduction

Chronic suppurative otitis media (CSOM) is a chronic infectious inammation of the middle ear and its associated spaces that lasts longer than 3months. Its main features are tympanic membrane perforation, ear discharge, and hearing loss. In addition to the CSOM clinic, the presence of subepithelial squamous cell keratin­ized epithelium accumulation in the middle ear and mastoid cavity and cholestea­toma accompanied by an inammatory layer around it is dened as CSOM with cholesteatoma. Treatment of both CSOM and CSOM with cholesteatoma is surgical intervention. Tympanoplasty and/or mastoidectomy techniques have been dened as two main surgical approaches.
22.2 Tympanoplasty, Ossiculoplasty, andMyringoplasty
Myringoplasty, tympanoplasty, and ossiculoplasty are techniques used in the surgi­cal management of acute and chronic middle ear disease. The goal of tympano­plasty is to treat existing middle ear disease, restore functional hearing, restore middle ear ventilation, and create a self-cleaning external auditory canal (EAC).
Myringoplasty only treats a perforated eardrum. It does not involve the middle ear and mastoid interventions. Myringoplasty is usually used for small and medium­sized perforations with no ossicular chain involvement. Fat, temporal muscle fascia,
H. Bayraktar (*) Department of Otorhinolaryngology, Kocaeli City Hospital, Kocaeli, Turkey
M. Iseri Private ENT Clinic, Kocaeli, Turkey
M. Mandala Department of Otolaryngology, University of Siena, Siena, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 M. T. Kalcioglu et al. (eds.), Otology Updates, Comprehensive ENT,
https://doi.org/10.1007/978-3-031-76173-7_22
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perichondrium, and cartilage with composite perichondrium are used as autografts. It is often used in the clinic as a fat and buttery myringoplasty. Allografts such as bovine pericardium collagen or dehydrated derma from donors can be used in case of repeated procedures with limited availability of autograft.
Ossiculoplasty is an additional surgical procedure that completes the tympano­plasty. The goal of ossiculoplasty is to transfer mechanical energy from the tym­panic membrane to the base of the stapes via the ossicular chain. Ossiculoplasty uses autograft, homograft, and allograft materials for ossicular chain defects.
Autograft materials are divided into bone and cartilage. Incus bone is the most commonly used material, although cortical mastoid bone may be used in rare cases. Concha, cymba, and tragus are used as cartilage materials. Autograft is inexpensive and easy to obtain, biocompatible, and non-extruded, which are its main advan­tages. However, there are also disadvantages, such as nutritional problems of the bone and cartilage tissue and the associated demineralization process, xation to surrounding tissues, and cholesteatoma recurrence.
Homograft materials are taken from the same site, so they adapt to the anatomy. Graft rejection is rare. There is also a risk of infection, especially with blood-borne and tissue-borne diseases.
Allograft materials are easy to use, but their disadvantages are cost and biocom­patibility (extruded prosthesis). Cartilage grafts are used between the prosthesis head and the eardrum to prevent extrusion of the allograft prosthesis. Prosthetic materials can be polymer, ceramic, or metal. Titanium prostheses are more com­monly used today, while polymer and ceramic prostheses were more commonly used in the past. The main advantages of titanium prostheses are their stiffness, tis­sue compatibility, lightweight, and durability. However, some studies have found no signicant difference in postoperative hearing outcomes between titanium and non­titanium prostheses [1]. Prostheses are divided into partial ossicular replacement prosthesis (PORP) for stapes suprastructure cases and total ossicular replacement prosthesis (TORP) for stapes base cases. In addition, the shape of the prosthesis may change depending on the tissue (tympanic membrane or malleus) in contact with the head of the prosthesis. The presence of a stapes suprastructure is extremely important for successful postoperative hearing outcomes. This is supported by stud­ies reporting better hearing outcomes in cases with PORP than TORP [2–6].
22.2.1 Transcanal, Endaural, andRetroauricular Approaches
The transcanal approach is often used for acute traumatic and/or posterior quadrant perforations. It is used in cases where the perforation margins are clearly visible on direct microscopic examination with the ear speculum and in large EACs. The pro­cedure refreshes the acute perforation edges, turns the epithelium outward, and lls the middle ear with spongostan for support. Myringoplasty in acute perforations is completed by placing the irregular edges of the perforation on the spongostan and placing it on the gel lm, silastic sheet, or paper membrane. Repaired tympanic membrane perforations and tympanomeatal aps are supported by silastik sheets
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and spongels at the end of the operation. The transcanal approach is commonly used in surgery for chronic otitis media and has recently been increasingly used in endo­scopic ear surgery. A rectangular tympanomeatal ap with the medial base of the EAC is usually raised between the 12 o’clock and 6 o’clock positions to allow the endoscope to enter the middle ear.
