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The Laryngoscope Lippincott Williams & Wilkins, Inc. © 2003 The American Laryngological, Rhinological and Otological Society, Inc.
How I Do It
A Targeted Problem and Its Solution
Modified Bondy’s Technique for Epitympanic Cholesteatoma Mario Sanna, MD; Manoj Agarwal, DLO RCS, DLO(Cal); Tarek Khrais, FRCS(I), HSDM; Giuseppe Di Trapani, MD
INTRODUCTION Localized epitympanic cholesteatoma with normal or near normal hearing gives the otologist an opportunity to achieve both aims of otologic surgery: a dry, safe ear and preservation of hearing. Clinical acumen coupled with the availability of modern radiologic technology allows the surgeon to recognize this group of cholesteatoma early. This clinical scenario is an ideal setting to perform a modified Bondy’s technique, the steps of which are described in the following paragraphs.
INDICATIONS 1. Epitympanic cholesteatoma in normal or good hearing ear with an intact tympanic membrane and ossicular chain (Fig. 1). 2. Epitympanic cholesteatoma in the better or only hearing ear with slightly compromised ossicular chain.
3.
4.
5.
An important prerequisite for performing modified Bondy’s technique is that the preoperative air-bone gap should not exceed 25 dB (calculated as the difference between the average of the air and bone-conduction thresholds at 0.5, 1, 2, and 4 kHz).1
SURGICAL STEPS 1. A standard postauricular incision is made, and the soft tissues are handled in regular fashion. A large piece of temporalis fascia is harvested for grafting. 2. A transcortical mastoidectomy is performed to
This article supported by a grant from Associazione Studio Aggiornamento Basicranio. From the Gruppo Otologico, Piacenza, Italy. Editor’s Note: This Manuscript was accepted for publication July 23, 2003. Send Correspondence to Dr. Mario Sanna, Gruppo Otologico, Via Emmanueli 42, 29100 Piacenza, Italy. E-mail: mario.sanna@ gruppootologico.com
Laryngoscope 113: December 2003
2218
6.
7.
8.
widely expose the sinodural angle and mastoid tip (Fig. 2). Once the mastoidectomy is completed, posterior epitympanotomy is performed. Care is taken not to touch the ossicles with the rotating burr during this step. This is imperative to avoid any postoperative sensorineural hearing loss because the ossicular chain is intact. To identify the ossicles as early as possible, the operating table is rotated away from the surgeon. Next, attention is directed toward the canal wall, which may need a canaloplasty. The meatal skin is elevated, folded medially, and protected using an aluminum strip while drilling the canal walls. The facial ridge must be lowered to the level of the tympanic annulus. The most medial part of the facial bridge is removed using a curette (Fig. 3). The use of a curette reduces the chances of dislocating the intact ossicular chain as compared with use of a rotating burr. The same instrument is used for removing the anterior and posterior buttresses. Care is taken to open the anterior epitympanum as far anterior as possible. Once adequate exposure of the mastoid and epitympanum is obtained, removal of cholesteatoma is initiated. Again, care is taken to avoid excessive manipulation of the ossicular chain for the reasons mentioned above. The posterosuperior annulus is partially detached from the tympanic sulcus, and the tympanic cavity is inspected for the presence of any cholesteatomatous extension that can be removed. Once the cholesteatoma is removed completely, a wide conchomeatoplasty is performed. The
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma www.medicsindex.com
Fig. 1. Coronal computed tomography scan of the right temporal bone without contrast showing presence of localized epitympanic cholesteatoma lateral to the ossicles: an ideal case for modified Bondy’s technique.
conchal cartilage obtained is used for the following steps. 9. A piece of cartilage is place in the attic and pushed as far anteriorly as possible, medial to the body of the incus and the head of the malleus (Fig. 4). If the anterior epitympanum is widely exposed, the cartilage is pushed as far as the orifice of the eustachian tube. The cartilage is placed to avoid any possible retractions in this area in the future. Another piece of cartilage may be placed lateral to the long process of the incus and medial to the handle of the malleus (Fig. 5). This cartilage prevents retraction in the posterosuperior quadrant of the grafted tympanic membrane. 10. A longitudinal cut is made in the temporalis fascia. One tongue is inserted medial to the
Fig. 2. Operative sketch of the right side demonstrating transcortical mastoidectomy with the cholesteatoma visible in the epitympanum. Note the wide exposure of the mastoid tip and sinodural angle.
