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# 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.

Updated Nov 12, 2026

**See it in 3D:** [Facial nerve (VII)](https://durgical.com/en/anatomy/facial-nerve/) · [Sigmoid sinus](https://durgical.com/en/anatomy/sigmoid-sinus/) · [Semicircular canals](https://durgical.com/en/anatomy/semicircular-canals/)

## Key points

- Cortical (simple): for acute coalescent mastoiditis not responding to antibiotics; preserves the posterior canal wall and the middle ear.
- Modified radical: cholesteatoma of the attic and antrum; takes down the posterior canal wall and keeps the remaining ossicles and eardrum.
- Radical: removes the posterior canal wall, eardrum, malleus and incus; the cavity opens into the canal and hearing worsens.
- Canal wall up (closed) keeps the canal but needs a second-look operation; canal wall down (open) recurs less but leaves a cavity.
- Key landmarks: Macewen's triangle (surface marking of the antrum), sigmoid sinus, tegmen (middle fossa floor) and facial nerve.

On this page

- The basics Key points
- What it is
- How it is done
- Types of mastoidectomy: what they remove and what they keep
- Memory aid
- Elsewhere in DurgiPedia

- Clinical Complications

- Treatment Next step / Initial management

- Safety Indications and contraindications

- Study Test yourself

- Connections Connections

## 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.

## Memory aid

Cortical = clean the house; modified radical = knock down the wall and keep the furniture; radical = knock down the wall and take the furniture (except the stapes).

## 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.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/ent/mastoidectomy-cortical-radical-and-modified-radical/)

## Elsewhere in DurgiPedia

- [Inner ear: the cochlea and the organ of Corti](https://durgical.com/en/histology/inner-ear-the-cochlea-and-the-organ-of-corti/)

## Connections

## See it in 3D 3

The structures of Durgical's 3D anatomy where it is found.

- [Facial nerve (VII)](https://durgical.com/en/anatomy/facial-nerve/)
- [Sigmoid sinus](https://durgical.com/en/anatomy/sigmoid-sinus/)
- [Semicircular canals](https://durgical.com/en/anatomy/semicircular-canals/)

## Related 2

- [Complications of otitis media: from mastoiditis to brain abscess](https://durgical.com/en/ent/complications-of-otitis-media-from-mastoiditis-to-brain-abscess/)
- [Myringoplasty and tympanoplasty](https://durgical.com/en/ent/myringoplasty-and-tympanoplasty/)

## Related conditions 2

- [Cholesteatoma](https://durgical.com/en/conditions/cholesteatoma/)
- [Acute mastoiditis](https://durgical.com/en/conditions/acute-mastoiditis/)

[← All of ENT](https://durgical.com/en/ent/)

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)](https://www.ncbi.nlm.nih.gov/books/NBK559153/) (StatPearls Publishing, NCBI Bookshelf, 2023); [Middle Ear Cholesteatoma (StatPearls)](https://www.ncbi.nlm.nih.gov/books/NBK448108/) (StatPearls Publishing, NCBI Bookshelf, 2024); [Mastoidectomy](https://medlineplus.gov/ency/article/003016.htm) (MedlinePlus, U.S. National Library of Medicine, 2024).

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Representative model, for educational purposes only.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ent/mastoidectomy-cortical-radical-and-modified-radical/