Page 4
The 21st century brought many advances in the diagnosis and treatment of otitis media. Early diagnosis, the use of preventive measures like peumococcal vaccination , increased rate of early myringotomy and grommet tubes, advanced imaging techniques and introduction of endoscopes, all lead to the diagnosis of retraction pockets and atelectatic eardrums, as well as cholesteatoma in its early stages, congenital choleasteatoma, secondary choleasteatoma to retraction pockets and atelectatic eardrums. Massive choleasteatoma with complications are uncommon now. Increased interest in tempotal bone dissection courses as well as otology fellowships produced a new generation of well trained otosurgeons. The introduction of endoscopic ear surgery and the use of endoscopes for meticulous removal of pathology in inaccessible areas of the middle ear has definitely improved the results of chronic ear surgery in the 21st century. What we need now is a new concept emphasizing the middle ear approach first, to remove pathology as much as required, preserve middle ear mucous membrane and arearation, do mastoidectomy only when needed, and reconstruct the tympano-ossicular chain. This concept, we called Functional Middle ear and Mastoid Surgery “FMMS” .
Materials and Methods
The study was carried prospectively on 120 patients seen with middle ear choleasteatoma in the period from January 2005 to December 2010. The cases were clinically examined and CT was ordered for each case then it was staged according to TMC staging system suggested by Belal (2005). Functional middle ear and mastoid surgery (FMMS) was performed on all the cases according to the surgical roadmap. The roadmap correlates the type of the surgical procedure done according to the TMC stage of choleasteatoma. All the surgery was performed by the senior author ( AB ) as a single stage procedure. 30◦ and 70◦ endoscopes were utilized to control the disease in the anterior epitympanun and sinus tympani. Ossiculoplasty was performed with the patient’s own ossicles (autograft). Middle ear and mastoid disease, age, sex, type of ossiculoplasty, pre- and postperative audiograms, postoperative findings and follow up time were recorded . Reviewed parameters were the graft take, change in PTA- ABG at each of four frequencies (0, 5, 1, 2, 4 KHZ) and complications such as reperforation , and recurrent choleasteatoma.
Surgical Technique:
FMMS is done in 3 steps :
Proper exposure of the middle ear ( anterior ± posterior ) ± mastoid
Complete clearance of pathology
Functional restoration of the middle ear and hearing mechanism .
Step 1 : Proper Exposure
Proper exposure of the middle ear and mastoid is crucial for proper clearance of pathology.