Abstract
To compare surgical outcomes with different meatoplasty techniques without removal of a cartilage piece in canal wall down mastoidectomy. Total 61 patients of canal wall down mastoidectomy included in the study where either inferior based flap technique or division in middle technique meatoplasty performed and 2 groups formed. Group A consisted of 33 patients and the inferior based flap technique of meatoplasty used in these patients. Group B consisted of 28 patients and the division in middle technique of meatoplasty used in these patients. Granulations, discharge or stenosis of canal were observed in less than 8% of cases in both the groups. Meatoplasty done without incision or excision of a piece of cartilage from pinna can be achieved with good success rates with either inferiorly based flap technique or division in middle technique.
Keywords: Meatoplasty, Mastoidectomy, Canal wall down mastoidectomy, Cholesteatoma
Introduction
Mastoidectomy is a common procedure done to treat Cholesteatoma. Cholesteatoma is a cause of curable deafness. In a developing country, this remains a common health problem and in many cases, a neglected one. If not treated in time, it can cause extra cranial or intra cranial complications. Canal wall down Mastoidectomy is a common surgery performed to address this condition and to cure it. In this surgery, Middle ear, Mastoid area and external auditory canal are converted into a single cavity after removing cholesteatoma completely. Grafting is also done by temporalis fascia. Bony part of the posterior wall of external auditory canal also removed in this procedure in order to achieve complete removal of disease. Meatoplasty is a very important and final step in canal wall down Mastoidectomy surgery to make the external opening of ear adequate in order to provide a dry and healthy cavity. If not performed adequately, then it can cause granulation formation, discharge or stenosis of canal but if performed excessively wide, then it can result in cosmetically bad looking external ear and it can also cause over-exposed cavity. There are many surgical techniques to perform meatoplasty described in literature, which may or may not include removal of a piece of conchal cartilage. Here we describe results of two of the commonly used techniques in our institute where cartilage has neither been removed from concha nor incised.
Material and Methods
Total 61 ears operated in our institute for canal wall down (CWD) procedure in 8 months were included in this study and minimum follow up of 6 months after surgery maintained. Approval from the Institute Ethical Committee obtained before carrying out this study. Detailed informed consent taken from all participants of the study. All the patients were operated by the same surgeon (Author 1), with the same type of CWD procedure, where the facial ridge had been lowered till the level of Lateral semicircular canal and grafting done by temporalis fascia graft in underlay method. Each patient has undergone either inferior based flap technique or division in middle technique. In inferior based flap technique, only one vertical incision is made at superior aspect of the external auditory canal (12’o clock position) and one horizontal incision made in canal wall just medial to the medial end of the conchal cartilage (Fig. 1) and this creates a flap based inferiorly, which was sutured to subcutaneous tissues post aurally. This creates a meatus which is wide enough to permit at least the tip of the middle finger of the surgeon and the skin flap will also help in epithelialisation of the cavity. Flap is thinned if appears excessively bulky. This technique is a modification of the technique described by Yanagisawa et al. [1]. Cases operated by this technique labeled as group A.
Fig. 1.
Vertical incision (thick arrow) at 12 o’clock position and horizontal incision (thin arrow) for inferiorly based flap (lower image with arrow) technique in a left ear
In the division in middle technique, the skin of the posterior wall of the external auditory canal was divided in middle by a vertical incision and a horizontal incision made just medial to the medial end of the conchal cartilage and this will create two flaps, superior and inferior (Fig. 2). Superior flap was sutured to subcutaneous tissues at superior aspect of post aural area. Inferior flap sutured with subcutaneous tissues at inferior aspect of post aural area. Flaps thinned and/or trimmed if excessively bulky. This technique is a modification of the technique described by Portman et at [2]. In this technique also, the meatus created permits passage of tip of the middle finger of the surgeon. Cases operated by this technique labeled as group B.
Fig. 2.
Division in the middle technique with creation of Superior (thick arrow) and Inferior (thin arrow) flaps in a left ear
Cartilage had never been removed in any of the techniques used in our study and adequate but not huge opening of the external ear created. However, in 3 cases where passage of middle finger was not possible, so the cartilage was divided in the middle and a piece of conchal cartilage also removed and these cases are not included in this study. The patients were regularly followed up after the surgery at 1 month, 3 months and 6 months. Ear endoscopy done at 3 months and 6 months to check for dryness and appearance of granulations. Patients will be asked during 3 month and 6 month follow up if they feel the external ear looks good to them, or if they feel it's very much altered or if it looks not good. Episodes of discharge from operated ear also recorded in the 6 months follow up period. Number of extra visits to OPD also recorded. At 6 months, size of ear canal assessed if it permits entry of 6 mm and 8 mm speculum. Canal labeled as stenosed if it does not permit entry of a 4 mm rigid endoscope.
