The mastoidectomy is a surgery performed for a multitude of reasons, the first and most basic being infection (acute mastoiditis) as first described by Riolan the Younger in the 17th century AD (1). Since then, many other indications for mastoidectomy have been recognised; cholesteatoma, chronic middle ear disease, chronic/recurrent tympanic membrane perforations, tumours and surgical access as well as artificial cochlear implantation. These indications mandate a varied surgical approach to the mastoidectomy. Mastoidectomies are commonly categorised into “radical mastoidectomy”, “modified radical mastoidectomy”, “canal wall down mastoidectomy (CWD)”, “canal wall up mastoidectomy (CWU)” and “simple” or “cortical mastoidectomy” (2). This paper evaluates epidemiological data from CWD and CWU mastoidectomies, as well as revision procedures for both approaches.
The type of mastoidectomy performed varies between surgeons, with most favouring one approach and only differing for exceptions. It is unclear which approach is superior in treating cholesteatoma and chronic discharging ear. The CWD procedure is associated with less recidivism and CWU is associated with better hearing outcomes (3,4).
This study will focus on patients that fall into the catchment area of the Cairns Base Hospital in Far North Queensland, Australia. This hospital serves as a primary otology referral centre for a population of 209,787, with a higher than average population of people identifying as Aboriginal or Torres Strait Islander (19,074, 9.1% by population) (5). This study will evaluate the incidence and indications of this operation in the local population to determine if there are differences in the diseases encountered compared to other reported populations.
A current epidemiological study of mastoidectomies performed in Australia and their indications, to the knowledge of the authors, has not been reported and as such, this study will evaluate all mastoidectomies performed in our institution over a 10-year period. Their indications, disease extent and intra-operative findings are reported and discussed below.
A retrospective cohort study of all patients (n=158) requiring a mastoidectomy within the Cairn’s Base Hospital catchment area from 2003 to 2013, including revision and paediatric operations. There were no exclusions. The variables collected were; clinical presentation, age, gender, ethnicity, surgical technique used (CWD, CWU and revision) and intraoperative findings (pathology found, anatomical location, state of ossicles, state of tympanic membrane). This data was collated from chart reviews using the existing medical records. This data was tabulated and analysed using standard industry spread sheet software. No statistical analysis was performed. Missing data points were omitted from the results.
The total number of cases included in this study undergoing a mastoidectomy was 158 of which 45.6% were female (n=72) and 54.4% were male (n=86). A further breakdown of the patient demographics is tabulated (Table 1).
The average age of patients is 33, the youngest patient receiving a mastoidectomy was 2 years old (acute mastoiditis) and the eldest 82 (cholesteatoma). Of all patient studied, 44 were classed as paediatric (18 years of age and under). Within the paediatric group 63.6% (n=28) of operations were performed for cholesteatoma, 20.5% (n=9) for granulation tissue and 15.9% (n=7) for retraction pocket (Table 2). The paediatric population had a higher percentage of indigenous children (56.8%) receiving mastoidectomies than the non-indigenous patients.
The indications for the mastoidectomies are shown below (Table 3). The most common indication for mastoidectomy in our population was for Cholesteatoma (67.7%, n=107), followed by granulation/Infection (20.9%, n=33) and retraction pocket (10.1%, n=16). Cholesteatoma comprised 66.7% (n=48) of female operations and 68.6% (n=59) of male operations. Granulation/infection comprised 20.8% (n=15) of female operations and 20.9% (n=18) of male operations. Retraction pockets comprised 11.1% (n=8) of female operations and 9.3% (n=8) of male operations.
The disease extent as recorded intra operatively is shown (Table 4).
The state of the tympanic membrane at the time of the operation was recoded and can be compared to the pathology (Table 5).
The range of extra cranial complications recorded at time of mastoid were, in order of frequency; acute mastoiditis (n=15), sub-periosteal abscess, facial paresis/paralysis (n=3), sensory neural hearing loss (n=3) and neck abscess (n=1). It is worth re-iterating that these cases of acute mastoiditis are only those requiring a mastoidectomy and do not reflect the conservatively treated population during this period.
The intra-cranial complications recorded are in order of decreasing frequency; meningitis (n=4), cerebral abscess (n=2), encephalocoele (n=2). The facial nerve was dehiscent in 15.8% (n=25) cases and the lateral semi-circular canal was dehiscent in 3.2% (n=5) cases. There was dehiscent tegmen resulting in exposed dura during operation in 5.7% (n=9) cases.
The variation of mastoidectomy performed is compared against the pathology present (Table 6).
There were 59 cases of CWD mastoidectomy and 37 cases of CWU mastoidectomy. There were 3 cases of CWD approaches requiring revision and 8 cases of CWU requiring revision. All retraction pockets were performed as canal wall up procedures as were the miscellaneous pathologies (trauma and tumour). Of granulation and infectious cases requiring mastoidectomy the majority (83.9%) were performed CWU.
The state of the hearing ossicles at the time of the operation was recorded (Table 7). The most commonly involved ossicular structures were the stapes superstructure (23.4%, n=37), the lenticular process of incus (20.8%, n=33), the incus body (13.3%, n=21) and the malleus head (6.3%, n=10).
The total number of mastoidectomies performed for any indication over the 10-year period studied was 158. This represents an annual incidence rate of 9.9 per 100,000 people. This is comparable to the incidence of mastoidectomy (for any indication) performed in the US, which was reported as 7.3–27.4 per 100,000 (5).
