Abstract
Purpose
To present the surgical technique and clinical outcomes of a novel modification to conventional meatoplasty.
Materials and methods
All consecutive patients undergoing canal wall down tympanomastoidectomy incorporating the one-cut meatoplasty technique between January 2009 and February 2013 were evaluated. Primary outcome measures included meatal stenosis requiring revision surgery, frequency of drainage beyond 2 months postoperatively and results of a composite patient questionnaire incorporating the Chronic Ear Survey.
Results
Twenty-eight of 36 (78%) eligible patients completed a questionnaire and were included. All ears underwent canal wall down tympanomastoidectomy utilizing the one-cut meatoplasty technique. At a mean follow-up of 38.0 months, the average Chronic Ear Survey score was 78.6 ± 2.6 points. There was only one case of postoperative meatal stenosis. Intermittent otorrhea developed in 14.3% of cases but was remedied by conservative measures including in-office cleaning, ototopical therapy and water precautions. Eighty-nine percent of patients denied any self-consciousness about the aesthetic appearance of the ear.
Conclusions
The one-cut meatoplasty is an effective alternative to traditional techniques that is simple to perform. The results of the Chronic Ear Survey indicate that the one-cut meatoplasty supports a stable and healthy, open cavity with functional results that compare favorably to other series evaluating canal wall down tympanomastoidectomy with traditional meatoplasty. Additionally, patients report high satisfaction with the appearance of their ear, and all hearing aid users could continue to utilize a hearing aid without feedback, pain, or other difficulties related to poor fitting.
1
Introduction
The primary objective in the surgical management of chronic otitis media is to create a dry and safe ear. Tympanomastoidectomy techniques in this setting can be distinguished by their treatment of the external auditory canal. The canal wall down (CWD) tympanomastoidectomy involves removal of the posterior bony canal in order to improve surgical exposure and to exteriorize refractory disease, leading to a lower rate of recidivism compared to intact canal wall (ICW) techniques . Conventional indications for CWD tympanomastoidectomy include recurrent or residual cholesteatoma after a prior ICW procedure, extensive erosion of the bony external ear canal, and unresectable cholesteatoma involving the facial nerve, sinus tympani, petrous carotid, Eustachian tube or labyrinth.
Meatoplasty is a crucial but often overlooked component of the CWD operation. In order to promote a dry, self-cleaning ear and to allow for in-office surveillance, the external auditory meatus must be widened. Traditionally, a large meatoplasty has been advocated to support adequate ventilation and reduce conditions favorable for microbial growth, debris accumulation and recurrent disease .
However, caloric disturbances, poor hearing aid fitting, and suboptimal cosmesis have all been associated with a wide meatoplasty . Thus, an ideal technique that affords adequate ventilation while minimizing the negative effects of exposure remains elusive. We present the surgical technique and outcomes of a simple novel method of meatoplasty that helps mitigate many drawbacks of conventional meatoplasty without sacrificing outcome.
2
Materials & methods
Following institutional review board approval (131658), a retrospective chart review was conducted, and all consecutive patients who underwent CWD tympanomastoidectomy by the senior author between January 2009 and February 2013 were identified. Primary outcome measures included: 1) postoperative meatal stenosis, 2) frequency of otorrhea, and 3) patient-reported questionnaire results. The following data were collected: basic patient demographics; number of surgeries performed prior to CWD tympanomastoidectomy; indication for CWD surgery; perioperative complications; frequency of follow-up visits; frequency of drainage; number of therapeutic drop prescriptions; frequency of mastoid cleanings; difficulty with hearing aid fitting; development of meatal stenosis; need for revision meatoplasty.
Data obtained from the electronic medical record were supplemented by a composite questionnaire conducted by telephone. The questionnaire included the Chronic Ear Survey (CES) with additional questions assessing post-operative caloric disturbances, drainage, and cosmetic outcome created by the authors ( Appendix A ). The CES is a validated tool used to evaluate quality of life following surgical intervention for chronic ear disease. It is a 13-item patient questionnaire containing 3 subscales: activity restriction, symptoms, and medical resource utilization . The activity restriction subscale assesses overall impact of chronic ear disease on daily life, and the symptom subscale evaluates presence of symptoms such as pain, odor and drainage associated with the ear as well as hearing loss. The last subscale, medical resource utilization, examines how often patients required antibiotics or needed to see a physician for their ear disease. Individual item scores were normalized to a 100-point scale with a higher score indicating a better outcome. The total score and the 3 individual subscale scores are reported.
2.1
Operative technique of the one-cut meatoplasty
A standard, postauricular incision is marked and infiltrated with lidocaine and epinephrine. The ear is then prepped and draped, the ear canal is cleaned, and middle ear pathology is visualized using otomicroscopy. Following injection of the ear canal for local hemostasis, canal cuts are performed to create a vascular strip. A standard, post-auricular incision is made to the level of the musculoperiosteum, and temporalis fascia then is harvested. Next, a T-incision is created in the musculoperiosteal layer with monopolar cautery, and the musculoperiosteum is elevated anteriorly until the bony external ear canal is visualized. The posterior canal skin is gently elevated until the canal cuts are encountered, granting postauricular access to the ear canal and tympanic membrane. A Perkins retractor is then placed in order to retract the ear forward and protect the vascular strip. A tympanomeatal flap is then elevated, involved tympanic membrane is excised, and middle ear disease is addressed.
