A Novel Technique of Reduction Meatoplasty for Correction of Very Large Meatus from a Previous Canal Wall-Down Mastoidectomy

Abstract

Objective:

To evaluate the efficacy of reduction meatoplasty, a novel technique aiming to improve the usage of molded hearing aids and ear plugs in patients undergoing mastoid obliteration of a previous canal wall-down (CWD) mastoidectomy, complicated with a very large meatus.

Patients:

Twenty-six patients from a tertiary care neurotology clinic with a very large meatus from a previous CWD mastoidectomy, who were unable to use molded hearing aids or ear plugs for water protection.

Intervention:

Reduction meatoplasty following mastoid obliteration (cartilage strips and bone pate) of the CWD mastoidectomy. The procedure involves removing a wedge of skin and underlying soft tissue superiorly in the meatus.

Main Outcome Measures:

Reduction in meatus size, enabling usage of hearing aids and ear plugs.

Results:

Twenty-six patients underwent mastoid obliteration and reduction meatoplasty to reduce meatus size. Patients were followed up for an average of 22 months post-operation. Following operation, the meatus size was significantly reduced in all patients, enabling usage of over-the-counter ear plugs. Additionally, all six patients with hearing aids could use standard occlusive hearing aid domes without requiring molded hearing aids. No patients showed symptoms of chronic infection in the mastoid cavity during the follow-up period.

Conclusions:

Results of reduction meatoplasty showed significant improvements in functionality of the external auditory meatus, indicating that this technique is effective in reducing meatus size and improving the normal meatal anatomy after mastoid obliteration.

Introduction

Canal wall-down (CWD) mastoidectomies are performed to treat cholesteatoma.¹ The challenges of CWD mastoidectomy include the creation of an open cavity that requires frequent debridement, chronic drainage, vertigo due to cold air or wind, and difficulty fitting hearing aids. The external auditory meatus must be wide enough for the ear to dry, self-clean, and enable in-office examination; all of which are important to prevent infection, debris accumulation, and recurrence of the initial disease.² However, it must also be narrow enough for cosmetic purposes and to enable hearing aid and earplug fitting.^2,3 CWD mastoidectomies are often performed in conjunction with a meatoplasty to achieve an adequate meatus size. Many techniques are discussed in the literature to widen the external auditory meatus;^2,4–7 however, published articles tackling reduction meatoplasty techniques have been scarce.^3,8 In this study, we evaluate the efficacy of a novel reduction meatoplasty for patients who underwent mastoid obliteration of previous CWD mastoidectomy with very large meatuses. With this reduction meatoplasty, we aim to reduce the meatus size to improve both the fitting of molded hearing aids and ear plugs and the cosmetic appearance of the external auditory meatus.

Methods

Following institutional review board approval, we performed a retrospective chart review of patients who underwent mastoid obliteration of previous CWD mastoidectomy with very large meatuses between 2009 and 2022. All patients underwent mastoid obliteration using cartilage strips and bone pate, followed by reduction meatoplasty (Figure 1). The obliteration involves meticulously separating the skin of the cavity from the mastoid up to the level of the tympanic segment of the facial nerve superiorly and the annulus posteriorly. Cartilage graft obtained from the concha or tragus is cut in strips and placed superior to the horizontal semicircular canal to close off the antral air cell area. Previously obtained bone pate is placed over the cartilage grafts and used to fill the mastoid. Some bone pate is placed under the concha to mobilize the concha to a more anterior position. During reduction meatoplasty, the meatus was infiltrated with 1% lidocaine and epinephrine. We incised, using a number 11 knife, the canal skin and underlying tissue between 11 and 1 o’clock along the upper border of the meatus. The subcutaneous tissues were excised with the wedge of skin. The deep tissues and skin were closed with 4–0 Vicryl and 6–0 fast-absorbing gut sutures, respectively. The canal and meatus were filled with Gelfoam and bacitracin, respectively. No packing was placed in the meatus. Patients were advised to keep their ear dry. During follow-up, patients were given a 21-day course of topical ofloxacin and a 7-day course of doxycycline for mastoid obliteration.

Figure 1.

A) Meatoplasty incision lines, B) Schematic of suture lines.

Collected data included the presence of reduction in meatus size determined by the ability to use hearing aids and ear plugs. Additionally, the outcomes measured at patient follow-up visits included the incidence of postoperative complications, wound infection, granulation tissue, meatal stenosis, perichondritis, acute otitis externa, and the need for revision. Finally, patients were asked about their subjective satisfaction with the meatus appearance and hearing aid usage following the procedure.

