Int. Adv. Otol.

2009; 5:(1) 24-30

ORIGINAL ARTICLE

Epitympanoplasty with Mastoid Obliteration Technique in Middle Ear Surgery:

12-Year Result

So-Hyang Kim, Myung-Koo Kang, Joong-Ki Ahn, Chi-Sung Han, Tae-Woo Gu

Department of Otorhinolaryngology -Head and Neck Surgery, Dong-A University College of Medicine, Busan, Korea (SHK, MKK, JKA, TWG)
Department of Otorhinolaryngology -Head and Neck Surgery, Wallace Memorial Baptist Hospital, Busan, Korea (CSH)

Objective; The aim of this study was to evaluate the usefulness of epitympanoplasty with mastoid obliteration
(EMO). Canal wall down (CWD) mastoidectomy can secure a good surgical field, allowing lesions to be
eliminated. However, cavity problems inevitably occur. Canal wall up (CWU) mastoidectomy can avoid cavity
problems, but complete removal of lesions is more difficult, and retraction pockets can form. The goal of EMO is
to obtain optimal surgical results as in CWD surgery while avoiding cavity problems. Here we introduce the
surgical techniques of EMO and discuss the results.
Materials & Methods; A retrospective case review of 401 ears in 398 patients was performed. The EMO
technique consists of a simple mastoidectomy, atticotomy, epitympanectomy and epitympanoplasty with mastoid
obliteration. The results of 12 years of surgery performed between December 1994 and June 2007 were analyzed
and the outcomes of the procedures were evaluated.
Results; Postoperative results from 401 ears were evaluated. The mean age was 42 years, and the mean follow
up period was 30 months. There was a 6.2 ( 7.8 dB hearing gain (p<0.05), and the tympanic cavity cholesteatoma
recurrence rate was 4.2%. In 0.9 % of cases, there was a residual mastoid cholesteatoma, and these cases
underwent revision CWD surgery. There was no attic retraction or retraction pocket formation.
Conclusion; Using EMO techniques, we can eliminate the disadvantages of CWD and CWU mastoidectomy.
Cavity problems can be avoided and retraction pocket formation can be prevented. EMO is a useful technique
and can be considered before CWD surgery.

Submitted : 29 August 2008 Revised : 09 October 2008 Accepted : 12 December 2008

The most effective surgical method for treating middle avoiding cavity problems, to obtain the advantages of
ear cholesteatoma and chronic otitis media has been both CWD and CWU. This study presents the results of
debated for decades, especially with regard to 12 years of EMO surgery with a detailed description of
differences in efficacy between canal wall down (CWD) the surgical concept, indications, and technique.
and canal wall up (CWU) mastoidectomy[1,2]. In Materials & Methods
cholesteatoma surgery, eradication of the cholesteatoma
and prevention of disease recurrence are the most In this retrospective case review, we studied 401 ears
important factors[3]. Postoperative care, including cavity in 398 patients (194 men and 204 women) who visited
problems and the wearing of hearing aids, also needs to the Department of Otorhinolaryngology, Head and
be considered[3]. The technique of epitympanoplasty Neck Surgery, at Dong-A University Hospital. The
with mastoid obliteration (EMO) is aimed at obtaining surgeries were performed between December 1994 and
optimal surgical results as in CWD[4] surgery while June 2007.
Corresponding address:
Myung Koo Kang, MD
Dong-A University College of Medicine, 3 Ga-1, Dongadashin-dong, Seo-Ku,
Busan 602-714, South Korea.
Phone: +82-51-240-5428; Fax : +82-51-253-0712; E-mail : mgkang@daunet.donga.ac.kr
Copyright 2005 © The Mediterranean Society of Otology and Audiology

