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Postoperative Mastoid
Bernadette L. Koch, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Diagnostic Checklist

          TERMINOLOGY

          • Definitions

            • Mastoid procedure to remove diseased tissue (inflammatory or neoplastic) & preserve normal structures
              • Closed cavity procedures leave wall of external auditory canal (EAC) intact
                • Transcanal anterior atticotomy
                  • Removal of scutum & obliteration of aditus to treat cholesteatoma limited to attic
                • Canalwall up mastoidectomy
                  • Uses facial recess approach
                  • Removal of mastoid air cells, lateral mastoid cortex, and Körner septum
                  • Surgically created cavity ("mastoid bowl") communicates with epitympanum & antrum
                • Simple cortical mastoidectomy
                  • Similar to canal wall up mastoidectomy; however, epitympanum and antrum not entered
                  • Ossicles not visualized
                • Translabyrinthine approach to internal auditory canal (IAC)
                  • Canal wall up mastoidectomy + semicircular canals removed, facial nerve canal skeletonized, sigmoid plate and posterior IAC removed
              • Open cavity procedures remove posterior EAC wall & scutum
                • Canal wall down mastoidectomy
                  • Similar to canal wall up + removal of posterior EAC wall and scutum
                  • 1 large cavity: EAC, mastoid, mastoid antrum, epitympanum, and mesotympanum
                  • ± obliteration of middle ear orifice of eustachian tube with fascia or fat, to prevent exposure of surgical cavity to nasopharynx
                  • ± filling of "mastoid bowl" with fat
                  • ± reconstruction of EAC using thin sheet of hydroxyapatite
                  • Termed modified radical mastoidectomy when ossicular chain is preserved
                  • Termed radical mastoidectomy for treatment of holotympanic disease: Skeletonization of mastoid segment facial nerve canal and diseased ossicles
              • Open-close procedures remove and then replace/reconstruct posterior EAC wall
                • Recent literature suggests mastoidectomy approach with posterior canal wall reconstruction and obliteration of mastoid cavity (MAPRO)
                  • To avoid disadvantages of both canal wall up and canal wall down mastoidectomy
              • Rectosigmoid approach to IAC
                • Suboccipital craniotomy ± bone flap over craniotomy defect
                • + resection of posterior wall of IAC