The endaural approach views the tympanic membrane more posteriorly than the transcanal approach in microscopic ear surgery. This allows both posterior and lim­ited anterior quadrant perforations to be treated with the transcanal approach. An endaural incision combined with canalplasty can treat all anterior quadrant perfora­tions. In addition to tympanoplasty/myringoplasty, ossiculoplastic procedures such as exploratory tympanotomy and otosclerosis surgery can be performed using this approach. In the endaural approach, a mini-incision is made in the incisura termina­lis between the tragus and the helix, which does not involve the cartilage and extends to the inferior border of the temporal muscle and the EAC bone. This approach allows simultaneous removal of the temporal muscle fascia for grafting purposes. The incision is then continued along the tympanosquamous suture, 6–8mm close to the tympanic annulus, and joined to the superior border of the horizontal incision between the 12 o’clock and 6 o’clock positions. A posteroinferior eshy skin ap is xed posteriorly by elevation with self-retrain retractors. The middle ear is entered under the annulus brosus by elevating the tympanomeatal ap while preserving the chorda tympani.
The retroauricular approach allows the eardrum to be viewed from the widest angle. All quadrants of the tympanic membrane can be seen, often without the need for canaloplasty. It is used for anterior quadrant perforations, especially in micro­scopic ear surgery, as it provides the most posterior view possible. In this approach, incisions are made approximately 1 cm posterior to the retroauricular sulcus, between the temporal line and the mastoid tip, following the curve of the sulcus. It passes through the subcutaneous tissue marking and cutting the postauricular mus­cle. It is dissected to the EAC in the supraperiosteal plane. Periosteal incisions are made parallel and perpendicular to the temporal line, with a T-shaped incision extending to the mastoid type. The lifted subperiosteal ap reveals the spine of Henle, the EAC, the tympanomastoid, and the squamous sutures. The EAC is then accessed with a medial sharp dissection and the tympanomeatal ap is elevated with a triangular or rectangular incision. The retroauricular approach allows access to graft material such as temporal muscle, conchal cartilage, and perichondrium through the same incision.
22.2.2 Canalplasty andMeatoplasty
Both the endaural and retroauricular approaches in microscopic ear surgery should be mastered in each quadrant of the tympanic membrane and all perforation margins for intraoperative and postoperative follow-up. For this reason, widening of the bony EAC is called canalplasty and widening of the cartilaginous EAC is called meatoplasty. In canalplasty, all walls, usually the anterior and inferior walls, are
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drilled to expose the tympanic annulus. Canalplasty is used to treat cases such as EAC cholesteatoma, exostosis, and osteoma.
Conversely, in cases of canal wall-down (CWD) tympanoplasty, meatoplasty is used to remove the posterior and superior walls of the EAC.Removal of skin and/or conchal cartilage widens the entrance to the EAC.
22.2.3 Graft Selection andGrafting Technique
Temporal muscle fascia, perichondrium, and cartilage are commonly used as grafts. Tragal and conchal cartilage are the cartilage sources. Tragal cartilage is preferred for near-total perforations because it is atter and thinner than conchal cartilage. It is harder than the fascia and the structure of the cartilage increases its resistance to retraction. It is used in patients with chronic Eustachian tube dysfunction, retraction pouch, and tympanic membrane adhesion. It is used between the hearing prosthesis and the tympanic membrane to prevent prosthesis extrusion. It is also used to close surgical defects such as atticotomy and cavity obliteration [7]. The cartilage graft can be used as a palisade, en-bloc, perichondrium composite, malleus notched, or bilobular cartilage island (pac-man grafth), depending on the surgeon’s preference and the replacement tissue. The main disadvantages of the cartilage graft compared to the fascia and perichondrium are its reduced elasticity (lower hearing perfor­mance) and the impossibility of looking through. In this case, a palisade-shaped cartilage can be used in appropriate cases so that chronic otitis media (COM) cases with cholesteatoma do not present limitations in the postoperative follow-up.
Graft placement is divided into lateral (overlay) and medial (underlay). A graft placed laterally to the tympanic membrane and bone annulus is dened as overlay, while those placed medially are dened as underlay. A total overlay technique is performed by drilling a secondary bony annulus and grafting. In the underlay tech­nique, the graft is placed under the mallei of the manubrium, covered by the skin of the EAC and/or the residual tympanic membrane.
The fascial graft material, often supported by spongostan in the middle ear, is placed laterally of the manubrium and under the anterior–inferior bony annulus.

22.3 Atticotomy

Removal of the lateral wall of the epitympanum by drilling allows visualization of the incudomalleolar joint. This technique is used in cases of attic retraction pouch and cholesteatoma, as well as in repair of ossicular chain xation, including the malleus and incus. In particular, it is used in cholesteatoma surgery to remove dis­ease that remains lateral to the head of the malleus and body of the incus. It can be used as an adjunct to tympanoplasty and in conductive hearing loss to visualize the ossicular chain during second-look surgery.