24
 Epitympanoplasty with Mastoid Obliteration Technique in Middle Ear Surgery: 12-Year Result

The preoperative inclusion criteria for EMO were a graft in the new attic. After the epitympanoplasty, only
cholesteatoma with attic destruction, a sclerotic the mesotympanum and the hypotympanum remain as
mastoid with poor Eustachian tube function and an spaces for air ventilation of the middle ear. The
intact posterior canal wall. Other middle ear diseases passage between the tympanic cavity and mastoid
such as chronic otitis media without cholesteatoma cavity is blocked with one large cartilage slice, and the
were included, but the latter two criteria were applied mastoid is obliterated with cartilage chips and bone
equally. chips, in that order. The periosteal flap is repositioned,
The detailed procedures of the EMO technique consist and sutures are inserted layer by layer (Figure 1).
of a simple mastoidectomy, atticotomy, The results over 12 years were analyzed, and the
epitympanectomy and epitympanoplasty with mastoid outcomes of the procedure were evaluated for hearing
obliteration. A retroauricular skin incision is made, results and complications.
and a musculoperiosteal flap is elevated. Conchal Results
cartilage is harvested from the auricle using a posterior
approach. As much bone chip as possible is harvested The preoperative diagnoses were 335 cases of chronic
from the mastoid cortex using a chisel and hammer. otitis media with cholesteatoma (83.5%), 37 cases of
After a simple mastoidectomy, an epitympanectomy is adhesive otitis media (9.2%), 26 cases of chronic otitis
done, removing the scutum and widening the canal. media without cholesteatoma (6.5%), and three cases
The canal wall is widened as far as possible but of cholesterol granuloma (0.8%). Among these, 69
ensuring preservation of the posterior wall of the cases were revision cases. Before EMO, the patients
external auditory canal. In most cases, the malleus had undergone CWU surgery. The mean age of the
head and incus are removed. At the end of these steps, group was 42 years, ranging from 12 to 67 years. The
the middle ear structures can be visualized via the mean follow-up period was 30 months, ranging from
surgical microscope as much as in a CWD six to 141 months.
mastoidectomy. After completely removing the attic Postoperative hearing results were analyzed in 184
disease, an epitympanoplasty is done with cartilage ears. The type of ossiculoplasty is summarized in
chips and slices, reforming the attic and filling it with Table 1. Among the tympanoplasty categories, 159
the cartilage to leave no space for aeration. Temporalis tympanization (tympanoplasty type 0) cases did not
fascia or perichondrium is grafted over the cartilage undergo a second-stage operation for ossiculoplasty.

Figure 1. Postoperative cross sectional drawing of EMO : A) axial view, B)coronal view.
In A, posterior EAC wall is drilled and EAC is widened. After tympanomastoid block with cartilage plate, mastoid is obliterated with inner
cartilage and outer bone chip. In B, epitympanum is obliterated with cartilage chips after epitympanectomy, and then outer surface is
covered with cartilage slices and perichondrium, completing epitympanoplasty.

25
 The Journal of International Advenced Otology

Table 1. Type of ossiculoplasty

Type Cases
Tympanoplasty type I 15 (8.0 %)
Short collumerization 125(66.8%)
Autologous incus 30(16.0%)
Hydroxyapatite PORP 95(50.8%)
Long collumerization 44(23.5%)
Autologous incus 3(1.6%)
Hydroxyapatite TORP 41(21.9%)
Fitted incus 2(1.1%)
Tympanoplasty type IV 1(0.5%)
Total 187(100%)

Most of these patients already had severe outpatient clinic-based dressings and oral antibiotics.
sensorineural hearing loss, so a second-stage The remaining complication rate was 11.2%. Residual
ossiculoplasty had little role in hearing improvement. tympanic cavity cholesteatoma was detected in 17
These patients were excluded from the hearing data cases, all of which were treated in the outpatient clinic
analysis. with a simple endaural procedure. In four cases, there
was residual mastoid cholesteatoma, and all of these
The majority of patients had mixed hearing loss:
patients underwent CWD revision surgery (Table 2).
preoperative air conduction was 52.6 ± 15.36 dB, and
Overall treatment flow chart is shown in Figure 2.
preoperative bone conduction was 20.4 ± 23.16 dB.
Postoperative bone conduction was nearly same as the Postoperative temporal bone computed tomography
preoperative one. Postoperative air conduction was (TBCTs) were taken in several cases. In the TBCTs,
46.4 ± 14.32 dB, a gain of 6.2 ± 7.8 dB (p < 0.05). This the reconstructed epitympanum is seen to have soft
is not a very good result with regard to hearing, but in tissue density with formation of a shallow tympanic
cavity (Figure 3). The scutum is absent, and the attic is
most cases, the preoperative disease was severe with
filled with cartilage, leaving no space for a retraction
ossicular chain disruption, cholesteatoma matrix
pocket. In the picture of postoperative tympanic
around the stapes and mixed hearing loss. Therefore,
membrane, the reconstructed epitympanum is seen
disease control becomes the primary goal of the
with no attic resorption or retraction pocket formation
surgery, not restoration of hearing.
(Figure 4). In early surgeries, we used chopped
There were 83 complications in 76 patients (19%). cartilage only, which caused no problems but gave a
Postoperative wound infections and otorrhea were coarse appearance. We now cover the cartilage chips
controlled within a few months after surgery using with thin cartilage slices to give a smooth surface.
Table 2. Postoperative complications.
Postoperative complications Cases
Postoperative infection (wound infection & otorrhea) 33(8.2%)
Tympanic cavity residual cholesteatoma 17(4.2%)
Hydroxyapatite ossicular prosthesis protrusion 9(2.2%)
Tympanic membrane perforation 20(4.9%)
Mastoid cavity residual cholesteatoma 4(0.9%)
Total 83(20.6%)

