OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
SUBTOTAL PETROSECTOMY Tashneem Harris & Thomas Linder
Subtotal petrosectomy involves complete
exenteration of all air cells of the temporal
bone (middle ear and mastoid). It includes
the following cell tracts: retrosigmoid,
retrofacial, antral, retrolabyrinthine, supra-
labyrinthine, infralabyrinthine, supratubal
and pericarotid cells. Only a few cells in
the petrous apex are left behind. The otic
capsule is either kept intact or removed
(subtotal petrosectomy with or without
removal of the otic capsule). The external
auditory canal is closed as a blind sac and
the cavity obliterated with abdominal fat
and a temporalis muscle flap. Complete Figure 1: Chronically discharging
removal of disease is important before mastoid cavity
obliterating the cavity.
Indications
Chronic otitis media when there is no
possibility of hearing reconstruction
and one wishes to attain a dry, safe ear
(Figure 1)
Chronic otitis media in a completely
deaf ear (Figure 2)
Middle ear tumours (Figure 3)
CSF leaks which may be traumatic,
iatrogenic or (rarely) spontaneous
Supralabyrinthine and/or infralabyrin- Figure 2: Audiogram showing dead left
thine cholesteatoma ear
Transverse temporal bone fracture
(Figure 4)
In combination with another neuro-
tologic procedure e.g. Transotic and
Infratemporal fossa approaches “Types
A, B or C”
Cochlear or middle ear implantations
where an open cavity has previously
been performed (Figure 5)
Cochlear implantation in the case of
congenital cochlear dysplasia where
there is a high risk of CSF gusher
Osteoradionecrosis of the temporal Figure 3: Type B temporal para-
bone ganglioma
Audiogram
Review audiograms to decide whether
it is necessary to remove the stapes
superstructure or if it should be
preserved
If there is no possibility of hearing
reconstruction e.g. a dead ear, then the
stapes superstructure may be removed
If hearing is reasonable then it may be
wise to preserve the stapes
superstructure as the patient may
decide to have a semi-implantable
Figure 4: Transverse temporal bone hearing aid (Vibrant Soundbridge)
fracture of right ear involving vestibule fitted in the future.
Antibiotics: Perioperative intravenous
amoxicillin with clavulanic acid
Operative site
The hair of the patient is shaved for a
distance of 7cm above and behind the
hairline
The inferior abdominal quadrant and
suprapubic areas are shaved and
prepared for harvesting a fat graft
Positioning of patient: The patient lies
Figure 5: Subtotal petrosectomy and
supine with the head turned away from the
cochlear implant
surgeon (Figure 6)
Preoperative management
Imaging
Patients undergoing subtotal petrosec-
tomy require High Resolution CT
(HRCT) scan prior to surgery
Refer to the preoperative CT checklist
in the chapter on mastoidectomy and
epitympanectomy
If patients have had previous surgery, it
is particularly important to pay
attention to structures which may have
been exposed at the primary surgery Figure 6: Positioning of patient
e.g. facial nerve, sigmoid sinus and
dura
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Facial nerve monitoring: Avoid long- open cavity where the periosteal tissue
acting muscle relaxants as the facial nerve may be of poor quality
should be monitored intra-operatively
Surgical steps
Skin Incision
A postauricular S-shaped incision is
made from the temporal region to 1cm
below the mastoid tip (Figure 7)
The superior part of the incision above
the temporal line is only made at the Figure 8: Mastoid periosteal flap
end of the procedure when a temporalis
muscle flap is needed Blind Sac closure of external auditory
canal
Transection of the auditory canal
The periosteal flap is elevated until the
bony-cartilaginous junction of the
external auditory canal is reached
An incision is made from 6 to 12
o’clock in the posterior auditory canal
(Figure 9)
Figure 7: Postauricular S-shaped
incision
Mastoid periosteal flap
This flap is used as second layer in the
closure of the external auditory canal
and is therefore left attached to the
cartilaginous canal
Using a surgical scalpel with a # 10 Figure 9: Incision in ear canal
blade the skin is reflected anteriorly
remaining superficial to temporalis To transect the anterior portion of the
fascia and muscle canal, use a curved clamp to find the
The anteriorly-based periosteal flap is tragal cartilage
developed measuring about the size of A large curved artery clamp is then
the surgeon’s finger. (Figure 8) used to develop a plane anterior to the
It has to be long enough to achieve tragal cartilage separating the parotid
closure of the external canal especially from the cartilage
in the case of previous surgery with an Holding the curved clamp in this
position, a # 15 blade is used to
