Radical Mastoidectomy

🦻 Radical Mastoidectomy

📌 Definition of Radical Mastoidectomy

Radical Mastoidectomy is a canal-wall-down procedure in which the posterior meatal wall is removed and the mastoid, middle ear, attic and antrum are exteriorized into one cavity.

Most middle ear contents (malleus, incus, membrane and mucoperiosteal lining) are removed, leaving only the stapes footplate (if possible). The eustachian tube is obliterated.

The ear is non-serviceable afterwards.

What are the aims of Radical Mastoidectomy?

What are other canal wall down procedures you know?

🩺 Indications of Radical Mastoidectomy

• Unresectable cholesteatoma

• Non-serviceable hearing ear with squamous disease

• Recurrent/intractable disease not controlled by MRM or CWU procedures

• Malignancies of middle ear / glomus tumors when radical clearance required

• Approach to petrous apex or related skull base pathology

Name the structures whose involvement leads to unresectable cholesteatoma.

⛔ Contraindications of Radical Mastoidectomy

• Serviceable hearing ear where hearing preservation is desired

• Medically unfit patients for general anesthesia

Is active ear discharge a contraindication of Cortical Mastoidectomy?

💉 Anaesthesia & Position

• General anaesthesia

• Supine position with face turned away; operated ear directed upwards to surgeon.

🔪 Operative Steps of Radical Mastoidectomy

Many initial steps mirror Modified Radical Mastoidectomy (cortical mastoidectomy → atticotomy → canal skin preservation → removal of buttresses/ridge). Radical Mastoidectomy diverges when middle-ear contents are deliberately removed and the Eustachian tube is obliterated.

1. Skin incision & exposure

• Wilde’s post-auricular incision: curved, ~1 cm behind & parallel to retroauricular sulcus from pinna attachment to mastoid tip.

• Elevate periosteum via T-shaped periosteal incision (horizontal along linea temporalis + vertical to mastoid tip); place retractors.

2. Cortical mastoidectomy

• Identify McEwan’s (suprameatal) triangle; antrum ~12–15 mm deep.

• Drill mastoid cortex.

• Exenterate mastoid, zygomatic & retrosinus cells; clear mastoid tip to digastric ridge.

3. Atticotomy & canal skin preservation

• Perform atticotomy to expose epitympanum and ossicles (incus body, short process, malleus head).

• Elevate posterior & superior canal skin + posterior annulus as pedicled flap for later lining/coverage.

4. Remove posterior canal wall elements

• Remove facial bridge

• Drill anterior buttress and posterior buttress

• Lower facial ridge

5. Clearance of disease (epitympanum → hypotympanum)

• Exenterate cholesteatoma / debris from aditus, epitympanum, mesotympanum, sinus tympani, facial recess, hypotympanum, around oval & round window niches.

6. Radical steps

• Separate incudostapedial joint

• Fracture & remove cochleariform process if required

• Mobilize and remove ossicular chain (malleus & incus removed; stapes footplate preserved if possible)

• Remove tympanic membrane and annulus and all mucoperiosteal lining from middle ear cavity.

• Make EAC floor and hypotympanum level; remove inferior bony annulus as needed.

• Obliterate Eustachian tube opening with muscle or cartilage pack to prevent mucosal re-ingrowth.

7. Saucerization & cavity preparation

• Saucerize mastoid bowl — smooth edges to promote epithelialization & prevent pockets.

• Irrigate cavity thoroughly.

8. Meatoplasty & cavity management

• Perform meatoplasty (widen EAC) for postoperative access, ventilation, self-cleansing and easier inspection.

• Optionally obliterate large cavities with temporalis muscle or other soft tissue if required.

• Line cavity with fascia/periosteum/gel foam as appropriate.

• Pack cavity with antibiotic-soaked ribbon gauze, close wound in two layers, apply mastoid dressing.

What is Facial Bridge and Facial ridge?

What is Anterior buttress and Posterior buttress?

What is Meatoplasty? What are the different types of Meatoplasty?

🩹 Post-operative care of Radical Mastoidectomy

• Remove mastoid dressing after 24–48 hours; inspect for perichondritis or infection of meatal pack.

• Sutures out around day 7; change meatal pack.

• Continue antibiotics & analgesics for ~7 days.

• Pack changes: weekly or leave cavity unpacked with regular suction & cleaning until epithelialization.

• Cavity epithelialization takes ~2–3 months.

• Cavity care & follow-up: check every 4–6 months during first year, then annually. Remove granulations (cauterize/excise) if present.

• Long-term: regular cleaning, periodic microscopy to detect debris or recurrent disease.

What are the different cavity problems that happen post Canal wall down surgeries?