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22.4 Mastoidectomy

Cortical mastoidectomy was rst performed by Schwartze [8, 9] in 1873 and radical mastoidectomy (RM) by Zaufal [10] in 1890. Bondy [8] described modied RM in the following years, while mastoidectomy was the primary treatment in the pre­antibiotic era. Jansen [11] and Sheehy and Patterson [12] described intact canal mastoidectomy with a facial recess approach that preserved hearing and normal anatomy. In addition to COM surgery, mastoidectomy is used for cochlear implanta­tion, facial nerve decompression, labyrinthine surgery, endolymphatic sac surgery, and petrosectomy.
22.4.1 Simple (Cortical) Mastoidectomy
The antrum is often reached by partial opening of the mastoid air cells. It is used to treat acute complications of otitis media such as subperiosteal abscesses and/or coalescent mastoiditis.
22.4.2 Canal Wall-Up Mastoidectomy
The canal wall-up (CWU) approach requires more mastoid air cells to be opened than cortical mastoidectomy. The facial recess approach is added to the CWU tech­nique to control the disease in the hypo-retrotympanum, especially in cases of COM with cholesteatoma. It can be associated with atticotomy to explore the epitympa­num. Cochlear implant surgery is performed with a combination of cortical mas­toidectomy and posterior tympanotomy.
Surgical Technique A C-shaped incision is made 1cm posterior to the retroau-
ricular sulcus. The temporal muscle is identied and muscle fascia graft material is harvested from the superior temporal line at the superior border of the incision. Composite grafts with perichondrium are harvested from tragus or conchal carti­lage, depending on the surgeon’s preference. Preparation for tympanoplasty is described in the retroauricular approach section. The posterior ap of the T-shaped periosteal incision is elevated posteriorly.
The mastoid cortex is exposed with self-retrain retractors. Bone incisions paral­lel and perpendicular to the temporal line and extending to the mastoid tip, such as the periosteal incision, are made with the burr. Drilling is performed with the largest burr available and accompanied by irrigation. Attention must be paid to highlight the middle fossa dura leaving some bony tissue for its protection. The cortical mas­toidectomy is then performed on cells and the osseous septum (Körner) is reached by drilling parallel to the sigmoid sinus. The antrum is reached at the projection of the area cribrosa, following the mastoid tegmen and drilling further medially. Bony structures on the EAC, sigmoid sinus, and tegmen are thinned and the digastric
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ridge is exposed inferiorly. The antrum is drilled anteriorly to dominate the aditus and epitympanum. The course of the facial nerve should be determined during the mastoidectomy. In this way, the facial nerve will be preserved in any surgical maneuver. The short process of the incus and the lateral semicircular canal (LSC) on the oor of the antrum are recognized as the dominant facial nerve localizations. The second elbow of the facial nerve and proximal to the mastoid segment lie medial and anterior to the LSC. The mastoid segment of the facial nerve is located at the medial part of the EAC and 1–2mm medial to the short process of the incus.
The CWU mastoidectomy and the facial recess approach (posterior tympanot­omy) can be combined in some cases, depending on the disease. The limits of the facial recess approach are the triangular bone formed by the chorda tympani later­ally, the mastoid segment of the facial nerve medially, and the fossa incudis superi­orly, after the EAC has been thoroughly thinned and the middle ear entered from the facial recess. In the middle ear, the pyramidal eminence, the stapes and the long process of the incus, the promontorium, the round window niche, the handle of the malleus, and the tympanic membrane can be seen. Even the entire tympanic sinus and hypotympanum can be seen in cases with appropriate anatomy. Tympanic membrane repair in COM surgery is performed with tympanoplasty after the dis­ease has been cleared from the mastoid cavity, antrum, and middle ear.
22.4.3 Canal Wall-Down Mastoidectomy
The posterior and superior walls of the EAC are removed by drilling in the CWD approach as opposed to the CWU.The wall of the EAC is lowered to the facial ridge after the level and location of the facial nerve is revealed, and the tympanic sinus and facial recess are dominated. Therefore, the mastoid cavity opens into the EAC.The superior wall of the attic and the cog are removed by drilling, exposing the supratubal recess and the Eustachian tube orice can be seen. After complete cleaning of the cholesteatoma or related disease, all surfaces are drilled with a dia­mond burr, and a at surface is prepared for epithelialization. The cartilaginous portion of the EAC is enlarged with meatoplasty and postoperative cavity and dis­ease management is followed. The tympanic membrane is repaired with grafts while ossiculoplasty can be performed in one single procedure or postponed for a second look placing removed ossicles in the mastoid cavity, depending on the severity of the disease.
This technique is preferred in patients with contralateral severe-profound hear­ing loss, high anesthesia risk, and difculties in postoperative clinical follow-up. In addition, a lowered canal wall facilitates the management of COM complications such as LSC dehiscence. Depending on the extent of cholesteatoma in the periop­erative assessment, CWD may be preferred in the presence of a low tegmen tympani level, anterior location of the sigmoid sinus, and deep retrotympanic sinuses. However, an endoscope may be used in both CWU and CWD tympanomastoidec­tomies if the boundaries of the cholesteatoma are not fully visualized.
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