Canal wall down mastoidectomy commences with a cortical mastoidectomy and antrotomy. The canal wall is then lowered to the level of the facial ridge. In most patients with chronic ear disease, the mastoid is contracted and sclerotic; cholesteatoma rarely involves the mastoid tip. For these reasons, the senior author prefers to create a round cavity in which the inferior limit of the mastoidectomy is at the level of the hypotympanum. Following CWD mastoidectomy with tympanoplasty, attention is turned to performing the meatoplasty ( Figs. 1, 2 ).
The ear is turned forward, and cartilage is removed from the inferior cavum conchae to the crus of the helix. Next, a horizontal single incision is marked, from the posterosuperior meatus to the antihelix ( Figs. 1 A, 2 A). Using a 15-blade, the single horizontal cut is made, thus creating an inferiorly based triangular conchal flap ( Fig. 2 C). A single vicryl suture is placed in the mid-portion of the flap, and the ear is laid back ( Figs. 1 B, 2 D). This suture is pulled in order to assess the appearance of the finished meatoplasty and whether the cut needs lengthening ( Figs. 1 C, 2 E). The traditional “second cut” or inferior cut of the flap is not needed. Avoiding an inferior cut facilitates healing and improves cosmesis. Instead of the traditionally described posterior meatoplasty suture, the retention suture is placed inferiorly towards the mastoid tip, directing the flap in a more natural lying position. Once satisfied, the surgeon secures the flap against the posteroinferior portion of the mastoid bowl, and the postauricular incision is closed in anatomic layers. By limiting mastoid tip drilling and opposing the triangular conchal flap over the inferior mastoid cavity, a large dependent region in the mastoid tip is avoided. In our experience, this strategy has significantly improved water tolerance and ease of in-office cleaning. The cavity is then filled with Gelfoam® (Pfizer Inc., New York NY) and ointment, a cotton ball is placed in the meatus, and a dressing is applied.
2
Materials & methods
Following institutional review board approval (131658), a retrospective chart review was conducted, and all consecutive patients who underwent CWD tympanomastoidectomy by the senior author between January 2009 and February 2013 were identified. Primary outcome measures included: 1) postoperative meatal stenosis, 2) frequency of otorrhea, and 3) patient-reported questionnaire results. The following data were collected: basic patient demographics; number of surgeries performed prior to CWD tympanomastoidectomy; indication for CWD surgery; perioperative complications; frequency of follow-up visits; frequency of drainage; number of therapeutic drop prescriptions; frequency of mastoid cleanings; difficulty with hearing aid fitting; development of meatal stenosis; need for revision meatoplasty.
Data obtained from the electronic medical record were supplemented by a composite questionnaire conducted by telephone. The questionnaire included the Chronic Ear Survey (CES) with additional questions assessing post-operative caloric disturbances, drainage, and cosmetic outcome created by the authors ( Appendix A ). The CES is a validated tool used to evaluate quality of life following surgical intervention for chronic ear disease. It is a 13-item patient questionnaire containing 3 subscales: activity restriction, symptoms, and medical resource utilization . The activity restriction subscale assesses overall impact of chronic ear disease on daily life, and the symptom subscale evaluates presence of symptoms such as pain, odor and drainage associated with the ear as well as hearing loss. The last subscale, medical resource utilization, examines how often patients required antibiotics or needed to see a physician for their ear disease. Individual item scores were normalized to a 100-point scale with a higher score indicating a better outcome. The total score and the 3 individual subscale scores are reported.
2.1
Operative technique of the one-cut meatoplasty
A standard, postauricular incision is marked and infiltrated with lidocaine and epinephrine. The ear is then prepped and draped, the ear canal is cleaned, and middle ear pathology is visualized using otomicroscopy. Following injection of the ear canal for local hemostasis, canal cuts are performed to create a vascular strip. A standard, post-auricular incision is made to the level of the musculoperiosteum, and temporalis fascia then is harvested. Next, a T-incision is created in the musculoperiosteal layer with monopolar cautery, and the musculoperiosteum is elevated anteriorly until the bony external ear canal is visualized. The posterior canal skin is gently elevated until the canal cuts are encountered, granting postauricular access to the ear canal and tympanic membrane. A Perkins retractor is then placed in order to retract the ear forward and protect the vascular strip. A tympanomeatal flap is then elevated, involved tympanic membrane is excised, and middle ear disease is addressed.
Canal wall down mastoidectomy commences with a cortical mastoidectomy and antrotomy. The canal wall is then lowered to the level of the facial ridge. In most patients with chronic ear disease, the mastoid is contracted and sclerotic; cholesteatoma rarely involves the mastoid tip. For these reasons, the senior author prefers to create a round cavity in which the inferior limit of the mastoidectomy is at the level of the hypotympanum. Following CWD mastoidectomy with tympanoplasty, attention is turned to performing the meatoplasty ( Figs. 1, 2 ).