Laryngoscope 113: December 2003
Fig. 3. Operative sketch of the right side demonstrating removal of the most medial part of the facial bridge, with use of a curette to minimize the chances of ossicular disruption. Note the movement of the curette is directed away from the ossicles.
body of the incus and the head of the malleus over the previously placed cartilage. The other tongue is inserted lateral to the long process of the incus and medial to the handle of the malleus by pushing it under the tympanic membrane.
Fig. 4. Operative sketch of the right side demonstrating the placement of cartilage in the attic medial to the incudomalleolar joint as far anterior as possible.
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma www.medicsindex.com
2219
avoid inadvertent opening of the temporomandibular joint.2 Similarly, caution is necessary while drilling the posterior external canal wall to avoid any injury to the facial nerve, which is particularly vulnerable to injury in the posteroinferior quadrant.3 7. Inspection of the tympanic cavity is mandatory to ensure complete removal of the disease process. 8. Modified Bondy’s technique is mainly indicated for localized epitympanic cholesteatoma and not recommended for more extensive cholesteatoma. RESULTS
Fig. 5. Operative sketch of the right side demonstrating the placement of cartilage between the long process of incus and the handle of the malleus.
11. The remaining part of the fascia covers the exposed bony surface of the mastoid cavity as far as possible. If necessary, another piece of fascia may be harvested to cover the same. 12. The tympanomeatal flap is replaced over the fascia, and the cavity is packed with an absorbable gelatin sponge (Spongostan, Johnson & Johnson, Skipton, UK). 13. The wound is closed in layers, and pressure bandage is applied.
During the period between December 1983 and December 2002, we performed a total of 153 surgeries using the surgical technique described above. Some of these cases have been reported previously.4,5 Of these, 57 cases had a follow-up of 3 years (36 months) or more. The mean follow-up was 86.6 (range 36 –196)months. Dry cavity was achieved in 54 (94.7%) cases. The remaining three (5.3%) cases had an occasional episode of otorrhea, which was controlled with local medication. There was no single instance of recurrence or reoperation. The air-bone gap was preserved or improved in comparison with the preoperative level in 43 (75.4%) cases. Nine (15.8%) cases showed a drop of air-bone gap of more than 10 dB but less than 20 dB in comparison with the preoperative level, whereas five (8.8%) cases showed a drop of more than 20 dB but less than 30 dB. This small group of patients (n ⫽ 14) exhibited the deterioration on long-term follow-up. Therefore, this deterioration is probably attributable to tubal dysfunction or ossicular fixation but definitely not to any intra-operative factor. The bone conduction was measured just before discharging the patient to assess the incidence of iatrogenic sensorineural hearing loss. It was maintained within 10 dB of the preoperative level in 55 (96.5%) cases. Two (3.5%) cases showed a deterioration of bone conduction of more than 10 dB but less than 20 dB.
HINTS AND PITFALLS 1. Adequate exposure of the sinodural angle and the mastoid tip is necessary to avoid recurrence. 2. A very deep sinodural angle should be obliterated using bone pate`, cartilage, and temporalis fascia. 3. A extensively pneumatized mastoid tip should be amputated to reduce the volume of the mastoid cavity. 4. As mentioned earlier, handling of the intact ossicles should be avoided lest the surgeon cause a sensorineural hearing loss. Extreme care should be exercised in this region, and the direction of the drilling and curetting should be away from the ossicles. 5. The anterior buttress should be removed completely to obtain a smooth continuation with the anterior wall of the external canal. This is necessary to avoid any bony overhang in this region that could hamper the self-cleansing property of the cavity. 6. Caution is advisable while drilling the anterior external canal wall during the canaloplasty to Laryngoscope 113: December 2003
2220
DISCUSSION In 1910, Gustave Bondy described a technique that attempted to provide a better outcome for his patients suffering from cholesteatomatous otitis media. He treated patients having epitympanic cholesteatoma with intact pars tensa and intact ossicular chain using a modified form of radical mastoidectomy wherein he removed the lateral attic wall and the posterior osseous wall.6 This enabled him to remove the pathology without disturbing the intact ossicular chain, thus providing the patient with a safe, dry ear and preserved hearing. However, his technique was not without pitfalls. The high facial ridge and incomplete removal of mastoid tip favored debris collection, which meant repeated visits to the otologist for the patients. There was also a possibility of leaving behind the pathology because of the restricted access. Moreover, he did not perform any meatoplasty. We, at the Gruppo Otologico, have been using the modified Bondy’s technique described above since 1983. We call it the modified Bondy’s technique because of the following reasons:
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma www.medicsindex.com
1. We put cartilage in the vicinity of the ossicles as described above to reduce the chances of retraction. 2. We inspect the middle ear to rule out any extension of the cholesteatoma in the mesotympanum. 3. Special attention is paid to the adequate lowering of the facial ridge up to the level of the tympanic annulus, which plays an important role in ensuring complete disease removal. Leaving the facial ridge high is an important cause of persistently discharging mastoid cavity.7 4. A wide conchomeatoplasty is performed for adequate aeration of the resultant cavity. 5. Treatment of the deep sinodural angle and highly pneumatized mastoid tip as outlined above is of paramount importance to achieve good results. By following these principles, the surgeon can expect to provide the patient with a dry, safe ear with preserved hearing in cases of localized epitympanic cholesteatoma in a single stage. Any procedure that
Laryngoscope 113: December 2003
achieves this end result in one stage is worth trying and therefore strongly recommendable.