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transect the anterior canal safely by
cutting onto the curved clamp. This
avoids injury to the facial nerve
(Figure 10)
Figure 11: Elevating skin of external
canal
Figure 10: Safely transecting anterior
wall of ear canal
Eversion of auditory canal skin
Ocular magnifying loupes are useful
for this step
The skin of the cartilaginous canal is
elevated for 1cm from the cut margin
with tympanoplasty scissors to Figure 12: Placing stay sutures
facilitate eversion of the canal (Figure
11)
It is important that the skin of the
external canal is not breached. To
avoid this, direct the curve of the
tympanoplasty scissors towards the
cartilage
It may be difficult to find the correct
plane, especially if a previous open
mastoidectomy with a wide
meatoplasty was performed
Two 2-0 vicryl stay sutures are placed
at 6 and 12 0’clock. These are placed Figure 13: Stay sutures
as 2 purse string sutures with the free
ends on the inside of the canal (Figures A curved artery clamp is passed
12, 13) through the canal from externally and
applied to each of the free ends of the
two stay sutures. Tension is applied to
the stay sutures to evert the canal skin
(Figure 14)
4
Figure 14: Everting the skin of the ear
canal Figure 17: Oversewing the sac with the
periosteal flap
The tragus is retracted with a skin hook
and the skin edges are oversewn with Removal of lateral external auditory
4-0 vicryl suture (Figures 15, 16) canal skin
The skin of the bony external canal is
elevated with a Key raspatory
This skin cuff is removed with
tympanoplasty scissors (Figure 18)
Figure 15: Oversewing canal
Figure 18: Removing skin of ear canal
Removal of medial external auditory
canal skin
A microraspatory and small strip of
adrenaline gauze is used to elevate the
remnants of the external auditory canal
Figure 16: Oversewn canal skin to the annulus
The middle ear is entered at the
The periosteal flap is folded back as a posterior tympanic spine and the
2nd layer to the blind sac closure of the annulus is elevated. The short process
external auditory canal (Figure 17). It of malleus, chorda tympani and
is sutured to the cartilage of the incudostapedial joint are now visible
external auditory canal with 2-0 vicryl
5
Chorda tympani is divided with a large confirm once again that the jugular
Bellucci scissors bulb is not high-riding
The incudo-stapedial joint is separated The pericarotid cells are exenterated by
with a 45° 1,5mm hook first approaching the anterocarotid
The malleus is cut at its neck with a cells. The carotid is recognised by its
malleus nipper whitish colour beneath bone. The
Tensor tympani tendon is cut with a carotid is not infrequently dehiscent at
large Bellucci scissors its bend medial to Eustachian tube
The tympanic membrane (with handle The mastoid tip may be left in place,
of malleus attached) is now be but is drilled down to the level of the
removed along with the incus and head digastric ridge
of malleus Retrofacial, retrosigmoid, retrolabyrin-
thine, supralabyrinthine, infralabyrin-
Mastoidectomy thine, and supratubal cells are all
exenterated. Figure 19 shows the
It is important that all mastoid cells are mastoid cavity once all the cell tracks
exenterated and no mucosa is left have been exenterated
behind as this can potentially form
mucocoeles
Structures like dura, sigmoid sinus and
facial nerve have to be skeletonised,
not exposed
Using a mastoid raspatory elevate the
soft tissues off the mastoid
The sternocleidomastoid muscle is
freed from its insertion into the mastoid
tip
Place a 2-0 silk stay suture from the
edge of temporalis muscle to its fascia Figure 19: Mastoid cavity with all cell
to expose the area above the temporal tracks have been exenterated
line
Next proceed as for open mastoido- Technical points
epitympanectomy (see chapter on When drilling in the supralabyrinthine
mastoidectomy) segment a diamond drill is used in
reverse when operating on the right ear
After performing an open mastoido- to avoid injuring the facial nerve
epitympanectomy the additional removal The mucosa of the middle ear can be
of cells are removed to complete the removed by using the microraspatory
subtotal petrosectomy: and scraping the mucosa with a small
The stapes superstructure is removed cotton ball, taking care not to sublux
by using crurotomy scissors to cut the the stapes superstructure if left intact
anterior and posterior crus
The inferior surface of the external ear Obliteration of Eustachian tube
canal cam be lowered to the level of
the hypotympanum The internal carotid artery is followed
Before skeletonising the jugular bulb, it superiorly to the medial wall of the
is important to review the CT scan to eustachian tube (watch out for a
dehiscent carotid at this point!)