Results

In this study, 26 patients underwent mastoid obliteration and reduction meatoplasty to correct a very large meatus from a previous CWD mastoidectomy. Of these patients, 14 were male (54%) and 12 were female (46%). Patients were followed up for an average of 22 months (SD=32), with a range from 1 to 144 months post-operation. The results of the operation included a significant reduction of meatus size to allow for the usage of over-the-counter ear plugs in all patients for water protection (Figure 2). Six patients who used hearing aids were able to use standard occlusive hearing aid domes without the need for molded hearing aids for their low-frequency hearing loss. In addition, none of these patients reported difficulty in fitting, discomfort, or excessive feedback of the hearing aids.

Figure 2.

A) Patient’s ear canal at presentation, B) Ear canal after reduction meatoplasty combined with mastoid obliteration, demonstrating reduced meatus size.

Of the post-operative complication outcomes measured, no cases of wound infection, chronic infection in the mastoid cavity, meatal stenosis, perichondritis, or facial paralysis were observed. One case of granulation tissue in the canal was observed. No patients required a revision operation. All patients were satisfied with the appearance of their ears (Table 1).

Table 1.

Novel Technique of Reduction Meatoplasty Outcomes

Outcomes	Number of Patients (%)
Wound Infection	0/26 (0%)
Granulation Tissue	1/26 (4%)
Meatal Stenosis	0/26 (0%)
Perichondritis	0/26 (0%)
Acute Otitis Externa	0/26 (0%)
Need for Revision	0/26 (0%)
Cosmetic Satisfaction	26/26 (100%)
Hearing Aids Usage Without Molds	6/6 (100%)

Discussion

In this study, we wanted to determine the efficacy of a novel technique of reduction meatoplasty in conjunction with mastoid obliteration for patients with a very large meatus from a previous CWD mastoidectomy. All patients had significant meatal size reduction and were able to use over-the-counter earplugs with no issues and were satisfied cosmetically.

CWD mastoidectomy is a surgical procedure used to primarily treat cholesteatoma and sometimes middle ear tumors.^9,10 Due to improved visualization of middle ear pathology, CWD mastoidectomy results in lower rates of recurrence relative to other techniques that also treat cholesteatoma and is therefore commonly performed.^11–14 The CWD mastoidectomy requires a meatus that is adequately sized to allow cleaning and drying of the mastoid cavity post-operatively. When the meatus is too small, the canal can encounter complications including build-up of debris, granulation tissue, infection, and otorrhea which then require frequent in-office visits to manage.¹ Thus, many surgeons remove concha cartilage and make incision(s) to allow the meatus to stay widely open long term.¹⁵ When the meatus is too large, patients suffer from the caloric effect of outside wind or cold temperature, a cosmetic deformity, and difficulty fitting over-the-counter ear plugs or hearing aids.^1,16 However, techniques to reduce the size of the meatus are rarely seen in the literature. A reduction in meatal size is accompanied by concern over complications seen in meatuses that are too small. However, the outcomes of this study showed no patients experiencing problems post-operatively. A reduction meatoplasty is best combined with a mastoid obliteration procedure which prevents the development of retained debris in the mastoid cavity and chronic infections. Our experience has shown that reduction meatoplasty in combination with mastoid obliteration allows for better ear plug and hearing aid use and is not accompanied by mastoid cavity infections.

This procedure in addition to obliteration can be performed in patients with chronic infections or those experiencing dizziness from exposure to wind or water. In addition, this technique is applicable to all forms of meatoplasty. Specifically, when we separated the concha from the mastoid, we placed bone pate to create a separation between the posterior aspect of the concha and the mastoid. This facilitated the anterior movement of the posterior wall of the meatus and allowed for the mobilization of the surrounding skin.

Limitations to this study include the small population size and no statistical comparison performed. Future studies with larger population sizes must be completed. Prospective data collection to include surveys prior to and after surgery will help shed light on quality-of-life outcomes after surgery.

Conclusions

The novel technique of reduction meatoplasty combined with mastoid obliteration demonstrated high efficacy in correcting a very large meatus from a previous CWD mastoidectomy. Results showed significant improvements in functionality and cosmesis of the external auditory canal, indicating that this technique is effective in making the meatus smaller and restoring the normal meatal anatomy after obliterating the mastoid cavity. Additionally, among all patients, there were no major postoperative complications observed which required a revision operation.