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\begin{document}

\title{Mastoid Obliteration using HA granules and pericranial flap : technique
and results.}



\author[1]{Wendy Smith}%
\author[2]{Swagatam Banerjee}%
\affil[1]{Leeds Teaching Hospitals NHS Trust}%
\affil[2]{University Hospitals Coventry and Warwickshire NHS Trust}%


\vspace{-1em}



  
  \date{May 15, 2024}


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\selectlanguage{english}
\begin{abstract}
Introduction: The creation of the ``open cavity'' to clear cholesteatoma
results in significant morbidity in over a third of patients. Various
biological and non-biological materials have been used to reduce or
obliterated these mastoid cavities. Materials and Methods: This study
reports the technique and results of using hydroxyapatite granules with
a pericranial flap to obliterate troublesome cavities. Results: 50
mastoid obliterations were performed in 48 patients. 94\% no longer
required water precautions 2 months post-operatively and may use
conventional hearing aids. Discussion: This technique improves patients'
quality of life and can enable discharge of patients previously reliant
on ENT services.%
\end{abstract}%



\sloppy


Abstract

Introduction: The creation of the ``open cavity'' to clear cholesteatoma
results in significant morbidity in over a third of patients. Various
biological and non-biological materials have been used to reduce or
obliterated these mastoid cavities.

Materials and Methods: This study reports the technique and results of
using hydroxyapatite granules with a pericranial flap to obliterate
troublesome cavities.

Results: 50 mastoid obliterations were performed in 48 patients. 94\% no
longer required water precautions 2 months post-operatively and may use
conventional hearing aids.

Discussion: This technique improves patients' quality of life and can
enable discharge of patients previously reliant on ENT services.

Keywords: mastoid obliteration hydroxyapatite granules cholesteatoma
pericranial flap quality of life

Keypoints:

The use of HA granules has been described previously emphasising a
thorough(revision) modified radical mastoidectomy before reconstruction
is performed. This study however describes the following modifications
of the technique:

\begin{itemize}
\tightlist
\item
  Optimise operative conditions with blood loss of 1-2ml with the
  anaesthestist to consider using remifentanyl, tranexaminc acid and
  hyperventilation of the patient so pCO2 is 4 to achieve this.
\item
  No drain is required enabling this to be a daycase procedure
\item
  Consider performing an anterior bony canalplasty to optimise middle
  ear surgery and prevent the ear canal becoming too narrow.
\item
  In addition to the cartilage to form the ``new ``posterior ear canal
  wall, consider placing a separate piece of cartilage to block the
  attic.
\item
  Using this technique 94\% patients no longer require water precautions
  and some may use a conventional hearing aid.
\item
  This operation has a positive impact on quality of life as measure by
  Glasgow benefit inventory scores.
\end{itemize}

Introduction:

Since Gustave Bondy, an Austrian surgeon popularized the modified
radical mastoidectomy technique in 1910,\textsuperscript{1} the problems
of the open cavity in some patients have been evident in ENT clinics.
There is often a need for patients to take water precautions (avoiding
swimming) and even following such advice some patient experience
constant or intermittent otorrhoea. Many patients are reliant on their
local ENT services for aural toilet (which can impact on work
commitments). Some patients with hearing loss are unable to use
conventional hearing aids either due to a poor fit and feedback
occurring due to the associated meatoplasty, or as a result of the
hearing aid increasing the humidity of the ear canal resulting in repeat
infections. Other patients may experience a caloric effect as a result
of the meatoplasty allowing cold air to stimulate an exposed
semi-circular canal.

In 1911 Mosher described Plummer's technique of using a soft tissue flap
to fill the excavated mastoid\textsuperscript{2}. Many others including
Popper,\textsuperscript{3} Meurman and
Ojala,\textsuperscript{4}Guildford,\textsuperscript{5}
Palva\textsuperscript{6} and the Hong Kong flap\textsuperscript{7} have
been described along with various fillers. Fat, cartilage, bone
chips/pate have been used but they tend to resorb with time and although
one could ``overfill'' to compensate, the results are unpredictable and
some authors have raised concerns that using cortical bone could result
in cholesteatoma becoming incorporated into the obliterated
cavity.\textsuperscript{8} A number of non-biological materials have
been tried including the use of titanium (covered with
cartilage),\textsuperscript{9}
bioglass,\textsuperscript{10}hydroxyapatite (HA)\textsuperscript{11} and
SerenoCem.\textsuperscript{12} The latter was introduced in 1999 but was
taken off the market in 2017 due to concerns that it caused skull base
erosion. Hydroxyapatite cement was associated with post-operative
infections however the granules introduced by Takahashi in 1991 do not
appear to have this issue.\textsuperscript{11} The technique and results
of using HA granules, cartilage and pericranial flap based on the
mid-temporal artery and vein is described.

