5.1 General Considerations for Ear Surgery

• Consider the hearing in the other ear, comorbidity, and patient’s wishes; great caution in operating on the better-hearing ear

• When considering the risks of ear surgery, weigh up against the risks of leaving the condition untreated; e.g., lifetime risk of developing an otogenic intracranial abscess ~1:200 but poor evidence that surgery lessens this risk

5.2 Cholesteatoma Surgery

• Modified radical mastoidectomy (MRM) or canal wall down mastoidectomy:

Preserves remnants of tympanic membrane (TM) and ossicular chain, keeping eustachian tube orifice covered (as distinct from radical procedure)

Leaves open mastoid cavity

Cavity problems minimized by creating well-saucerized small cavity, covering middle ear (ME) mucosa with TM remnant, keeping facial ridge low, and creating adequate meatoplasty for ventilation and access

Often necessitates long-term aural toilet and water exclusion; may be more difficult to create well-fitting hearing aid (HA) mold or reconstruct hearing by ossiculoplasty

• Combined approach tympanoplasty or canal wall up mastoidectomy:

Preservation of ear canal wall with posterior tympanotomy to allow for access to facial recess

Requires second-look surgery to exclude residual disease (found in up to 20% of cases), so need to be medically fit for at least two general anaesthetics and have reliable follow-up

Use of potassium titanyl phosphate laser can help reduce residual disease rate and allow for ossicular chain preservation to preserve hearing

Diffusion-weighted magnetic resonance imaging techniques may allow for detection of residual disease and so prevent unnecessary second-look procedures

In the long term, no need for continued aural toilet or water exclusion; may allow for better ossiculoplasty results and easier HA fitting

• Atticoantrostomy or front-to-back surgery:

For more limited attic disease can allow for disease removal with a small cavity

Can be extended to an MRM

• Revision mastoidectomy:

A problem cavity may be improved by lowering facial ridge, obliterating cavity, closing TM perforation, or creating larger meatus

If no hearing, consider subtotal petrosectomy and blind sac closure

• Complications:

Much the same as for untreated disease: deafness, dizziness, facial palsy

Taste disturbance, sigmoid sinus bleed, semicircular canal fistula

5.3 Tympanoplasty

• Operation to eradicate disease in the ME with or without TM reconstruction

• Myringoplasty: operation to repair TM without removal of disease from the ME

In children, generally consider after ~8 years of age, once grown out of childhood ear conditions