26
 Epitympanoplasty with Mastoid Obliteration Technique in Middle Ear Surgery: 12-Year Result

Figure 2. Treatment of postoperative complications: Total recidivism cases were 21 cases. Tympanic cavity residual cholesteatoma was
detected in 17 cases and 10 cases were treated in the out patient clinic. The other 7 cases were detected during the subsequent staged
operation and treated without any further problems. 4 cases of mastoid remnant cholesteatoma underwent a revision canal wall down
mastoidectomy operation. There were a total of 20 cases with tympanic membrane perforation. All were treated in the outpatient clinic.
N: number; Primary N: patients who underwent first operation; Secondary N : patients who underwent revision operation; CWU N:
patients who had previously underwent canal wall up mastoidectomy, and underwent revision surgery at this time; EMO:
epitympanoplasty and mastoid obliteration; Rev: revision; Op: operation; f/u: follow up; NED: no evidence of disease; CWD: canal wall
down mastoidectomy; OPD: out patient department

Figure 3. Postoperative TBCTs: A) axial view & B) coronal view. The reconstructed epitympanum (*) is seen to have soft tissue density,
and a shallow tympanic cavity has been formed. Obliterated mastoid (**) is seen with a soft tissue density with inner cartilage and outer
bone chip.

Discussion mastoidectomy procedures for addressing middle ear

Optimal surgical treatment for managing pathology[1,2]. Previously, CWD surgery has been the
cholesteatoma has remained in dispute for a very long gold standard in cholesteatoma surgery[3,4]. CWD
time. There are many articles comparing the surgery is better for complete eradication of the
advantages and disadvantages of CWU and CWD disease, and the recurrence rate is lower than for CWU

27
 The Journal of International Advenced Otology

Figure 4. Postoperative right TM photos taken at 9 months postoperatively. Epitympanoplasty was done with cartilage chips and slices.
Big cartilage slices are used to cover the outer surface of the attic, making smooth appearance.

surgery[2]. However, because of problems with the mastoid remnant cholesteatoma was discovered after
CWD technique, the CWU technique is often used. By these early cases, which could be attributed to trial and
using CWU surgery, issues such as cavity problems, error or imperfections in performing the technique
bowl infections, difficulties with postoperative fitting initially. If we exclude those four cases, the total
of hearing aids and precautions around water to recurrence rate is reduced to 5.1%.
prevent dizziness from stimulation of the semicircular For successful cholesteatoma surgery, complete
canal can be solved. However, the recurrence rate of removal of the disease is important to prevent
cholesteatoma is much higher. Therefore, a variety of recurrence, as is prevention of retraction pocket
methods have been developed to make up for the weak formation in the attic[6,8,15]. Our technique of
points of each technique.[5-8,10-12] epitympanoplasty and mastoid obliteration has strong
advantages in both regards.
In this study, we examined a hybrid of CWD and
CWU surgeries with slightly more similarity to the The most serious disadvantage of CWU surgery is
CWU technique. The most encouraging result was the limitation of the surgical view, which makes it difficult
low recurrence rate. Of 401 ears, there were 332 ears to remove the cholesteatoma completely[3,4,7]. The sinus
with cholesteatoma, and the recurrence rate was 6.3% tympani, lateral epitympanum, stapes footplate and
(21 cases). Among these, there were four cases of other sites are critical points to check for any
residual mastoid cholesteatoma. These occurred only in remaining cholesteatoma[3,7]. Meticulous elimination of
the early years of using this surgical technique and are the cholesteatoma matrix is essential, and an adequate
clustered in the five years from 1994, when we started to surgical view is essential for viewing every important
use the epitympanoplasty and mastoid obliteration area in the tympanic cavity and mastoid cavity. In our
technique. The mastoid obliteration technique cannot be technique, we performed an epitympanectomy and
used in cases where complete intraoperative removal of widened the posterior canal wall. With this method,
a mastoid cholesteatoma is questionable[10,13,14]. No further nearly the same surgical field can be obtained as in