Materials and methods: All 46 patients who had a secondary mastoid
obliteration having failed active medical management of their
problematic modified radical mastoidectomy cavities along with 4
patients having a modified radical mastoidectomy and primary
obliteration were included in this study. Their data was
contemporaneously collected on the Common Otology Database and further
information collated with Glasgow Benefit Inventory questionnaires sent
to the patients following their surgery.

Surgical technique:

The surgery was performed under general anaesthesia and the conditions
optimised to minimise blood loss to 1-2 ml. This was achieved by the
anaesthetist using remifentanil (most patients are young and so other
techniques may result in a rebound tachycardia when hypotension is
induced), tranexamic acid 1g on induction noticeably reduced ``ooze''
after 20 minutes and by hyperventilating the patient so the partial
pressure expired CO2 was only 4, further vasoconstriction was achieved.

Skin preparation was applied after tape was used to cover the hair
avoiding the need for hair removal, an important factor for the
patients.

A thorough modified radical mastoidectomy is performed ensuring
cholesteatoma has been removed with particular attention to the
sinodural angle, mastoid tip, around the semi-circular canals and the
anterosuperior mesotympanum. Keeping any high facial ridge and using
endoscopes to visualise the middle ear makes subsequent reconstruction
easier.

The hydroxyapatite granules are soaked in an antibiotic solution
(cefuroxine 750mg in 10ml water for injections) for at least 15 minutes.

Conchal cartilage is harvested. In addition to a large piece of
cartilage used to form the new posterior canal wall, a separate smaller
piece is used to block the ensuring good positioning to prevent the
formation of recurrent cholesteatoma as shown in figures 1a, 1b and 2.

The pericranial flap is then raised by lifting the temporalis muscle
fibres off the pericranium and an anterior based flap is raised taking
care not to cut the mid temporal artery and vein as in figures 3a and
3b. In order to gain ``extra length'' a channel as shown in figure 4 can
be used.

Once the any pars tens perforation has been repaired with for example
temporalis fascia the cartilage is placed and HA granules (having
drained the antibiotic solution) are used to fill the mastoid cavity
ensuring that they also fill the anterior attic.

The pericranial flap is then place between the cartilage and the fascia
as shown in figures 5a and 5b.

The ear canal is then packed. The senior author prefers Betnovate C
ointment ribbon gauze avoiding the use of BIPP to prevent the
development of allergic reactions associated with BIPP.

The patient is usually allowed home after 2 hour observation period on
the ward. The patient removes their head bandage the following day
keeping the 2 packs in the ear canal for 10 days. This is replaced in
the clinic with another pack that the patient removes a week later
before commencing 5 days of antibiotic/steroid ear drops. The patient
observes water precautions until 2 months after surgery when they are
next reviewed with a hearing test. If healed no water precautions are
required.

Patients are followed up at 6 months then yearly, having non-EPI DWI MRI
scans at 1, 3 and 5 years before discharging patients from the clinic.

Results: 50 mastoid obliteration surgeries have been performed in 48
patients over the 9 year study period. There were 10 female and 38 male
patients. Their age was 10-78 years with a median age of 34 years old.
Operations were performed on 24 right and 26 left ears.

The main indication for surgery was discharging ears (31 intermittent
had discharge, and 16 having constant discharge). Only 3 patients had
surgery without having a history of ear discharge; 2 had surgery to stop
their dizziness experienced in the wind (caloric effect) and the other
patient had surgery for social reasons after having had a successful
operation on the other ear.

Follow-up was 2 to 9 years with a median follow-up of 4.5 years and the
typical post-operative appearance is shown in figures 6a, 6b \& 6c.

Table 1 shows the number of ears with perforated ear drums which may
contribute to the ears discharging.

Table 2 shows the distribution of ears with and without the presence of
cholesteatoma found intra-operatively.

Patients were followed up in the clinic to assess whether any
cholesteatoma was evident. An anterior attic pocket where the cartilage
blocking the attic had not reached the anterior attic wall led to
recurrent cholesteatoma formation in one patient who underwent revision
surgery to address this. One patient was found to have an area of
restricted diffusion in the attic of his right ear detected at 3 years
following his revision mastoidectomy and obliteration. (Figure 7).

