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Due to the changing trends in the presentations of chronic ear disease , as well as the advances in its diagnosis and treatment, FMMS presents a logical surgical solution for tympano-mastoid cholesteatoma in the 21st century. It stresses the fact that the middle ear should be the primary target of otosurgeons to clear pathology and reconstruct the hearing mechanism. Mastoidectomy is performed, only if necessary, to approach the middle ear posteriorly and to clear pathology extensions if needed.
Mastoidectomy has classically been the treatment of middle ear choleasteatoma for more than one hundred years. In 1890, Zaufal introduced radical mastoidectomy to treat chronically draining ears.Modified radical mastoidectomy was introduced in 1910 by Bondy. In 1958, Sheehy and Jansen almost simultaneously, performed intact canal wall mastoidectomy. Since then, otologists argued the pros and cons of open versus closed mastoidectomy. There was no much concern whether mastoidectomy is needed in every case of choleasteatoma or not.
Choleasteatoma is a middle ear disease in almost all the cases, and extends in varying percentages to the mastoid according to its pathological type. Mastoid involvement by choleasteatoma varies from 20 percent in the congenital type to 60 percent in secondary acquired and 80 percent in primary acquired types according to their site of origin and pathways of spread. On the other hand, residual choleasteatoma following open or closed cavity mastoidectomy occurs mostly in the middle ear (20 to 30 percent), and occasionally in 6 percent of the cases in the mastoid. Otosurgeons have long been trained that choleasteatoma surgery is “mastoidectomy”. They start the operation doing a meticulous mastoidectomy. By the time they reach the middle ear, where most of the choleasteatoma is, and important anatomical structures lies around e.g. ossicles and facial nerve, the surgeon is usually tired. The result is a perfect mastoid cavity, residual choleasteatoma in the middle ear and less than satisfactory functional restoration of hearing.