28
 Epitympanoplasty with Mastoid Obliteration Technique in Middle Ear Surgery: 12-Year Result

CWD surgery. Therefore, complete removal of the can further reduce the air burden of the stenotic
cholesteatoma is possible, and cavity problems can be Eustachian tube and reduce the risk of negative
avoided. pressure formation[5,11-14].
To treat attic destruction, we used epitympanectomy A normal mastoid cavity acts as an air reservoir[5,16].
and epitympanoplasty. The epitympanectomy is After mastoid obliteration, abrupt rises or falls in air
needed to obtain a broad surgical view, and in the pressure can cause trauma in the middle ear. However,
reconstruction of the attic, we obliterated the with poor Eustachian tube function, the pressure
epitympanum with cartilage. Scutum reconstruction change ranges observed in the middle ear cavity are
with the formation of a new aerated attic can also be narrow compared with the ranges observed with patent
used[3,7]. Eustachian tubes. Therefore, poor Eustachian tube
Postoperative attic retraction pockets are a critical function is an important preoperative consideration in
issue because of the possibility of their progression to epitympanoplasty and mastoid obliteration.
recurrent cholesteatoma[5,6,8,11,15]. Retraction pockets can A variety of materials have been used for mastoid
be caused by negative pressure in the middle ear and obliteration[9,10,13,14]. When beginning to use
mastoid cavity, and in cases with stenotic Eustachian epitympanoplasty and mastoid obliteration in 1994, we
tubes, retraction pocket formation happens more used abdominal fat as the obliterating material.
frequently; however, obliteration of the attic can However, fat tends to be absorbed over time,
eliminate these potential spaces. We used producing postauricular dimpling. Therefore, we
epitympanoplasty in order to obliterate the potential currently use cartilage and bone chips harvested from
space for retraction pocket formation in the attic. At the auricular cartilage and temporal cortical bone
the same time, the mastoid is obliterated to prevent respectively. The cartilage is used in the inner portion
negative pressure in the mastoid. We obliterated the attic first, then the bone chips are used over the cartilage to
with small cartilage chips, trimmed the outer surface of completely fill the mastoid cavity.
the obliterated attic, making it smooth with a covering of After EMO, the mastoid and epitympanum are
larger cartilage slices, and then covered the raw surface obliterated, which gives advantages in postoperative
with perichondrium-steps that together make up the care. There was postoperative tympanic cavity
epitympanoplasty. There was no postoperative cholesteatoma recurrence in 4.2% of cases (17 cases);
formation of a retraction pocket in 401 ears. however, as the mastoid cavity and attic were already
There is continuous gas exchange and gas absorption obliterated, tympanic cholesteatoma cannot grow into
in the mastoid mucosa, and continuous air ventilation those spaces. Therefore, even if a cholesteatoma
is maintained via patent Eustachian tubes. However, in recurs, it is confined to the mesotympanum and
most cases of cholesteatoma or chronic otitis media, hypotympanum, where the surgeon can easily view
Eustachian tube function tends to be poor, and and manipulate the disease using a transcanal approach
negative pressure may result from increased nitrogen in the outpatient department. This can decrease the
absorption across the diseased mastoid mucosa[5,16]. To need for revision surgery for recurrent cholesteatoma
prevent this, exenteration of the mastoid mucosa is and can lower the burden on the surgeon and the
important in the rehabilitation of a poorly aerated ear. patient.
However, with poor Eustachian tube function, In advanced cholesteatoma, most patients have mixed
exenteration of the mastoid mucosa is not sufficient to hearing loss, and a hearing aid is needed for
prevent mastoid negative pressure and to prevent postoperative hearing rehabilitation. A strong
retraction pocket formation[5,8]. Mastoid obliteration advantage of the epitympanoplasty and mastoid

