Q5 LONG ANSWER 10M ★ High-yield

Describe the surgical management of chronic otitis media.

ENT · 3rd Professional

Principles and Reconstructive Surgery

Surgery for chronic otitis media has two distinct purposes, and every operation is a combination of them: eradication of disease, and reconstruction of the sound-conducting mechanism. Eradication always takes precedence
Myringoplasty is repair of the tympanic membrane alone, with a normal ossicular chain. Tympanoplasty is repair of the drum with reconstruction of the ossicular chain
Indications for myringoplasty — a dry central perforation to prevent recurrent infection, permit water exposure, improve hearing, and as a preliminary to fitting a hearing aid

Mastoid Surgery

Operation	What is done and when
Cortical (simple, Schwartze) mastoidectomy	The mastoid air cells are exenterated, the antrum opened, but the posterior canal wall and the middle ear are left intact. For acute mastoiditis, subperiosteal abscess, masked mastoiditis, and as an adjunct to tympanoplasty where mastoid disease persists
Canal wall UP (intact canal wall) mastoidectomy	Disease removed from the mastoid and (through a posterior tympanotomy) from the middle ear, preserving the canal wall. NO cavity, better hearing potential, normal anatomy — but a higher residual and recurrent rate, so it requires a second look or MRI surveillance
Canal wall down (modified radical) mastoidectomy	The posterior canal wall is taken down, creating a single open cavity continuous with the ear canal. The middle ear and any remaining ossicles are preserved, so hearing can be reconstructed. Lowest recurrence; but a cavity needing lifelong cleaning and permanent water avoidance
Radical mastoidectomy	As above, but the middle ear is also exteriorised — drum remnant, malleus and incus removed, Eustachian tube closed. Hearing is sacrificed. Now reserved for extensive or inaccessible disease and malignancy
Atticotomy / atticoantrostomy	Limited removal of the outer attic wall for disease confined to the attic
Meatoplasty	Widening of the cartilaginous meatus, performed with every canal wall down procedure so the cavity can be cleaned and aerated

The choice between canal wall up and down depends on the extent of disease, the state of the only or better hearing ear, the presence of a labyrinthine fistula or complication, the degree of mastoid pneumatisation, the reliability of follow-UP, and the surgeon’s experience
Complications of mastoid surgery.
Postoperative care — packing removal, aural toilet, water precautions, and audiometry at 3 months
Follow up for life after cholesteatoma surgery; this is not a condition that can be discharged
Eradication always takes precedence over reconstruction, and a hearing result is never bought at the cost of leaving disease
Myringoplasty repairs the drum and tympanoplasty the chain as well.
Operate only on a dry ear; grafting a wet ear fails and wastes both the anaesthetic and the opportunity
Assess Eustachian function before grafting; without ventilation the graft retracts and the operation fails slowly
Check the cochlear reserve; there is no point restoring conduction to an ear whose cochlea no longer works
Consider the opposite ear before operating, since the risk that is acceptable depends entirely on what the patient has to lose
Temporalis fascia is the standard graft, being available through the same incision and of similar thickness to the drum
Cartilage resists retraction better, and is preferred in revision surgery, poor tube function, atelectasis and subtotal perforations

Prerequisite for myringoplasty	Why it matters
Dry ear for 6 weeks to 3 months	A graft placed in a wet ear becomes infected and is rejected
Adequate eustachian tube function	Without ventilation the graft retracts, blunts and fails, however well it was placed
NO cholesteatoma or active mastoid disease	Closing the drum over disease traps it and converts a draining ear into a silently expanding one
Reasonable cochlear reserve	There is no point restoring conduction to a cochlea that no longer works
Nose and throat treated	Untreated rhinitis, sinusitis or adenoids will undo the repair
State of the opposite ear known	Determines how much risk is acceptable — one operates cautiously on an only hearing ear
Age and reliability for follow-up	Very young children have poor tube function and higher failure rates

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