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Is modified radical mastoidectomy a permanent cure "blocked aditus" ?

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Hi I have been suffering from ear problem and had two mastoidectomies (both cortical mastoidectomies) which could not clear my infection from mastoid. Now doctor has suggested me a modified radical mastoidectomy. I want to know the following: 1. Both the cortical mastoidectomies found my aditus to be blocked. Now the doctor is again suspecting that my aditus is blocked. Will modified radical mastoidectomy clear the problem of "blocked aditus" for ever? 2. Many of my aircells are still there even after 2 cortical mastoidectomies. Will modified radical mastoidectomy clear all my aircells from the temporal bone? 3. I am having a neuralgic pain and doctor says my trigeminal nerve is affected because of this infection. Will modified radical mastoidectomy clear this problem? 4. I am having headache and nerve irritation of trigeminal nerve. Will it go by modified radical mastoidectomy? One doctor also suggested petrosectomy but other doctor denied it saying there is no bone erosion in petrous apex and he is not sure that petrous cells contain infection. Which is better for me - modified radical mastoidectomy or petrosectomy? 5. Does the trigeminal nerve pass through mastoid so that if there is mastoid inflammation that nerve will be affected? 6. When I burp my ear drum bulges out. This is a new thing after 2nd mastoidectomy. When I asked my doctor about it he said this is because normally the air during burping goes to the mastoid but since my aditus is blocked after mastoidectomy so my ear drum is bulging out in this abnormal way. Is this true? 7. I hear a tiiii sound in my ear always. What can cause this - mastoidectomy or remaining infection? Thanks, XXXX.
Posted Fri, 7 Feb 2014 in Ear, Nose and Throat Problems
Answered by Dr. Prahlad Duggal 25 minutes later
Brief Answer: Descriptive answer Detailed Answer: Hi, Thanks for the query. Modified radical mastoidectomy opens up the aditus permanently as the middle ear, mastoid antrum and air cell system is converted in to single cavity. Not all but most of the air cells are removed, most means all those which are necessary so as to remove diseased mucosa from the mastoid. If trigeminal nerve neuralgia is suspected, the mastoidectomy is unlikely to cure this problem. Mastoidectomy is unlikely to cure trigeminal neuralgia. Mastoidectomy and petrosectomy have different indications and retained infection especially osteomyelitis of petrous bone can be an indication of petrosectomy. But if previous two surgeries were cortical mastoidectomies, then it is unlikely that the next surgery will be a petrosectomy. Trigeminal nerve does not pass through mastoid. Ear drum bulging with burping is indicative of a patent and may be patulous Eustachian tube. The sound you hear is known as tinnitus and the cause can be related to middle ear (eustachain tube dysfunction or increased vascularity of middle ear mucosa/edema because of infection) or inner ear (which can be because of some damage to inner ear (may be because of long standing disease or due to previous surgeries). If the infection from mastoid is not going with two cortical, the next option is usually modified radical mastoidectomy or an intact canal wall mastoidectomy but the final call can be taken by the doctor who is actually examining the case. Feel free to ask another query. Regards
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Follow-up: Is modified radical mastoidectomy a permanent cure "blocked aditus" ? 13 hours later
Hi, 1. Is there any way to know from outside without mastoidectomy if the aditus is blocked? 2.In last mastoidectomy a bone biopsy was done which showed focus of calcification in mastoid. Bone scan shows increased uptake in mastoid but CT shows no bone erosion. In such a scenario is modified radical mastoidectomy going to help? 3. My ear seems to be blocked after the last mastoidectomy. My doctor says it is due to aditus block. Why such a feeling came after mastoidectomy? 4. Can the trigeminal nerve be effected in any way due to my mastoid problem? Can it spread to petrous or anywhere and cause this type of neuralgia? 5. I had eye pain after 3 months of surgery. Pain around the eye. Doctors said it might be due to neuralgia. I was given pipercillin for it. The pain has subsided but not gone fully. Should I contunue with medicines or go for surgery? 6. During last surgery doctor did not find any pus, only granulation tissues. My surgeon said that mastoid bone is inflammed. How much will radical mastoidectomy help for inflammed mastoid bone? 7. My neurologist has done a special MRI for ruling out micro vascular compression of trigeminal nerve. There is no microvascular compression. In that case how can trigeminal neuralgia be related to my infection? 8. My ESR is 6 and CRP is 16. XXXXXXX is negative. Can it suggest anything about infection? My CRP is always high in the range of 10 to 20. Is this because of active infection? Thanks, XXXX
Answered by Dr. Prahlad Duggal 1 hour later
