Mastoidectomy using an osteoplastic flap.

DURING the past 20 years there have been numerous changes in our approach to mastoid surgery. New procedures have been evolved, and old ones discarded or sometimes revived. In our present state of knowledge, three principles govern our approach to surgery of chronic ear and mastoid suppuration. Firstly, all disease and especially all cholesteatoma, must be eradicated at operation. As a corollary, any mastoid operation must allow good exposure to every part of the middle ear and mastoid. Secondly, as much as possible of the normal anatomy must be preserved so as to give the best chance of restoring hearing by reconstruction. Thirdly, the exteriorized mastoid bowl with its unstable epithelium is no longer acceptable to the patient nor to the otologist. Like many other otologists, the authors have become disillusioned with the techniques of obliterating the mastoid cavity with various autogenous grafting materials. Such grafts frequently become infected or shrink to such an extent as to leave behind a large mastoid bowl. The combined-approach operations of Jansen and Smyth have gone a long way towards solving this difficulty in that they preserve the posterior bony meatal wall, thereby eliminating the problem of an exposed mastoid cavity. These combined-approach operations however, do not give adequate surgical access to the posterior part of the middle ear because visibility is hampered by the preserved posterior bony meatal wall in its normal position. We have therefore reached a situation where preservation of the bony bridge is a highly desirable ultimate objective, yet its presence during the operation is an intolerable obstruction to proper exposure. The operation described in this paper is designed to resolve this dilemma by allowing temporary displacement and subsequent replacement of the bony posterior canal wall. Its blood supply is kept intact by maintaining its attachment to meatal skin using the osteoplasticflap principle. Operations using a similar principle have been described by Schnee (1963) and by Portmann (1967, 1969). Schnee performs a per-meatal atticotomy and then mobilizes the posterior canal wall after exenterating the mastoid. Portmann (1967) removes the posterior bony canal wall altogether and then reconstitutes it with bone chips. In 1969, Portmann described a method in which the meatal skin is elevated from the bony