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The mucosa of the bony eustachian Technical points
tube is removed as far as the isthmus The tensor tympani muscle can be
with a 2mm/3mm diamond burr dissected out of its semicanal by
At this point the remaining mucosa is drilling its lateral surface and reflecting
coagulated with bipolar forceps and the it anteriorly with a microraspatory into
eustachian tube is obliterated with bone the protympanum and the eustachian
wax (Figure 20) tube orifice
Bone wax is then placed over this so
that the muscle lies sandwiched
between two layers of bone wax, thus
obliterating the eustachian tube
Obliteration of Operative Cavity
The middle ear cleft is obliterated with
abdominal fat harvested from the lower
quadrant of the abdomen (Figure 22)
It is important to achieve meticulous
haemostasis as the most common
Figure 20: Eustachian tube obliterated complication of subtotal petrosectomy
with bone wax is a haematoma of the abdominal
wound
Using a cottonoid, the bone wax may A suction drain is placed in the
be pushed into the orifice of the abdominal wound
eustachian tube with a suction tip. The The abdominal wound closed in layers
tip of the microraspatory is directed using 3-0 vicryl subcutaneously and
away from the carotid (Figure 21) monocryl 3-0 or nylon 3-0 to skin
With osteoradionecrosis of the
temporal or chronic infection it is
advisable not to use abdominal fat to
obliterate the cavity. Rather use only
temporalis muscle
Figure 21: Microraspatory directed
away from carotid
A temporalis muscle musculofascial Figure 22: Abdominal fat
graft is used as an additional seal of
orifice by placing it lateral to the bone
wax
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Transposition of temporalis muscle
The skin incision is extended
superiorly above the temporal line to
expose the temporalis muscle
Remaining in a plane above the
temporalis fascia, the skin and soft
tissue edges are undermined
Using two skin rakes, the assistant
retracts the skin edges for adequate Figure 24: Additional fat placed in
exposure defect
The posterior 2/3 of the temporalis
muscle is mobilized by creating a flap Wound Closure
using a diathermy knife
To facilitate mobilisation and A 3mm suction drain is placed under
transposition of the temporalis flap the scalp over the squamous part of the
over the mastoid cavity, a small temporal bone and not over the mastoid
inverted v-shaped incision is made at cavity
the base of the temporalis muscle The wound is closed in layers with 2-0
The muscle flap is rotated inferiorly vicryl sutures subcutaneously and skin
over the cavity and sutured to the clips
sternocleidomastoid muscle and soft A compression bandage is applied
tissues of the occiput with 2-0 vicryl
suture (Figure 23)
Postoperative care
Antibiotics (amoxicillin with clavula-
nic acid) are continued for one week
postoperatively
The drain is left in place until the
drainage is less than 10mls/24hrs.
If the surgery was done for CSF leak,
then the drain is removed on the first
postoperative day
The abdominal drain is removed when
Figure 23: Temporalis flap and the drainage is less than 10mls/24hrs
abdominal fat in petrosectomy defect Clips/sutures are removed after 10 days
The resorbable vicryl sutures within
Inevitably the fat used to obliterate the the external ear canal are removed at 4
cavity will atrophy, therefore more fat weeks
is placed in the cavity once the
temporalis muscle has been sutured to
the soft tissues via the superior pocket Long-term follow-up
created by the transposed temporalis
flap (Figure 24) Imaging
Where subtotal petrosectomy is
performed for chronic otitis media, CT
8
scans are routinely performed after one Author
year and then again at 3 years
In cases of previous cholesteatoma, a Dr. Tashneem Harris MBChB, FCORL,
diffusion weighted non-EPI MRI MMED (Otol)
would detect recurrent disease Fisch Instrument Microsurgical Fellow
Otolaryngologist
Auditory rehabilitation Kimberley, South Africa
harristasneem@yahoo.com
This depends on the status of hearing of
opposite ear, the degree and type of
hearing loss and cochlear function. The Senior Author
options are: bone anchored hearing aid
(BAHA), if the inner ear function has been Thomas Linder, M.D.
preserved of the ipsilateral or contralateral Professor, Chairman and Head of
ear; active middle ear implant (e.g. Vibrant Department of Otorhinolaryngology,
soundbridge) where there is good cochlear Head, Neck and Facial Plastic Surgery
reserve; or cochlear implant (bilateral Lucerne Canton Hospital, Switzerland
deafness) thomas.linder@ksl.ch
Editor
References
Johan Fagan MBChB, FCORL, MMed
1. Fisch U, Mattox D, eds. Microsurgery Professor and Chairman
of the Skull Base. Stuttgart,Germany: Division of Otolaryngology
Georg Thieme Verlag, 1988. University of Cape Town
2. Linder T, Schlegel C, DeMin N, van Cape Town
der Westhuizen S.Active Middle Ear South Africa
Implants in Patients Undergoing johannes.fagan@uct.ac.za
Subtotal Petrosectomy: New
Application for the Vibrant
Soundbridge Device and Its THE OPEN ACCESS ATLAS OF
Implication for Lateral Cranium Base OTOLARYNGOLOGY, HEAD &
Surgery. Otol Neurotol. 2008;30:41-7
NECK OPERATIVE SURGERY
www.entdev.uct.ac.za/index_files/Page650.htm
Acknowledgements
This guide is based on the text by
Professor Fisch (Microsurgery of the Skull The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
Base) and personal experience of Professor johannes.fagan@uct.ac.za is licensed under a Creative
Linder, as well as course materials for the Commons Attribution - Non-Commercial 3.0 Unported
License
lateral skull base course conducted
annually by Professors Fisch and Linder at
the Department of Anatomy, University of
Zurich, Switzerland.
