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 Table of Contents  
Year : 2019  |  Volume : 35  |  Issue : 2  |  Page : 168-172

Impact of mastoidectomy on tympanoplasty for recurrent suppurative otitis media

1 Department of Otorhinolaryngology, ENT, Faculty of Medicine for Girls Al-Azhar University, Cairo, Egypt
2 Otolaryngology, Faculty of Medicine for Girls Al-Azhar University, Cairo, Egypt

Date of Submission27-Apr-2018
Date of Acceptance29-Apr-2018
Date of Web Publication12-Apr-2019

Correspondence Address:
Sayed Mohammed Said Kadah
Al Zahraa Hospital, Al Abbasya, Cairo 11646
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejo.ejo_34_18

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Background There are still many questions about the pathogenesis of chronic suppurative otitis media (CSOM) and consequently about the optimal management medical or surgical interventions. Many otolaryngologists continue to routinely perform mastoidectomy with tympanoplasty, arguing that surgical aeration of the mastoid will improve outcomes by providing a reservoir of air that can buffer pressure changes in the middle ear according to Boyle’s law.
Patients and methods During the period from December 2013 to October 2017, the mean age was ranging from 20 to 50 years; 25 (62.5%) patients were females, whereas 15 (37.5%) patients were male who were attending the Otorhinolaryngology Department, Al Zahraa University Hospital, with recurrent suppurative otitis media refractory to medical treatment. The 20 patients selected for this study were randomly assigned to undergo tympanoplasty with cortical mastoidectomy (n=20) and tympanoplasty alone (n=20).
Results The factors that may influence surgery success rates are age, perforation location and size, Eustachian tube conditions, status of the middle-ear mucosa, the type of graft used, and surgeon experience. The primary argument in favor of mastoidectomy has been an improvement in the middle ear and mastoid environment through clearance of the diseased mucosa and through the ventilatory mechanisms of an open mastoid system, as a buffer to the changes in pressure within the middle ear.
Conclusion There was no additional benefit to performing mastoidectomy with tympanoplasty for uncomplicated perforations. Mastoidectomies were generally performed with a worst disease, as suggested by the presence of extensive inflammation, or a sclerotic middle ear or mastoid.

Keywords: mastoidectomy, otitis media, tympanoplasty

How to cite this article:
Kadah SS, Mokhemar SM, Ibrahim HA, Ibrahim HE. Impact of mastoidectomy on tympanoplasty for recurrent suppurative otitis media. Egypt J Otolaryngol 2019;35:168-72

How to cite this URL:
Kadah SS, Mokhemar SM, Ibrahim HA, Ibrahim HE. Impact of mastoidectomy on tympanoplasty for recurrent suppurative otitis media. Egypt J Otolaryngol [serial online] 2019 [cited 2020 Feb 20];35:168-72. Available from: http://www.ejo.eg.net/text.asp?2019/35/2/168/255946

  Introduction Top

Chronic suppurative otitis media (CSOM) remains one of the most common chronic infectious diseases worldwide. Although microbial, immunological, and genetically determined factors, as well as eustechian tube (ET) dysfunction, are supposed to be involved in the pathogenesis of CSOM, many aspects of the pathogenesis still need to be clarified [1],[2],[3].

Tympanoplasty is a commonly performed surgical procedure to close perforations of the tympanic membrane; the results of tympanic membrane repair, although generally favorable, can vary significantly based on multiple factors, including infection (ET), dysfunction, and variations in the operative technique. The contribution of mastoid pneumatization remains controversial, and the role of mastoidectomy in treating tympanic membrane perforations continues to be debated, particularly in the cases of chronic suppurative otitis media in the absence of cholesteatoma [2].

Mastoidectomies were generally performed with worst disease, as infection, extensive inflammation, or a sclerotic middle ear or mastoid [4].

The aim of this study is to assess the effect of mastoidectomy on treatment of chronic noncholesteatomatous otitis media; we performed a comparison of patients with recurrent tympanic membrane perforations treated with tympanoplasty or with tympanoplasty combined with the intact canal wall mastoidectomy.

  Patients and methods Top

A prospective study was performed on 40 patients ranging in age from 20 to 50 years, attending the Otorhinolaryngology Department, Al Zahraa University Hospital, who presented with recurrent suppurative otitis refractory to medical treatment, from December 2013 to October 2017. All of these patients had symptoms and signs of chronic suppurative otitis media that include audible whistling sounds during sneezing and nose blowing, decreased hearing, and a tendency to infection during colds and when water enters the ear canal. All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional and or national research comitte and with the 1964 Helsinki declaration and its later amendment or comparable ethical standards. Copious purulent drainage, which may be sanguineous in both acute and chronic perforation, did not respond well to medical treatment. Following routine physical ear–nose–throat examination, we focused on detailed ear examination.