To date 48 ears (all asymptomatic) have had non-EPI DWI MRI scans. 2
patients had failed to attend follow-up. 5 ears were reported to have
cholesteatoma present on follow-up scans. Two ears were explored in a
tertiary centre and cholesteatoma was only found in one of these (figure
7). 2 ears were explored by the senior author and in both only
cholesterol granuloma was found. One patient has been monitored with
serial non-EPI DWI MRI scans and the 4mm area of restricted diffusion
has remained the same size over 6 years.

There have been no facial nerve palsies or residual/new tympanic
membrane perforations. One patient became dizzy 4 days post-surgery
(cholesteatoma had eroded the labyrinth but no residual cholesteatoma
was found when this ear was re-explored). Post-operatively some patients
had some granulations, myringitis treated with silver nitrate cautery
and mild otitis externa that were treated with topical antibiotic and
steroid preparations. One patient had a polyp in the ear canal removed
under a short general anaesthetic (patient factors prevented its removal
in the clinic). One patient had excess skin to line the new ear canal
and it took 4 months to settle completely. 94\% of patients had their
ears free from infection and no longer required any water precautions at
3 months post-operatively as demonstrated in figures 6a, 6b, 6c.

This primary aim of this surgery is not to improve hearing but to stop
ear discharge and for social reasons. After surgery many patients were
offered a conventional hearing aid but they decline this since their
hearing loss was not an issue to them. In 30 of the 50 ears no attempt
was made to reconstruct the hearing. In 14 ears cartilage alone was
placed onto the stapes head to bridge the gap between the stapes head
and the tympanic membrane. In 2 ears a titanium PORP and in 4 ears a
titanium TORP covered with cartilage was used. The hearing at 2-3 months
against the hearing pre-operatively is demonstrated in graph 1. The line
indicates what the hearing post-operatively would be if it remained the
same as the pre-operative level. Interestingly the patient with the
greatest improvement in their hearing had a TORP inserted.

Graph 2 shows the hearing results at 6 months. There appears to be a
gradual drift towards the pre-operative hearing level perhaps as a
result of a fibro-adhesive process in the middle ear.

Graph 3 shows the change in hearing in patients who had their hearing
measured at 2-3 and 6 months. None had a significant loss of hearing
post-operatively and in some patients the hearing improvement was
translated to a clinically apparent gain.

Patients attending the clinic expressed the improvement to the quality
of life that this surgical procedure had made and this is borne out by
the values obtained in 35 patients who had completed the Glasgow Benefit
Inventory. The results are shown in table 3.

Discussion:

In 1996, Yung described the use of HA granules and an inferior based
periosteal flap in 34 mastoid obliteration operations achieving trouble
free ears in all except one patient due to incomplete epithelialization
of the obliterated cavity.\textsuperscript{13} Munjal et al using the
same technique with HA granules and pericranial flap and achieved
trouble free ears in 84\% of their 25 cases. They reported a 2.04dB
reduction in their AB gap.\textsuperscript{14}

The majority (39/50) of the ears had no perforation indicating that the
discharge was related to an unhealthy mastoid cavity. Cholesteatoma was
present within the middle ear in a third of the ears with either frank
cholesteatoma within the residual mastoid air cells or a significant
build-up of keratin within the mastoid bowl with underlying unhealthy
mucosa. 11 of 50 ears did have a perforation of the pars tensa and one
could argue that this increase in the humidity within the outer ear
could be addressed with a myringoplasty however performing the mastoid
obliteration offers these patients a dry ear which does not require
water precautions and may enable them to pursue water sports.

Yung described the use of high resolution CT scanning in detecting
cholesteatoma in temporal bones obliterated with muscle and with HA
granules.\textsuperscript{15} The contrast of the dark shadows produced
by epithelial cysts contrasted to the white background of HA granules
but not with the appearance of the muscle. One false positive occurred
in 31 bones due to a cholesterol granuloma. Non -EPI DWI MRI scanning
has replaced follow-up CT scanning as a means to detect residual
cholesteatoma since CT scans only detected the presence of soft
tissue/fluid to be present\textsuperscript{16}. The SI values of
cholesteatoma and HA granules were measured for the purpose of this
study and found to be 1150-1525 Si and 500-600 SI respectively.
Cholesteatoma has a value of 2-3 times greater than HA granules and can
therefore be easily differentiated. To date 48 ears (all asymptomatic)
have been scanned. 2 patients had failed to attend follow-up. The
relatively high false positive reports of cholesteatoma being present
have led to unnecessary further surgery in asymptomatic ears.
Cholesterol granuloma was found and it is now the senior author's
practice to rescan if a 4mm or less area or restricted diffusion is
found as well as reviewing the ADC, T1 and T2 MRI sequences which can
differentiate cholesteatoma from other pathology.