Brief Answer: Descriptive answer Detailed Answer: Hi, No, there is practically no way to know from outside whether aditus is blocked or not. Trans eustachian or trans tympanic endoscopy is an option but is not usually practically employed. Bone biopsy report is not going to alter the current line of management. Feeling of ear blockade is not due to aditus blockade. Aditus blockade prevents ventilation of mastoid air cell system and thus prevents the complete resolution of infection from the mastoid and thus the waxing and waning course. Presently either your middle ear is open, that is the graft has not fully taken up or the neo tympanic membrane is retracted markedly and giving the adhesive change appearance. Both the conditions warrant a surgery. Very unlikely from your history. Your modified radical mastoidectomy may or may not relieve your pain in the regions other than mastoid. If a low grade simmering infection is there in the bone, the culture during surgery and then specific antibiotic post surgery will be more effective. Long term low dose antibiotics help in such situations. Please discuss with your doctor. Modified radical mastoidectomy (MRM) provides a better ventilation of the mastoid and is independent of the aditus patency. So, there is better chance of it making your problem resolve. MRM has its own problems with the cavity, so please discus with your doctor regarding cavity problems and understand well before going for MRM. Trigeminal neuralgia, if it is there, can many a times be there without any finding in MRI. Your mastoid infection is unlikely to lead to a continuously raised CRP. But a sustained infection in bone like an osteomyelitis in the region can be a cause for this. As your ear is giving you lot of problems, and two conservative surgeries have not helped much, a little radical approach is the next option available. Feel free to ask another query. Regards
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Follow-up: Is modified radical mastoidectomy a permanent cure "blocked aditus" ? 1 hour later
Hi 1. During my first surgery culture was done (doctor got some glue in my mastoid then) but nothing came out. During my 2nd surgery doctor said there was no pus so no culture was done. Only histopathology and bone biopsy. I have attached the biopsy report. If I go in for a 3rd surgery now, not sure if culture will yield anything. I am on 2 oral antibiotics now - levofloaxacin 500 mg and clindamycin 300 mg twice. I am also taking pregabalin. No pain on pressing the mastoid region. But there is a dull pain over half of scalp and forehead sometimes radiating to eyelids and face on the affected side. 2. If I go in for 3rd surgery and if culture does not yield anything, what should I do? 3. I have seen that after both surgery my condition worsened. Is it due to spread of infection through blood that comes out during surgery? 4. If total infection is not cleared if it is in my bone then I suppose there will be chances of wound infection and further complication after surgery? 5. My ENT says that my ear is not retracted. I have a grommet on it. I had 3 grommets inserted in last 2 years. Can grommet insertion and removals make the eardrum thick and give the effect of a blocked ear? 6. As you stated there might be tympanic membrane retraction or graft problem after mastoidectomy and I need to go for surgery. How long can I wait in this condition? Will I affect my mastoid problem resolution? Will MRM clear this? 7. If I go for MRM, is eustacian tube the only way for blood (accumulated after surgery) to go out of mastoid? 8. My new doctor said I need to go in for MRM to remove the dead bone. Is it possible to remove all dead bone? Can infection stay in dead bone which cannot be removed and cause problems for ever or will the dead bone get repaired some day? I have been with this for 2 years now. What is the fate of this? Regards, XXXX.
Answered by Dr. Prahlad Duggal 14 minutes later
Brief Answer: Descriptive. Detailed Answer: Hi, Ventilating the area with MRM helps in resolving the low grade infection even if the culture is negative. Culture may not reveal anything but 3rd surgery is MRM which makes a permanent pathway for drainage of infection from mastoid and helps. No, there is usually no spread of infection through blood in mastoid surgery. Making a cavity and wide meatoplasty is part of MRM and wide meatoplasty helps in ventilating the area and drainage of infection even after the surgery is over. Repeated scarring can make the membrane thick and this can give blocked feeling but the thickening partially resolves with time. If your doctor says that there are no changes of attico antral disease with chances of bony erosion in attic or postero superior bony wall of external auditory canal, you can wait for some time but that call needs to be taken by the doctor who has physically examined the ear. After MRM minimal blood accumulates in the middle ear and this gets resorbed or may be drained via Eustachian tube but this is not usually an issue at all. Ventilation of the region is the basic purpose of MRM apart from removing the infected or dead bone and the ventilation helps in healing in the infected bone also. So more or less the lining over the mastoid bone develops which is healthy and makes the ear dry and helps in resolving the multiple problems you are facing. Only thing I am cautioning you about is the non resolution of facial pain which may or may not occur. Feel free to ask another query. Regards
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Follow-up: Is modified radical mastoidectomy a permanent cure "blocked aditus" ? 21 hours later
Hi 1. I never had any tympanoplasty. Only grommet was inserted during mastoidectomy. Can you please let me know what you mean my middle ear is open and graft had not taken up in the ear? 2. What are the difficulties that I may face after MRM? 3. I have uploaded a pic of my ear drum and my last biopsy report. During my mastoidectomy grommet was inserted but then removed after a month. After grommet removal I started getting this blocked sensation. So again the grommet was put back. When I asked my ENT he says there is not much retraction. But my eardrum is white. Can you give any reason for my ear blockage? 4. When is petrosectomy done? What are the indications for it? There is no bone erosion seen in my CT but my bone scan is showing increased uptake which mainly is in mastoid region and not going towards midline. 5. Can MRM clear up cell tracts going to petrous so that I don't need to actually have a petrousectomy? Regards, XXXX.