Patients who presented with prior tympanoplasty and no active evidence of infection, were fit for surgery under general anesthesia, and tubotympanic disease was not associated with otitis externa. The noncholesteatomatous ear was selected. Patients were having active infection with ossicular abnormalities, cholesteatoma, prior mastoidectomy, and associated otitis externa.

Primary perforations were excluded from the study.

Informed consent was obtained from all patients. A total of 20 patients (12 females and eight males) were treated with cortical mastoidectomy with tympanoplasty (group A). A total of 20 patients (13 females and seven males) were treated with tympanoplasty alone (group B).

Surgical procedures

Surgeries were performed under general hypotensive-controlled anesthesia with the patients in supine position with the head rotated ∼30–45° away from the surgeon positioned.

Cortical mastoidectomy operation

Cortical mastoidectomy operation was performed under general anesthesia. The operative side is prepared by shaving the patient hair away from the field by a distance of approximately two-finger width from the attachment of the auricle. Macewen’s triangle is an area defined by three lines:
  1. A tangent drawn vertically up from the posterior edge of the external auditory meatus (EAM).
  2. A second tangent drawn horizontally back at a level between the superior edge of the EAM and the temporal line.
  3. A third tangent drawn at the posterosuperior margin of the EAM. The area enclosed by these lines is the surface marking for the mastoid antrum, which lies 2–3-cm deep and slightly anterior to it. The aim is a round smooth cavity sharp edges that are drilled off. The epithelium is worked toward the antrum from the less-dangerous regions.

Tympanoplasty operation

  • Incision: end aural incision.
  • Approaches: preauricular.
  • Technique: underlay technique.

The ear canal is opened by subperiosteal injection at the 3, 6, and 12 o’clock positions.

Lempert 2 incision

The intercartilaginous incision starts with a no. 10 scalpel with permanent contact to the bony external ear canal. The incision is extended parallel to the anterior portion of the helix upward in a smoothly curved line with reduced pressure.

Lempert 1 incision

The medial circumferential incision is placed 4–5 mm lateral to the tympanic annulus. The elevation of the tympanomeatal flap is created using the Plester’s knife, until the portion of the annulus tympanicus can be posteriorly and circumferentially seen. The undersurface of the membrane is scarified to provoke a slight bleeding to improve the attachment to the graft. The middle ear is checked. The perforation is routinely closed by an underlay technique. A small piece of gauze was soaked with an antibiotic. It was removed after 10 days.

Outcome parameters

The patients’ satisfaction with the procedure was evaluated according to improvement of hearing and success of tympanic membrane healing: preoperatively and in 3 and 6 months after the procedure.

Statistical analysis

Data were analyzed using statistical package for the social science (SPSS, version 20.0). Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage.

The following tests were done.

The χ2 test of significance was used in order to compare proportions between two qualitative parameters. A one-way analysis of variance was used when comparing between more than two means. The confidence interval was set to 95% and the margin of error accepted was set to 5%. So, the P value was considered significant as the following:
  1. P value less than 0.05 was considered significant.
  2. P value less than 0.001 was considered as highly significant.
  3. P value more than 0.05 was considered insignificant.

Graft uptake between the two studied groups, improved significantly after the operation in both the groups. Intergroup comparisons did not reveal any significant differences between the two methods after 3 and 6 months postoperatively (P<0.05). The results are summarized in [Figure 1].
Figure 1 Bar chart of the studied groups according to graft uptake.

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And after 6 months (mean±SD), the values were 24.95±11.30 in group A and 25.86±9.35 in group B. The results are summarized in [Figure 2] and [Figure 3] and [Table 1].
Figure 2 Bar chart of the studied groups according to the postoperative ABG.

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Figure 3 Bar chart of the studied group A according to the relation between graft uptake and aeration of mastoid air cells. The graph shows statistical significance as the graft uptake was 50.0% in pneumatized cells compared to 25.0% in both sclerosed and inflamed mastoid air cells.

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Table 1 Comparisons between the two studied groups according to postoperative airborne conduction gap (ABG) audiometric results

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There were two studied groups according to the relation between graft uptake and graft type in both groups. There is a highly statistical significant difference as the graft uptake was 71.0% when we use cartilage graft, compared with 29.0% when we use facial graft (P=0.001) ([Figure 4]).
Figure 4 Bar chart of the studied groups according to graft uptake and graft type.

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The graph shows a statistical significant difference as the graft uptake in group B with good ET compared to 13.0% of group B with fair ET ([Figure 5] and [Figure 6]).
Figure 5 Bar chart of the studied group A according to the relation between graft uptake and ET function. The graph shows a highly statistical significant difference as the graft uptake occurs in 75.0% of group A with good ET compared to 25.0% of group A with poor ET.

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Figure 6 Bar chart of the studied group B according to the relation between graft uptake and ET function.