BIBLIOGRAPHY 1. Committee on Hearing and Equilibrium. Committee on Hearing and Equilibrium guidelines for the evaluation of results of treatment of conductive hearing loss. Otolaryngol Head Neck Surg 1995;113:186 –187. 2. Selesnick SH, Carew JF, DiBartolomeo JR. Herniation of the temporomandibular joint into the external auditory canal: a complication of otologic surgery. Am J Otol 1995;16: 751–757. 3. Adad B, Rasgon BM, Ackerson L. Relationship of the tympanic annulus to the facial nerve: a direct anatomic examination. Laryngoscope 1999;109:1189 –1192. 4. Naguib MB, Aristegui M, Saleh E, et al. Surgical management of epitympanic cholesteatoma with intact ossicular chain: the modified Bondy technique. Otolaryngol Head Neck Surg 1994;111:545–549. 5. Shaan M, Landolfi M, Taibah A, et al. Modified Bondy technique. Am J Otol 1995; 16: 695– 697. 6. Glasscock ME III, Shambaugh GE Jr. Surgery of the Ear. Philadelphia: WB Saunders, 1990. 7. Wormald PJ, Nilssen EL. The facial ridge and the discharging mastoid cavity. Laryngoscope 1998;108:92–96.
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma www.medicsindex.com
2221
How I Do It
A Targeted Problem and Its Solution
Modified Bondy’s Technique for Epitympanic Cholesteatoma Mario Sanna, MD; Manoj Agarwal, DLO RCS, DLO(Cal); Tarek Khrais, FRCS(I), HSDM; Giuseppe Di Trapani, MD
INTRODUCTION Localized epitympanic cholesteatoma with normal or near normal hearing gives the otologist an opportunity to achieve both aims of otologic surgery: a dry, safe ear and preservation of hearing. Clinical acumen coupled with the availability of modern radiologic technology allows the surgeon to recognize this group of cholesteatoma early. This clinical scenario is an ideal setting to perform a modified Bondy’s technique, the steps of which are described in the following paragraphs.
INDICATIONS 1. Epitympanic cholesteatoma in normal or good hearing ear with an intact tympanic membrane and ossicular chain (Fig. 1). 2. Epitympanic cholesteatoma in the better or only hearing ear with slightly compromised ossicular chain.
3.
4.
5.
An important prerequisite for performing modified Bondy’s technique is that the preoperative air-bone gap should not exceed 25 dB (calculated as the difference between the average of the air and bone-conduction thresholds at 0.5, 1, 2, and 4 kHz).1
SURGICAL STEPS 1. A standard postauricular incision is made, and the soft tissues are handled in regular fashion. A large piece of temporalis fascia is harvested for grafting. 2. A transcortical mastoidectomy is performed to
This article supported by a grant from Associazione Studio Aggiornamento Basicranio. From the Gruppo Otologico, Piacenza, Italy. Editor’s Note: This Manuscript was accepted for publication July 23, 2003. Send Correspondence to Dr. Mario Sanna, Gruppo Otologico, Via Emmanueli 42, 29100 Piacenza, Italy. E-mail: mario.sanna@ gruppootologico.com
Laryngoscope 113: December 2003
2218
6.
7.