There is a high incidence of operations performed on Aboriginal patients (46.2% of operations) despite this population demographic comprising only 9.2% of the total population (6). This is at least in part due to the increased incidence of chronic middle ear disease in this population (7). The number of mastoidectomies performed on indigenous children for cholesteatoma accounted for the largest subgroup in the paediatric data (Table 2) (36.4%) which may be in direct conflict with the existing publications that state that incidence of cholesteatoma in indigenous populations are indeed below the population average (8,9). Possible anatomical and social reasons for this were discussed by Jassar et al. (10). It is reasonable to expect that by collecting this data from patients who underwent mastoidectomies, there is likely a confounding factor in that more cholesteatomas are going to require a surgical intervention than chronic ear disease with or without perforation.
The most common indication for mastoidectomy was cholesteatoma (67%). This represents an incidence of 6.7 per 100,000 people and is lower than the reported incidence rate of 9 to 12.6 cases per 100,000 (11-13). This may represent an underdiagnoses of the condition or a geographical or genetic component of the condition.
Granulation tissue or infection represented the second most common indication for mastoidectomy (20.9% of operations performed). It is well documented in the literature that a high prevalence of chronic suppurative otitis media (CSOM) is present in the Indigenous population in Australia (12–30% of the population) (14). Because of this, it would be expected that surgeries for CSOM including mastoidectomies would be higher.
The most common surgical approach for the treatment of cholesteatoma was the CWD approach (n=59), followed by CWU (n=37). There were 3 recorded cases of CWD procedures requiring revision, and a total of 8 cases of CWU procedures requiring revision (5 of which were revised with CWD approach and 3 of which were revised with a CWU approach). This suggests that CWD approaches result in fewer episodes of disease recurrence. This is consistent with the most recently published research (15).
This study evaluates the epidemiological data obtained over a 10-year period in a rural Australian hospital. The incidence of mastoidectomies performed is comparable with published data, though a higher incidence of operations were performed on indigenous patients. Additionally, our data shows a higher incidence of cholesteatoma in the Indigenous population than previously published articles. A greater understanding of this discrepancy could be obtained from further investigation with a prospective study. Cholesteatoma represents the most common indication for mastoidectomy though the reported incidence is lower than other published data. The incidence of disease recurrence in CWD and CWU mastoidectomies is comparable to worldwide data.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Bennett M, Warren F, Haynes D. Indications and technique in mastoidectomy. Otolaryngol Clin North Am 2006;39:1095-113. [Crossref] [PubMed]
- Cummings CW, Haughey BH, Thomas JR. Cummings Otolaryngology: Head and Neck Surgery. Elsevier Mosby, 2005.
- Dodson EE, Hashisaki GT, Hobgood TC, et al. Intact canal wall mastoidectomy with tympanoplasty for cholesteatoma in children. Laryngoscope 1998;108:977-83. [Crossref] [PubMed]
- Dornhoffer JL. Retrograde mastoidectomy with canal wall reconstruction: a follow-up report. Otol Neurotol 2004;25:653-60. [Crossref] [PubMed]
- French LC, Dietrich MS, Labadie RF. An estimate of the number of mastoidectomy procedures performed annually in the United States. Ear Nose Throat J 2008;87:267-70. [PubMed]
- Miller M, Tulip A, Anders F. Health Indicators 2009 - Cairns and Hinterland Health District. In: Cairns QH. editor. Cairns: Queensland Health: Cairns; 2009.
- Coates H. Chronic suppurative otitis media in indigenous populations: the Australian aborigine. Ear Nose Throat J 2002;81:11-2. [PubMed]
- McCafferty GJ, Lewis AN, Coman WB, et al. A nine-year study of ear disease in Australian aboriginal children. J Laryngol Otol 1985;99:117-25. [Crossref] [PubMed]
- Ratnesar P. Chronic ear disease along the coasts of Labrador and Northern Newfoundland. J Otolaryngol 1976;5:122-30. [PubMed]
- Jassar P, Murray P, Wabnitz D, et al. The posterior attic: An observational study of aboriginal Australians with chronic otitis media (COM) and a theory relating to the low incidence of cholesteatomatous otitis media versus the high rate of mucosal otitis media. Int J Pediatr Otorhinolaryngol 2006;70:1165-7. [Crossref] [PubMed]
- Aquino JE, Cruz Filho NA, de Aquino JN. Epidemiology of middle ear and mastoid cholesteatomas: study of 1146 cases. Braz J Otorhinolaryngol 2011;77:341-7. [Crossref] [PubMed]
- Kemppainen HO, Puhakka HJ, Laippala PJ, et al. Epidemiology and aetiology of middle ear cholesteatoma. Acta Otolaryngol 1999;119:568-72. [Crossref] [PubMed]
- Tos M. Incidence, etiology and pathogenesis of cholesteatoma in children. Adv Otorhinolaryngol 1988;40:110-7. [Crossref] [PubMed]
- O'Connor TE, Perry CF, Lannigan FJ. Complications of otitis media in Indigenous and non-Indigenous children. Med J Aust 2009;191:S60-4. [PubMed]
- Kerckhoffs KG, Kommer MB, van Strien TH, et al. The disease recurrence rate after the canal wall up or canal wall down technique in adults. Laryngoscope 2016;126:980-7. [Crossref] [PubMed]
Cite this article as: Placanica T, Griffin A, Mahanta V, Jumeau P. Mastoidectomy indications and incidence in the indigenous population of Far North Queensland. Aust J Otolaryngol 2018;1:24.