Mastoidectomy: cortical, radical and modified radical
- Procedure
With a drill and a microscope, the mastoid air cells behind the ear are opened to remove infection or cholesteatoma.
See it in 3D: Facial nerve (VII) · Sigmoid sinus · Semicircular canals
What it is
Mastoidectomy opens the mastoid air cells by removing the bony partitions between them. It is done under general anaesthesia, through an incision behind the ear, with a drill and a microscope. The types differ in how much they remove: cortical (simple) mastoidectomy only clears the mastoid and leaves the canal and middle ear intact; modified radical mastoidectomy takes down the posterior canal wall to exteriorise the disease but preserves the remaining hearing; classic radical mastoidectomy joins mastoid, middle ear and canal into a single cavity and sacrifices hearing. It is also the approach for cochlear implantation.
Indications and contraindications
- Acute coalescent mastoiditis or subperiosteal abscess not improving with intravenous antibiotics and myringotomy.
- Cholesteatoma (acquired or congenital) and unsafe (atticoantral) chronic suppurative otitis media.
- Complications of otitis: brain or cerebellar abscess, sigmoid sinus thrombosis, labyrinthitis, facial palsy.
- Access for other operations: cochlear implant, facial nerve decompression, endolymphatic sac, temporal bone tumours.
- Contraindications: patient unfit for general anaesthesia; in an only hearing ear, the most conservative management possible is preferred.
- A severe intracranial complication is stabilised first (neurosurgery) and the ear is operated on afterwards.
How it is done
- Before: audiometry and temporal bone CT to see the extent, the tegmen, the sigmoid sinus and the facial nerve.
- Incision behind the ear and exposure of the mastoid cortex and Macewen's triangle.
- The drill enters the mastoid antrum and removes the cells, following the tegmen above and the sigmoid sinus behind.
- Cortical: the mastoid is cleared, the antrum opened and the posterior canal wall left intact.
- Modified radical or radical: the posterior canal wall is taken down and the cholesteatoma removed from the attic and middle ear.
- The facial nerve is protected in its vertical segment; in the radical type, eardrum, malleus and incus are removed and the stapes kept.
- The canal entrance is widened (meatoplasty) so that the open cavity can be cleaned in clinic.
- After: wound care behind the ear, regular cavity cleaning and follow-up with imaging or a second-look operation.
Types of mastoidectomy: what they remove and what they keep
| Type | What it removes | What it keeps | Typical indication |
|---|---|---|---|
| Cortical (simple) | Mastoid cells and antrum | Posterior canal wall, eardrum and ossicles | Acute coalescent mastoiditis |
| Canal wall up (closed) | Cells, antrum and attic disease from behind | Posterior canal wall | Limited cholesteatoma, with a planned second look |
| Modified radical (canal wall down) | Posterior canal wall and cholesteatoma | Remaining eardrum and ossicles; hearing | Cholesteatoma of the attic and antrum |
| Radical | Posterior wall, eardrum, malleus, incus and middle ear mucosa | Only the stapes (or its footplate) | Extensive cholesteatoma without useful hearing |
Complications
- Facial palsy (injury to the facial nerve in its tympanic or mastoid course).
- Hearing loss, especially sensorineural if the labyrinth is injured; vertigo from a lateral semicircular canal fistula.
- Cerebrospinal fluid leak from tegmen injury; bleeding from the sigmoid sinus.
- Taste change from injury to the chorda tympani.
- Chronically discharging cavity and residual or recurrent cholesteatoma.
- Tinnitus and wound infection.
Next step / Initial management
- Before referral: otoscopy with suction if possible, audiometry and temporal bone CT if the specialist requests it.
- For acute mastoiditis, start broad-spectrum intravenous antibiotics according to local protocol and analgesia while awaiting assessment.
- After surgery: the open cavity needs regular cleaning by ENT; keep the ear dry and watch the wound.
- Refer urgently, the same day, if there is fever with headache, neck stiffness, drowsiness, severe vertigo or new facial palsy.
- Refer on a routine basis to ENT any chronic foul-smelling discharge or marginal or attic perforation, as cholesteatoma is suspected.
Test yourself
Think of the answer, then tap the question to see it.
A child with acute coalescent mastoiditis gets worse despite intravenous antibiotics. Which type of mastoidectomy is done?
Cortical (simple) mastoidectomy: it clears the cells and antrum and keeps the posterior canal wall, the eardrum and the ossicles.
Which structures does classic radical mastoidectomy remove?
The posterior canal wall, the eardrum, the malleus, the incus and the middle ear mucosa; the stapes is kept and a single cavity opens into the canal.
What distinguishes modified radical from radical mastoidectomy?
The modified operation also takes down the posterior canal wall, but keeps the remaining eardrum and ossicles, and with them the hearing.
Which surface landmark of the temporal bone marks the projection of the mastoid antrum?
Macewen's suprameatal triangle, behind and above the external ear canal.
Elsewhere in DurgiPedia
Connections
See it in 3D3
The structures of Durgical's 3D anatomy where it is found.
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Mastoidectomy (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2023); Middle Ear Cholesteatoma (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2024); Mastoidectomy (MedlinePlus, U.S. National Library of Medicine, 2024).
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Representative model, for educational purposes only.