8.
widely expose the sinodural angle and mastoid tip (Fig. 2). Once the mastoidectomy is completed, posterior epitympanotomy is performed. Care is taken not to touch the ossicles with the rotating burr during this step. This is imperative to avoid any postoperative sensorineural hearing loss because the ossicular chain is intact. To identify the ossicles as early as possible, the operating table is rotated away from the surgeon. Next, attention is directed toward the canal wall, which may need a canaloplasty. The meatal skin is elevated, folded medially, and protected using an aluminum strip while drilling the canal walls. The facial ridge must be lowered to the level of the tympanic annulus. The most medial part of the facial bridge is removed using a curette (Fig. 3). The use of a curette reduces the chances of dislocating the intact ossicular chain as compared with use of a rotating burr. The same instrument is used for removing the anterior and posterior buttresses. Care is taken to open the anterior epitympanum as far anterior as possible. Once adequate exposure of the mastoid and epitympanum is obtained, removal of cholesteatoma is initiated. Again, care is taken to avoid excessive manipulation of the ossicular chain for the reasons mentioned above. The posterosuperior annulus is partially detached from the tympanic sulcus, and the tympanic cavity is inspected for the presence of any cholesteatomatous extension that can be removed. Once the cholesteatoma is removed completely, a wide conchomeatoplasty is performed. The
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma www.medicsindex.com
Fig. 1. Coronal computed tomography scan of the right temporal bone without contrast showing presence of localized epitympanic cholesteatoma lateral to the ossicles: an ideal case for modified Bondy’s technique.
conchal cartilage obtained is used for the following steps. 9. A piece of cartilage is place in the attic and pushed as far anteriorly as possible, medial to the body of the incus and the head of the malleus (Fig. 4). If the anterior epitympanum is widely exposed, the cartilage is pushed as far as the orifice of the eustachian tube. The cartilage is placed to avoid any possible retractions in this area in the future. Another piece of cartilage may be placed lateral to the long process of the incus and medial to the handle of the malleus (Fig. 5). This cartilage prevents retraction in the posterosuperior quadrant of the grafted tympanic membrane. 10. A longitudinal cut is made in the temporalis fascia. One tongue is inserted medial to the
Fig. 2. Operative sketch of the right side demonstrating transcortical mastoidectomy with the cholesteatoma visible in the epitympanum. Note the wide exposure of the mastoid tip and sinodural angle.
Laryngoscope 113: December 2003
Fig. 3. Operative sketch of the right side demonstrating removal of the most medial part of the facial bridge, with use of a curette to minimize the chances of ossicular disruption. Note the movement of the curette is directed away from the ossicles.
body of the incus and the head of the malleus over the previously placed cartilage. The other tongue is inserted lateral to the long process of the incus and medial to the handle of the malleus by pushing it under the tympanic membrane.
Fig. 4. Operative sketch of the right side demonstrating the placement of cartilage in the attic medial to the incudomalleolar joint as far anterior as possible.
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma www.medicsindex.com
2219
avoid inadvertent opening of the temporomandibular joint.2 Similarly, caution is necessary while drilling the posterior external canal wall to avoid any injury to the facial nerve, which is particularly vulnerable to injury in the posteroinferior quadrant.3 7. Inspection of the tympanic cavity is mandatory to ensure complete removal of the disease process. 8. Modified Bondy’s technique is mainly indicated for localized epitympanic cholesteatoma and not recommended for more extensive cholesteatoma. RESULTS
Fig. 5. Operative sketch of the right side demonstrating the placement of cartilage between the long process of incus and the handle of the malleus.
11. The remaining part of the fascia covers the exposed bony surface of the mastoid cavity as far as possible. If necessary, another piece of fascia may be harvested to cover the same. 12. The tympanomeatal flap is replaced over the fascia, and the cavity is packed with an absorbable gelatin sponge (Spongostan, Johnson & Johnson, Skipton, UK). 13. The wound is closed in layers, and pressure bandage is applied.
During the period between December 1983 and December 2002, we performed a total of 153 surgeries using the surgical technique described above. Some of these cases have been reported previously.4,5 Of these, 57 cases had a follow-up of 3 years (36 months) or more. The mean follow-up was 86.6 (range 36 –196)months. Dry cavity was achieved in 54 (94.7%) cases. The remaining three (5.3%) cases had an occasional episode of otorrhea, which was controlled with local medication. There was no single instance of recurrence or reoperation. The air-bone gap was preserved or improved in comparison with the preoperative level in 43 (75.4%) cases. Nine (15.8%) cases showed a drop of air-bone gap of more than 10 dB but less than 20 dB in comparison with the preoperative level, whereas five (8.8%) cases showed a drop of more than 20 dB but less than 30 dB. This small group of patients (n ⫽ 14) exhibited the deterioration on long-term follow-up. Therefore, this deterioration is probably attributable to tubal dysfunction or ossicular fixation but definitely not to any intra-operative factor. The bone conduction was measured just before discharging the patient to assess the incidence of iatrogenic sensorineural hearing loss. It was maintained within 10 dB of the preoperative level in 55 (96.5%) cases. Two (3.5%) cases showed a deterioration of bone conduction of more than 10 dB but less than 20 dB.