The Glasgow Benefit Inventory scores for the patients in this study are
comparable to those observed by Kurien who used autologous bone graft in
both primary and secondary obliterations.\textsuperscript{17} In the
secondary obliterations he found the Total Score to be 31, General
Health 34, Social Support 39 and Physical Health of 25. Interestingly,
he found that the patients who had mastoid obliteration as a secondary
procedure had higher scores to those who had a primary obliteration.
This may result from the more prolonged period of symptoms including
foul smelling discharge from the ears prior to their surgery. Hurley and
Iyer in 2020 also reported improved quality of life scores using GBI and
COMBI questionnaire with the biggest improvement in resolution of smelly
and discharging ears.\textsuperscript{18}

References:

\begin{enumerate}
\tightlist
\item
  Richards GL. The so-called conservative mastoid operation, with a
  description of the technic of Heath, Bondy and Siebenmann.\emph{Annals
  of Otology Rhinology and Laryngology} . 1911;20:578-94
\item
  Mosher HP. A method of filling the excavated mastoid with a flap from
  the back of the auricle. \emph{Laryngoscope} 1911;21(12):1158-1163.
\item
  Popper O. Periosteal flap grafts in mastoid operations. \emph{South
  African Medical Journal.} 1935;9:77-81
\item
  Meurman Y, Ojala L. Primary reduction of a large operation cavity in
  radical mastoidectomy with a muscle-periosteal flap. \emph{Acta
  Otolaryngology} . 1949;37(3):245-52
\item
  Guildford F. Indications for obliteration and closed mastoid
  operations. \emph{Archives of Otolaryngology} 1969;89(1):191-5
\item
  Palva T, Makinen J. The meatally based musculoperiosteal flap in
  cavity obliteration. \emph{Archives of
  Otolaryngology}1979;105(7):377-80
\item
  Hasselt CA ,Liu KC, Tong MC. The Hong Kong vascularised temporalis
  fascia flaps for optimal, mastoid cavity reconstruction. \emph{Rev
  Laryngology Otology and Rhinology (Bord)} 1995;116(1):57-60
\item
  Roberson JB, Mason TP, Stidham KR. Mastoid obliteration: Autogenous
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  Neurotology}2003;24:132-40
\item
  Schwager K, Zirkler J. Reconstruction of the mastoid using a titanium
  cage. \emph{Otology and Neurotology} 2014;35(8):1463-5
\item
  Silvola JT. Mastoidectomy cavity obliteration with bioactive glass: A
  pilot study. \emph{Otolaryngology Head and Neck
  Surgery}2012;147(1):119-26
\item
  Takahashi S. Tympanoplasty with mastoid obliteration using
  hydroxyapatite granules for aural cholesteatoma---a clinical and
  experimental study. \emph{Nihon Jibiinokoka Gakkai
  Kaiho}1991;94(6):833-42 {[}Abstract only. Full article in Japanese{]}
\item
  Harrison L, Kumar S, Bull M et al Clinical case series describes a
  contraindication for SerenoCem granules \textsuperscript{TM} in
  mastoid obliteration: Our experience in sixty-four
  patients.\emph{Clinical Otolaryngology Allied Science}
  2017;42(5):1095-1100
\item
  Yung MW. The use of hydroxyapatite granules in mastoid
  obliteration.\emph{Clinical Otolaryngology Allied Science}
  1996;21(6):480-4
\item
  Munjal M, Passey J, Agarwal A et al. Hydroxyapatite granules for
  mastoid cavity obliteration: A study of 25 cases. \emph{TheInternet
  Journal of Otorhinolaryngology} 2004;3:2
\item
  Yung MW, Karia KR. Mastoid obliteration with hydroyapatite---the value
  of high resolution CT scanning in detecting recurrent
  cholesteatoma.\emph{Clinical Otolaryngology} \emph{Allied Science}
  1997;22(6):553-7
\item
  VercruysseJP, De Foer B, Somers T et al. Long-term follow-up after
  bony mastoid and epitympanic obliteration:radiological
  finding.\emph{Journal of Laryngology and Otology} 2010;124(1):37-43
\item
  Kurien G, Greeff K, Gomaa N et al Mastoidectomy and mastoid
  obliteration with autologous bone graft:a quality of life
  study.\emph{Journal of Otolaryngology Head and Neck Surgery}
  2013;42(1):49
\item
  Hurley, R. and Iyer, A. (2020), Cavity obliteration in revision
  mastoidectomy leads to dry ear and improved quality of life: Our
  experience in 29 patients. Clin Otolaryngol, 45: 604-607.
  doi:10.1111/coa.13532
\end{enumerate}\selectlanguage{english}
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