Results
33 cases were included in group A and 28 cases included in group B. All patients were between 18 and 50 years of age. 1 patient in group A and none in group B developed canal wall stenosis, as observed on follow up visit, who required a revision procedure and then maintained good results. All patients in the study responded as having a good looking external ear and did not find any major alterations (Fig. 3). Granulations were seen in 1 patient in group A and 2 cases in group B on follow up visits and they responded well to local application of 10% Trichloroacetic acid once a week for 3 weeks. 57 cases did not find any ear discharge after surgery and maintained a dry healthy ear on follow up visits and these cases did not have to make any extra visits to OPD for ear related issues. The summary of results is shown in Table 1. 2 cases in Group A and 2 cases in Group B developed discharge, as they were the same cases who developed either granulations or stenosis.
Fig. 3.
Appearance of external ear immediately (Left) and 6 months after (Right) meatoplasty
Table 1.
Results in Group A and Group B cases
| Group A | Group B | |
|---|---|---|
| Granulations | 1 (3.03%) | 2 (7.1%) |
| Stenosis | 1 (3.03%) | 0 (0%) |
| Problem with appearance of ear | 0 (0%) | 0 (0%) |
| Discharge from ear | 2 (6.06%) | 2 (7.1%) |
| Accumulation of cerumen | 0 (0%) | 0 (0%) |
Discussion
It is very important that a proper meatoplasty is done after a canal wall down Mastoidectomy procedure in order to provide a dry and safe ear after surgery that maintains a good drainage and also it is for the betterment of the patients that the appearance of external ear and pinna is not very much altered after meatoplasty and it does not give very wide external canal. To achieve these objectives, two simple but meticulous approaches have been used in this study. In the inferior based flap technique, the flap itself covers inferior part of the mastoid including the mastoid tip area. This should prevent accumulation of debris in the dependent part of the cavity and also that it would help in reducing the overall size of the cavity. In the division in middle technique, two flaps created and they cover postero-superior part and postero-inferior part of the cavity, thereby helping in epithelialisation and also providing good posterior cover of the cavity. Both the techniques avoid incision or partial excision of conchal cartilage and this should maintain a good shape of the pinna after surgery. In this study, problems like granulations or stenosis or discharge after surgery were seen in less than 8% of cases in both techniques and this when compared with other studies is a very favorable observation. Only one patient (of total 61) required a revision procedure in this study. Appearance of pinna found to be very satisfactory and acceptable by all cases in this study. These results clearly indicate that the need to incise or excise a piece of conchal cartilage is in fact very minimal and in most cases not required at all if appropriate technique of meatoplasty performed, as described in this study.
Some observations of literature search about Meatoplasty are described and a comparison made between findings of current study with few other studies:
Fisch [3, 4] described a technique of meatoplasty with one incision in the posterior canal wall. Y modification of Fisch meatoplasty has been described with good success rates [5]. Mirck has described the M meatoplasty for external auditory canal [6]. Mini meatoplasty has been described [7] with good results and as effective technique for widening the external auditory meatus after bony canalplasty. Hovis et al. [8] described one cut meatoplasty with good outcomes. In the technique described by Memari et al. [9], the canal skin and conchal cartilage were incised at 5 and 12 o’clock positions. In our technique, cartilage was never incised nor excised and this completely avoids risk of perichondritis in post op period. A perichondrial posterior fixation technique has been described by Choi et al. [10] and appears very promising.
Tong et al. [11] have described sling stitch endaural meatoplasty with good results. Toronto meatoplasty is also very popular [12]. Helix advancement meatoplasty has been described by Goodyear et al. [13]. Comparison of results of our study with some other studies is shown in Table 2.
Table 2.
Comparison of results with other studies
The technique used in current study is a modification of standard techniques and it avoids unnecessary removal of cartilage piece, however the surgeon needs to be careful in case of a narrow canal.
Conclusion
Meatoplasty done without incision or excision of a piece of cartilage from pinna can be achieved with good success rates with either inferiorly based flap technique or division in middle technique. Further research in this direction will be required to consolidate the observations of this study and this study would provide technical as well as evidence based guidance towards an era of doing adequate but not excessively wide and unsightly meatoplasty.
Acknowledgements
Authors’ independent work. No grant or funds taken.
Funding
This study is author's independent work. No funds taken.
Compliance with Ethical Standards
Conflict of interest
The authors of this article declare that he/she has no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval from Institutional Ethical Committee taken prior to conducting the study.
Human and Animal Rights
Animals were not involved in this study.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
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Contributor Information
Sohil I. Vadiya, Email: sohilv81@gmail.com
Parth Makwana, Email: dr.parth.ent@gmail.com.
Nisarg Mehta, Email: mehtanisarg03@gmail.com.
Sridhar Khetani, Email: 28shreek@gmail.com.
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