ICW MASTOIDECTOMY Attic Wall Defect Repair Past techniques. Bruce Black MD

Transcription

1 ICW MASTOIDECTOMY Attic Wall Defect Repair Past techniques

2 EAC WALL REPAIRS Surgical Variants, Difficulties Onlay Inlay Occlusion of EAC Prone to under-flanking recurrence Unstable Prone to out-flanking after EAC erosion Underlay Unstable Impedes attic re-inspection

3 EARLY ATTIC REPAIR TECHNIQUES Bone Sections, chips, pate Cartilage Homograft, autogenous Grote HA wall implants Ceravital

4 Common sites of residual cholesteatoma. Canal wall repairs should not impede re-inspection of the at-risk attic.

5 Onlay autograft cartilage attic repair after ICW surgery. The repair appears effective, but the graft obscures inspection of the anterior attic site. A Spanner head is visible below the graft/

6 Extensive cartilage onlay grafting for a large canal wall defect after ICW surgery, intruding into the EAC.

7 Two-chip cartilage attic repair after ICW. Effective, but potentially prone to pars tensa retraction and underflanking sac reformation.

8 A large onlay tragal cartilage slice overlying an extensive canal wall defect. The cartilage is poorly adapted to the curvature of the EAC.

9 A similar onlay tragal graft sealing the attic, supplemented by shavings deep to the handle of the malleus. A Spanner MFA is in situ.

10 A small autograft cartilage slice fitted into the attic defect. A thin membrane has closed the drum between the cartilage and an Oval-Top PORP, but this site is at risk of invagination, should tubal insufficiency develop.

11 Attic wall resorption subsequent to ICW and attic repair with autograft cartilage, without recurrent cholesteatoma. Spanner MFA in situ.

12 Cartilage underlay grating of a larger attic defect. This would have precluded ready attic re-inspection. An Oval- Top is present and early drum invagination has occurred.

13 ATTIC WALL REPAIR Optimal Attributes Simple technique Versatile: adapts to all wall defects Reliable Prevents recurrence Durable, good biomaterial qualities. Permits deep EAC, and second stage attic access

14 HA ATTIC DEFECT PLATE REPAIRS 1991

15 Porous hydroxylapatite (HA)ceramic attic defect plates. Early models. The 14 mm diameter semicircular pattern, left, became the definitive design.

16 HA attic plate wall repair technique, initial concept. The 14 mm semicircular plate is sited deep to the defect as an underlay seal. ad: attic defect; ha: hydroxylapatite plate; s: stabilising Silastic strip

17 Post-aural view of the Rt attic during ICW. A deep slot is cut into the root of the zygoma to receive the HA plate.

18 HA plate in situ, resting along the horizontal facial nerve, sealing the attic from recurrent disease that might underflank attic wall repairs.

19 A strip of.020 inch Silastic is used to stabilise the strip in situ

20 HA plate fixed in situ by the spring of the Silastic strip. The latter was removed at 2 nd stage surgery to facilitate attic reinspection, the plate being fixed to the wall at that stage by tissue response.

21 View of the attic defect via the canal showing the closure of the defect and the plate sited on the VII. The canal wall is somewhat thin, better left thicker than as shown.

22 A 2 nd stage view of a plate in a paediatric ICW case. Vigorous secondary ossification has enveloped the implant.

23 Post-ICW, HA attic plate repair. Early cases were not covered with defect inlay cartilage. The epithelialised HA is seen via the defect. An Oval-Top TORP in situ.

24 Early HA plate ICW case, The HA is evident and covered with a fine epithelium, but at risk of dehiscence.

25 HA plate ICW case. To avoid biomaterial reactions, the HA is covered with bone pate. Spanner head under the malleus handle.

26 HA plate ICW, Oval-Top present. The defect is filled with bone pate, but this has caused malleus handle fixation; cartilage inlays were therefore substituted.

27 ICW, attic HA plate repair, overlain with autograft cartilage. This became the standard wall repair technique until superseded by the titanium sheeting method.

28 Coronal CT view, Lt ear after ICW with an HA plate repair evident in the attic. An Oval -Top TORP is adjacent in a well aerated middle ear.

29 HA plate attic repair seen to the right in a coronal CT section. The middle ear is heavily fibrosed, with only minor pockets of aeration.

30 A bulging inflammatory mass partially occluding the EAC. Delayed chronic infection of an HA plate in the attic, 9/12 after surgery.

31 HA PLATES Analysis of Performance Simple technique, given ICW skills Versatile for small and medium attic defects Reliable with cartilage inlay. Problems EAC wall erosion causing outflanking pockets Some attic access limitation Low infection tendency