          IMAGING

          • General Features

            • CT Findings

              • MR Findings

                • Imaging Recommendations

                  DIFFERENTIAL DIAGNOSIS

                    PATHOLOGY

                    • General Features

                      CLINICAL ISSUES

                      • Demographics

                        • Natural History & Prognosis

                          DIAGNOSTIC CHECKLIST

                          • Consider

                            • Image Interpretation Pearls

                              Selected References

                              1. Kronenberg J et al: Mastoidectomy reconstruction of the posterior wall and obliteration (MAPRO): preliminary results. Acta Otolaryngol. 132(4):400-3, 2012
                              2. Yamashita K et al: Detection of middle ear cholesteatoma by diffusion-weighted MR imaging: multishot echo-planar imaging compared with single-shot echo-planar imaging. AJNR Am J Neuroradiol. 32(10):1915-8, 2011
                              3. Cimsit NC et al: Diffusion-weighted MR imaging in postoperative follow-up: reliability for detection of recurrent cholesteatoma. Eur J Radiol. 74(1):121-3, 2010
                              4. De Foer B et al: Middle ear cholesteatoma: non-echo-planar diffusion-weighted MR imaging versus delayed gadolinium-enhanced T1-weighted MR imaging--value in detection. Radiology. 255(3):866-72, 2010
                              5. Plouin-Gaudon I et al: Diffusion-weighted MR imaging for evaluation of pediatric recurrent cholesteatomas. Int J Pediatr Otorhinolaryngol. 74(1):22-6, 2010
                              6. Rajan GP et al: Preliminary outcomes of cholesteatoma screening in children using non-echo-planar diffusion-weighted magnetic resonance imaging. Int J Pediatr Otorhinolaryngol. 74(3):297-301, 2010
                              7. Schwartz KM et al: Diffusion-weighted imaging for cholesteatoma evaluation. Ear Nose Throat J. 89(4):E14-9, 2010
                              8. Lehmann P et al: 3T MR imaging of postoperative recurrent middle ear cholesteatomas: value of periodically rotated overlapping parallel lines with enhanced reconstruction diffusion-weighted MR imaging. AJNR Am J Neuroradiol. 30(2):423-7, 2009
                              9. Thiriat S et al: Apparent diffusion coefficient values of middle ear cholesteatoma differ from abscess and cholesteatoma admixed infection. AJNR Am J Neuroradiol. 30(6):1123-6, 2009
                              10. Trijolet JP et al: [Acute mastoiditis in children: can mastoidectomy be avoided?.] Ann Otolaryngol Chir Cervicofac. 126(4):169-74, 2009
                              11. Venail F et al: Comparison of echo-planar diffusion-weighted imaging and delayed postcontrast T1-weighted MR imaging for the detection of residual cholesteatoma. AJNR Am J Neuroradiol. 29(7):1363-8, 2008
                              12. De Foer B et al: Single-shot, turbo spin-echo, diffusion-weighted imaging versus spin-echo-planar, diffusion-weighted imaging in the detection of acquired middle ear cholesteatoma. AJNR Am J Neuroradiol. 27(7):1480-2, 2006
                              13. Dubrulle F et al: Diffusion-weighted MR imaging sequence in the detection of postoperative recurrent cholesteatoma. Radiology. 238(2):604-10, 2006
                              14. Aikele P et al: Diffusion-weighted MR imaging of cholesteatoma in pediatric and adult patients who have undergone middle ear surgery. AJR Am J Roentgenol. 181(1):261-5, 2003
                              15. Kösling S et al: CT and MR imaging after middle ear surgery. Eur J Radiol. 40(2):113-8, 2001
                              16. Castillo M et al: Imaging of Bezold's abscess. AJR Am J Roentgenol. 171(6):1491-5, 1998
                              17. Mukherji SK et al: CT of the temporal bone: findings after mastoidectomy, ossicular reconstruction, and cochlear implantation. AJR Am J Roentgenol. 163(6):1467-71, 1994
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Imaging

                                  • Top Differential Diagnoses

                                    • Diagnostic Checklist

                                      TERMINOLOGY

                                      • Definitions

                                        • Mastoid procedure to remove diseased tissue (inflammatory or neoplastic) & preserve normal structures
                                          • Closed cavity procedures leave wall of external auditory canal (EAC) intact
                                            • Transcanal anterior atticotomy
                                              • Removal of scutum & obliteration of aditus to treat cholesteatoma limited to attic
                                            • Canalwall up mastoidectomy
                                              • Uses facial recess approach
                                              • Removal of mastoid air cells, lateral mastoid cortex, and Körner septum
                                              • Surgically created cavity ("mastoid bowl") communicates with epitympanum & antrum
                                            • Simple cortical mastoidectomy
                                              • Similar to canal wall up mastoidectomy; however, epitympanum and antrum not entered
                                              • Ossicles not visualized
                                            • Translabyrinthine approach to internal auditory canal (IAC)
                                              • Canal wall up mastoidectomy + semicircular canals removed, facial nerve canal skeletonized, sigmoid plate and posterior IAC removed
                                          • Open cavity procedures remove posterior EAC wall & scutum
                                            • Canal wall down mastoidectomy
                                              • Similar to canal wall up + removal of posterior EAC wall and scutum
                                              • 1 large cavity: EAC, mastoid, mastoid antrum, epitympanum, and mesotympanum
                                              • ± obliteration of middle ear orifice of eustachian tube with fascia or fat, to prevent exposure of surgical cavity to nasopharynx
                                              • ± filling of "mastoid bowl" with fat
                                              • ± reconstruction of EAC using thin sheet of hydroxyapatite
                                              • Termed modified radical mastoidectomy when ossicular chain is preserved
                                              • Termed radical mastoidectomy for treatment of holotympanic disease: Skeletonization of mastoid segment facial nerve canal and diseased ossicles
                                          • Open-close procedures remove and then replace/reconstruct posterior EAC wall
                                            • Recent literature suggests mastoidectomy approach with posterior canal wall reconstruction and obliteration of mastoid cavity (MAPRO)
                                              • To avoid disadvantages of both canal wall up and canal wall down mastoidectomy
                                          • Rectosigmoid approach to IAC
                                            • Suboccipital craniotomy ± bone flap over craniotomy defect
                                            • + resection of posterior wall of IAC