HINTS AND PITFALLS 1. Adequate exposure of the sinodural angle and the mastoid tip is necessary to avoid recurrence. 2. A very deep sinodural angle should be obliterated using bone pate`, cartilage, and temporalis fascia. 3. A extensively pneumatized mastoid tip should be amputated to reduce the volume of the mastoid cavity. 4. As mentioned earlier, handling of the intact ossicles should be avoided lest the surgeon cause a sensorineural hearing loss. Extreme care should be exercised in this region, and the direction of the drilling and curetting should be away from the ossicles. 5. The anterior buttress should be removed completely to obtain a smooth continuation with the anterior wall of the external canal. This is necessary to avoid any bony overhang in this region that could hamper the self-cleansing property of the cavity. 6. Caution is advisable while drilling the anterior external canal wall during the canaloplasty to Laryngoscope 113: December 2003
2220
DISCUSSION In 1910, Gustave Bondy described a technique that attempted to provide a better outcome for his patients suffering from cholesteatomatous otitis media. He treated patients having epitympanic cholesteatoma with intact pars tensa and intact ossicular chain using a modified form of radical mastoidectomy wherein he removed the lateral attic wall and the posterior osseous wall.6 This enabled him to remove the pathology without disturbing the intact ossicular chain, thus providing the patient with a safe, dry ear and preserved hearing. However, his technique was not without pitfalls. The high facial ridge and incomplete removal of mastoid tip favored debris collection, which meant repeated visits to the otologist for the patients. There was also a possibility of leaving behind the pathology because of the restricted access. Moreover, he did not perform any meatoplasty. We, at the Gruppo Otologico, have been using the modified Bondy’s technique described above since 1983. We call it the modified Bondy’s technique because of the following reasons:
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma www.medicsindex.com
1. We put cartilage in the vicinity of the ossicles as described above to reduce the chances of retraction. 2. We inspect the middle ear to rule out any extension of the cholesteatoma in the mesotympanum. 3. Special attention is paid to the adequate lowering of the facial ridge up to the level of the tympanic annulus, which plays an important role in ensuring complete disease removal. Leaving the facial ridge high is an important cause of persistently discharging mastoid cavity.7 4. A wide conchomeatoplasty is performed for adequate aeration of the resultant cavity. 5. Treatment of the deep sinodural angle and highly pneumatized mastoid tip as outlined above is of paramount importance to achieve good results. By following these principles, the surgeon can expect to provide the patient with a dry, safe ear with preserved hearing in cases of localized epitympanic cholesteatoma in a single stage. Any procedure that
Laryngoscope 113: December 2003
achieves this end result in one stage is worth trying and therefore strongly recommendable.
BIBLIOGRAPHY 1. Committee on Hearing and Equilibrium. Committee on Hearing and Equilibrium guidelines for the evaluation of results of treatment of conductive hearing loss. Otolaryngol Head Neck Surg 1995;113:186 –187. 2. Selesnick SH, Carew JF, DiBartolomeo JR. Herniation of the temporomandibular joint into the external auditory canal: a complication of otologic surgery. Am J Otol 1995;16: 751–757. 3. Adad B, Rasgon BM, Ackerson L. Relationship of the tympanic annulus to the facial nerve: a direct anatomic examination. Laryngoscope 1999;109:1189 –1192. 4. Naguib MB, Aristegui M, Saleh E, et al. Surgical management of epitympanic cholesteatoma with intact ossicular chain: the modified Bondy technique. Otolaryngol Head Neck Surg 1994;111:545–549. 5. Shaan M, Landolfi M, Taibah A, et al. Modified Bondy technique. Am J Otol 1995; 16: 695– 697. 6. Glasscock ME III, Shambaugh GE Jr. Surgery of the Ear. Philadelphia: WB Saunders, 1990. 7. Wormald PJ, Nilssen EL. The facial ridge and the discharging mastoid cavity. Laryngoscope 1998;108:92–96.
Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma www.medicsindex.com
2221