29
 The Journal of International Advenced Otology

obliteration technique over the CWD mastoidectomy in canal wall down tympanoplasty with soft-wall
is that postoperative fitting of completely-in-the-canal reconstruction. Arch Otolaryngol Head Neck Surg.
type hearing aids is possible because the posterior 2008; 134:652-7.
canal wall is preserved.
8. Hinihira Y, Yanagihara N, Gyo K. Surgical
Conclusion treatment of retraction pocket with bone pate: scutum
With the EMO technique, we can make up for the plasty for cholesteatoma. Otolaryngol Head Neck Surg
disadvantages of CWD and CWU. After 2005; 133:625-8.
epitympanoplasty and mastoid obliteration, all of the 9. Cevat U. Canal wall reconstruction and mastoid
cavity-related problems seen with CWD surgery can obliteration with composite multi-fractured osteoperiosteal
be avoided without sacrificing the broad surgical view, flap. Eur Arch Otorhinolaryngol 2006; 263:1082-86.
and the recurrence rate is lower, as in CWD surgery.
In attic cholesteatoma with sclerotic mastoid and poor 10. Takahashi H, Iwanaga T, Kaieda S, Fukuda T,
Eustachian tube function, the epitympanoplasty and Kumagami H, Takasaki K, Hasebe S, Funabiki K.
mastoid obliteration technique can be considered Mastoid obliteration combined with soft-wall
before CWD surgery. reconstruction of posterior ear canal. Eur Arch
Otorhinolaryngol. 2007 Aug; 264:867-71.
References
11. Mehta RP, Harris JP. Mastoid obliteration.
1. Smyth GD. Canal wall for cholesteatoma: up or
Otolaryngol Clin N Am 2006; 39:1129-42.
down? Long-term result. Am J Otol 1985; 6:1-2
12. Yung M, Smith P. Mid-temporal pericranial and
2. Syms MJ, Luxford WM. Management of
inferiorly based periosteal flaps in mastoid obliteration.
cholesteatoma: status of the canal wall. Laryngoscope.
2003; 113:443-8 Otolaryngol Head Neck Surg 2007; 137:906-12.

3. Meuser W. The exenterated mastoid: A problem of 13. Dornhoffer JL. Smith J. Richter G, Boeckmann J.
ear surgery. Am J Otol 1985; 6:323-5 Impact on Quality of life after mastoid obliteration
Laryngoscope. 2008; 118:1427-32.
4. Hulka GF, McElveen JT Jr. A randomized, blind
study of canal wall up versus canal wall down 14. Duckert LG, Makielski KH, Helms J. Management
mastoidectomy determining the diffefences in viewing of anterior epitympanic cholesteatoma: expectations
middle ear anatomy and pathology. Am J Otol 1998; after epitympanic approach and canal wall
19:574-8. reconstruction. Otol Neurotol. 2002; 23(1):8-13

5. Gantz BJ, Wilkinson EP, Hansen MR. Canal wall 15. Sade J. Treatment of retraction pockets and
reconstruction tympanomastoidectomy with mastoid cholesteatoma. J Laryngol Otol 1982; 96:685-704
obliteration. Laryngoscope 2005; 1743-40. 16. Ars B, Wuyts F, Van de Heyning P, Miled I,
6. Yanagihara N, Gyo K, Sakai Y, Hinohira Y. Boqers J, Van Marck E. Histomorphometric study of
Prevention of recurrence of cholesteatoma in intact the normal middle ear mucosa.Prelominary results
canal wall tympanoplasty. Am J Otol 1993; 6:590-4. supporting the gas-exchange function in the postero-
7. Haginomori S, Takamaki A, Nonaka R, Takenaka superior part of the middle ear cleft. Acta Otolaryngol
H. Residual cholesteatoma: incidence and localization 1997; 117:704-7

30