                                      IMAGING

                                      • General Features

                                        • CT Findings

                                          • MR Findings

                                            • Imaging Recommendations

                                              DIFFERENTIAL DIAGNOSIS

                                                PATHOLOGY

                                                • General Features

                                                  CLINICAL ISSUES

                                                  • Demographics

                                                    • Natural History & Prognosis

                                                      DIAGNOSTIC CHECKLIST

                                                      • Consider

                                                        • Image Interpretation Pearls

                                                          Selected References

                                                          1. Kronenberg J et al: Mastoidectomy reconstruction of the posterior wall and obliteration (MAPRO): preliminary results. Acta Otolaryngol. 132(4):400-3, 2012
                                                          2. Yamashita K et al: Detection of middle ear cholesteatoma by diffusion-weighted MR imaging: multishot echo-planar imaging compared with single-shot echo-planar imaging. AJNR Am J Neuroradiol. 32(10):1915-8, 2011
                                                          3. Cimsit NC et al: Diffusion-weighted MR imaging in postoperative follow-up: reliability for detection of recurrent cholesteatoma. Eur J Radiol. 74(1):121-3, 2010
                                                          4. De Foer B et al: Middle ear cholesteatoma: non-echo-planar diffusion-weighted MR imaging versus delayed gadolinium-enhanced T1-weighted MR imaging--value in detection. Radiology. 255(3):866-72, 2010
                                                          5. Plouin-Gaudon I et al: Diffusion-weighted MR imaging for evaluation of pediatric recurrent cholesteatomas. Int J Pediatr Otorhinolaryngol. 74(1):22-6, 2010
                                                          6. Rajan GP et al: Preliminary outcomes of cholesteatoma screening in children using non-echo-planar diffusion-weighted magnetic resonance imaging. Int J Pediatr Otorhinolaryngol. 74(3):297-301, 2010
                                                          7. Schwartz KM et al: Diffusion-weighted imaging for cholesteatoma evaluation. Ear Nose Throat J. 89(4):E14-9, 2010
                                                          8. Lehmann P et al: 3T MR imaging of postoperative recurrent middle ear cholesteatomas: value of periodically rotated overlapping parallel lines with enhanced reconstruction diffusion-weighted MR imaging. AJNR Am J Neuroradiol. 30(2):423-7, 2009
                                                          9. Thiriat S et al: Apparent diffusion coefficient values of middle ear cholesteatoma differ from abscess and cholesteatoma admixed infection. AJNR Am J Neuroradiol. 30(6):1123-6, 2009
                                                          10. Trijolet JP et al: [Acute mastoiditis in children: can mastoidectomy be avoided?.] Ann Otolaryngol Chir Cervicofac. 126(4):169-74, 2009
                                                          11. Venail F et al: Comparison of echo-planar diffusion-weighted imaging and delayed postcontrast T1-weighted MR imaging for the detection of residual cholesteatoma. AJNR Am J Neuroradiol. 29(7):1363-8, 2008
                                                          12. De Foer B et al: Single-shot, turbo spin-echo, diffusion-weighted imaging versus spin-echo-planar, diffusion-weighted imaging in the detection of acquired middle ear cholesteatoma. AJNR Am J Neuroradiol. 27(7):1480-2, 2006
                                                          13. Dubrulle F et al: Diffusion-weighted MR imaging sequence in the detection of postoperative recurrent cholesteatoma. Radiology. 238(2):604-10, 2006
                                                          14. Aikele P et al: Diffusion-weighted MR imaging of cholesteatoma in pediatric and adult patients who have undergone middle ear surgery. AJR Am J Roentgenol. 181(1):261-5, 2003
                                                          15. Kösling S et al: CT and MR imaging after middle ear surgery. Eur J Radiol. 40(2):113-8, 2001
                                                          16. Castillo M et al: Imaging of Bezold's abscess. AJR Am J Roentgenol. 171(6):1491-5, 1998
                                                          17. Mukherji SK et al: CT of the temporal bone: findings after mastoidectomy, ossicular reconstruction, and cochlear implantation. AJR Am J Roentgenol. 163(6):1467-71, 1994