Inside out VS Outside in Mastoidectomy

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🦻Inside out Mastoidectomy VS Outside in Mastoidectomy

Topic	Inside-out Mastoidectomy	Outside-in Mastoidectomy
Definition	Start from the middle ear/attic and work outward to aditus, antrum and mastoid - selective, disease-directed removal.	Start from the mastoid cortex and work inward to antrum, aditus and middle ear - wide exenteration of mastoid cells.
Approach / Sequence	Tympanomeatal flap → atticotomy → clear attic → aditus → antrum → mastoid air cells (from inside → out).	Post-auricular incision → expose mastoid cortex → drill mastoid air cells → reach antrum → widen aditus/attic → disease clearance → tympanoplasty.
Extent of mastoid clearance	Selective - remove only diseased cells; preserve healthy mastoid	Extensive - exenterate most accessible mastoid air cells (wide clearance)
Typical indications	- Isolated attic cholesteatoma - Limited pediatric cholesteatoma - Combined approach tympanoplasty when disease centered in attic/epitympanum	- Diffuse mastoid disease - Acute/coalescent mastoiditis - Cases where mastoid is the primary site of disease - When landmarks are intact and wide access needed
Skill level required	High - technically demanding; requires detailed anatomical knowledge and experienced surgeon.	Lower - landmark-based and systematic; suitable for trainees / more predictable.
Main advantages	- Targeted/disease-directed clearance - Less bone removal → smaller cavity - Potentially shorter operative time (if surgeon experienced) - Good for attic-predominant pediatric disease	- Systematic, landmark-based (easier to teach/learn) - Wide exposure → lower chance of hidden residual disease - Good for diffuse mastoid involvement and acute mastoiditis
Main disadvantages / risks	- Higher technical difficulty - Risk of missing disease in hidden recesses (retrofacial, tip, retrosigmoid cells) if not meticulous - Landmarks may not be encountered in usual order	- More bone removed (larger cavity) - Longer operating time - Risk of over-drilling normal mastoid where unnecessary - Less efficient for attic-predominant disease

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