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  Discussion Top

Mastoidectomy can allow surgical debridement of infected and devitalized tissues that can lead to persistent middle-ear disease. Others argue that performing mastoidectomy in these patients is unnecessary, does not improve the surgical outcome, and patients to increased surgical risks [5].

Eliades and Limb [6] showed a success rate for repair of tympanic membrane perforation. Success rates were generally good (>80%) for all studies, regardless of whether a mastoidectomy was performed or not. A total of 44% showed higher success rates with tympanoplasty plus mastoidectomy, and 66% showed the same.

Eliades and Limb [6] showed better success with tympanoplasty alone but none of the differences were statistically significant.

Mishiro et al. [4] compared tympanoplasty alone (104) with tympanoplasty and mastoidectomy (147). The authors found that graft success rates were 93.3 and 90.5%, respectively [4].

Boone et al. [7] assess the success of cartilage grafting for revision tympanoplasty without mastoidectomy; they reported that the use of cartilage in cases of retraction, recurrent perforation, bilateral perforations, and craniofacial abnormalities predisposing to (ET) dysfunction are common places. The intrinsic characteristics of cartilage provide a stiffer, hardier alternative to traditional graft materials. They use cartilage grafts in the tympanoplasty and rarely include mastoidectomy in the absence of cholesteatoma. Cartilage grafting provides enough structural stability during times of negative middle-ear pressure to allow the mucosa to revert to a more normal state naturally, and more readily resists continued (ET) dysfunction [7].

Mohamad et al. [8] found that temporal muscle fascia graft is of poor stability, because it contains connective fibrous tissue with irregular elastic fibers [7]. Otherwise, cartilage or composite cartilage grafts are more resistant to infections, middle-ear pressure, and lack of capillary feed. Therefore, it can be preferred for revision tympanoplasty, in which the risk of perforation or retraction is higher [8].

Toros et al. [9] showed that the mean air bone gape (ABG) was generally good after tympanoplasty, ranging between 10 and 20 dB. The results for patients undergoing mastoidectomy were almost universally worse (ABG) than those who did not have a mastoidectomy. However, due to a more extensive disease requiring a mastoidectomy, the preoperative ABG was also often higher in mastoidectomy patients as well [9].

Mishiro et al. [4] compared tympanoplasty alone (104) with tympanoplasty and mastoidectomy (147). They found that the postoperatively airborne gap within 20 dB was 90.4 and 81.6%, respectively. No statistically significant differences were noted for these variables or for discharging versus dry ears [4].

Ruhl and Pensak [2] found that hearing outcomes are dependent on more than just the elimination of middle-ear disease and restoration of an intact tympanic membrane. The status of the ossicles and the need for ossicular reconstruction also play an important role, regardless of the mastoid [2].

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Verhoeff M, van der Veen EL, Rovers MM, Sanders EAM, Schilder AGM. 2015 Chronic suppurative otitis media: a review Int J Pediatr Otorhinolaryngol 2006; 70:1–12.  Back to cited text no. 1
Ruhl CM, Pensak ML. Role of aerating mastoidectomy in noncholesteaomatous chronic otitis media. Laryngoscope 1999; 109:1924–1927.  Back to cited text no. 2
Bluestone CD. Studies in otitis media: children’s Hospital of Pittsburgh-University of Pittsburgh progress report. Laryngoscope 2004; 114:1–26.  Back to cited text no. 3
Mishiro Y, Sakagami M, Takahashi Y, Kitahara T, Kajikawa H, Kubo T. Tympanoplasty with and without mastoidectomy for non-cholesteatomatous chronic otitis media. Eur Arch Otorhinolaryngol 2001; 258:13–15.  Back to cited text no. 4
Balyan FR, Celikkanat S, Aslan A, Taibah A, Russo A, Sanna M. Mastoidectomyin non cholesteatomatous chronic suppurative otitis media: is it necessary? Otolaryngol Head Neck Surg 1997; 117:592–595.  Back to cited text no. 5
Eliades SJ, Limb CJ. The role of mastoidectomy in outcomes following tympanic membrane repair: a review. Laryngoscope 2013; 123:1787–1802.  Back to cited text no. 6
Boone RT, Gardner EK, Dornhoffer JL. Success of cartilage grafting in revisiontympanoplasty without mastoidectomy. Otol Neurotol 2004; 25:678–681.  Back to cited text no. 7
Mohamad SH, Khan I, Hussain SS. Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review. Otol Neurotol 2012; 33:699–705.  Back to cited text no. 8
Toros SZ, Habesoglu TE, Habesoglu M, Bolukbasi S, Naiboglu B, Karaca CT, Egeli E. Do patients with sclerotic mastoids require aeration to improve success of tympanoplasty? Acta Otolaryngol 2010; 130:909–912.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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