On the facial nerve canal until the level of the lateral semicircular canal is reached. (F) The whole inferior cavity is filled with bone pate upon which the musculoperisteal obliteration flap will be placed. (E) Ear canal has been fortifiefiwith vertical large piece of lyodura (crrroir,). Filling of the epitympaniczygomatic area is continued. (D) Further pieces of lyodura have been applied to raise the new annular rim area (arrow). Triangle is filled with bone chips and bone pate. (C) Fascia1 graft has been turned behind the canal $kin (open trrrow,).the epitympanum and facial nerve area have been raised with lyodura (cirrow) and Trautmann's ( B ) Homograft incus columella (mnnt') by gelfoarn, the short process projecting to the umbo area. Arrow indicates a projecting surrounded stapes. ( A ) Stage before the start of reconstruction, cholesteatoma having been removed. Various stages of mastoid obliteration surgery. Any remaining cavity is filled with bone chips and bone pate.Īi’to ~ t O / ~ ~. The former annulus is reconstructed using iyodurd and periost-bearing bone and the canal wall is fortified and the cavity tilled with the meatally based postauricular musculoperiosteal flap. bone pate from the cortical bone and lyophilized dura can all be employed effectively to fill the epitympanic space and Trautmann’s triangle. Mastoid obliteration i s recommended as a rou. The first stage of the obliteration technique Postoperative follow-up of our first series is to place 2 to 4 pieces of lyophilized dura (Palva et al., 1965) showed that in the ears on top of each other in the epitympanum andĪcta Otolaryngol Downloaded from by Nyu Medical Center on 04/15/15 For personal use only.Īhstrtrcr. tate the liberation of the flap backwards. In case of doubt, second stage behind the postauricular fold in order to facili- surgery is performed 3 to 12 months later. Unintentionally it may be left in a deep The incision should always be made 1-1 cm facial sinus. As to length and width, the flap can be niche and an area covering a labyrinthine fistailored as desired to fill large cavities too. The only areas where at primary area down to the bone, preserving the facial surgery remnants of cholesteatoma epithelium nerve branches intact inside the broad meatal may be left intentionally are the oval window pedicle. obliteration (Palva, 1962) and later also for ear Very often the posterior canal wall has to be canal reconstruction (Palva, 1963), has the drilled down to the level of the lowermost same form as Popper’s flap but includes all part of the tympanic cavity along the facial subcutaneous tissues from the retro-auricular nerve canal. sure total removal of cholesteatoma epitheThe flap I have advocated, first for mastoid lium from both the mastoid and the middle ear. The primary concern is to enterior part of the cavity. Popper’s aim was not to obliterate the cavity but rather tympanic area and to the lower part of the reto provide a living lining over bone in the pos- moved bridge. Particular attention is directed to the epibroad pedicle towards the auricle. A better flap was which the sigmoid and dural laminae are exdevised by Popper (1935) who employed a posed and the semicircular canals deskelehorse-shoe formed, periosteal flap with a tized. resulted in a rather poor blood supply obliteration is thorough mastoid bone work in from the thin upper pedicle. Leaving a superior pedicle, The present technique utilizes periosteumhe cut t h e flap at the back of the auricle, which attached bone chips from the mastoid tip, bone meant that all facial nerve branches to the flap pate drilled from healthy cortical bone, and were invariably severed and which, in addi- lyophilized dura. To prevent this, some modifications have subseMastoid obliteration was introduced by quently been made to obliterate the whole Mosher (1911 ) to promote healing of the post- original cavity more effectively. In a few cases, on account of the relative narrowness of the lateral part of the ear canal, pockets formed which were difficult to clean from wax and accumulating keratin from the skin. Which became adhesive, the flap had yielded posteriorly, which resulted in an ear canal that was wider than normal, and sometimes SO wide as to resemble a small cavity. MASTOID OBLITERATION Tauno Palva From the Depurtment of O t o l t i r ~ n g o l o g Unit~ersirv ~.
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