Answered by Dr. Prahlad Duggal 1 hour later
Brief Answer: Descriptive Detailed Answer: Hi, Tympanoplasty is usually combined with mastoidectomy as surgeon inspects the ossicular chain integrity. From your history it appears that you have been operated for coalescent mastoiditis as you have not given any history of ear discharge pre-operatively. A grommet must have been inserted to provide ventilation to the middle ear and to make the retracted ear drum (if it was) normal. Open middle ear means a perforation in the ear drum and it is open to the outside. If so it needs a graft to patch that area. Post MRM ear needs to kept dry and there is need to get ear examined and if need be cleaned once or twice a year. There will be some hearing loss post surgery depending upon the type of tympanoplasty done. White ear drum post grommet can be because of scarring or because of sclerotic patch. Both can give a blocked feeling. Petrosectomy is usually done for tumours involving that region and for complications of chronic suppurative otitis media when there is evidence of infection going to the tip of petrous bone. Your CT scan report is not indicating that. MRM clears cell tracts in the mastoid, attic/antrum and we do not go till petrous apex during MRM. Feel free to ask another query. Regards
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Follow-up: Is modified radical mastoidectomy a permanent cure "blocked aditus" ? 25 minutes later
Hi 1. Do all people have air cells in the petrous apex? 2. Doctor who suggested me petrosectomy told that he will open the petrous and make a link to the mastoid so that if there is infection it will come out. Now if there is no infection in petrous and there is infection in the mastoid then infection can enter petrous through that drainage link also. Am I right? 3. My main problem is a dull headache on top of my head near the vertex on the affected side. This has been there from the start of infection. But there is no visible bone erosion in the CT scan. I have been like this for two years. CT shows opacification of remaining mastoid aircells after mastoidectomy. Is such a headache sign of petrous infection for 2 years? 4. How can ear and mastoid be cleaned from outside after MRM? After MRM I assume I don't need another surgery involving cutting back portion of ear to clear the mastoid again. Everything can be done from front. Am I right? 5. I had 2 surgeries in a year (9 months apart). Now I am going for 3rd one after 8 months of 2nd surgery. Is it safe to have so many surgeries so early or should I give time to the body to repair itself? 6. What are the disadvantages/bad effects of opening the petrous? 7. How long does it usually take for trapped blood inside remaining aircells to clear after a mastoidectomy? Regards, XXXX
Answered by Dr. Prahlad Duggal 7 hours later
Brief Answer: Descriptive Detailed Answer: Thanks for the query. No. The other way round is usually not true. Infection in the petrous apex is visible on CT and you have not stated that your CT report is suggesting that. Headache can have many reasons but believing petrous infection to be a cause of that needs some evidence on CT. Yes everything can be cleaned from front and no need of cutting. You can take some more time if you feel like. Otherwise 8 months s sufficient time. To be on more safer side, you can wait for 4 more months. That is a bigger surgery and can do more damage to hearing. No fixed period but Six weeks to three months should be sufficient. Feel free to ask another query.
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Follow-up: Is modified radical mastoidectomy a permanent cure "blocked aditus" ? 12 hours later
Hi 1. If it has become osteomyelitis (which my doctor suspects), will I get any benefit from MRM or do I need to go for some other surgery? 2. I am on clindamycin and levofloxacin. How strong are these drugs against osteomyelitis? Culture did not yield anything. 3. Can osteomyelitis cause pain on top of head? Can't find any reason for my top of head pain. 4. I have attached my bone biopsy report. Can you please comment on that? 5. Doctors say it is a neuralgic pain but there is no vascular compression. In such case what can cause a neuralgic pain? Can an inflammed bone be the cause of such a pain? 6. Is there any chance that after MRM my osteomyelitis gets worse? 7. My surgeon who did the last mastoidectomy said there is some bone inflammation and dead bone. But that can't be taken out. In such case what is the solution? 8. CT shows there is no major bone erosion. But my surgeon says there is some microscopic bone destruction. How fatal is that? Will it repair or get cured on its own? 9. Is it true that all people with long standing mastoid infection has osteomyelitis to some level? Thanks, XXXX
Answered by Dr. Prahlad Duggal 45 minutes later
Brief Answer: Descriptive Detailed Answer: Thanks for the query. MRM is required for osteomyelitis if it involves mastoid only. There is nothing like strong or weak antibiotics, culture tells about the need. If culture is not yielding anything, these two should be sufficient. Osteomyelitis can cause pain in head. Insignificant report. Management is not going to change with report. Inflamed bone, soft tissue inflammation and nerves passing through such area can lead to neuralgic pain. Vascular cause is not there always. Unlikely Let the MRM with meatoplasty drain that infection out post surgery. Drainage and ventilation of the area helps cure it. Usually not fatal with the extent you have described. Yes very true. Feel free to ask another query. Regards
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