0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

The Z-Meatoplasty for Modified Radical Mastoidectomy in Children FREE

David E. Tunkel, MD
[+] Author Affiliations

Author Affiliation: Departments of Otolaryngology–Head and Neck Surgery and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md.


Arch Otolaryngol Head Neck Surg. 2006;132(12):1319-1322. doi:10.1001/archotol.132.12.1319.
Text Size: A A A
Published online

Objective  To determine the effectiveness of the Z-meatoplasty technique for enlargement of the external auditory meatus of children undergoing modified radical mastoidectomy.

Design  Case series.

Setting  Pediatric otolaryngology practice in an academic setting.

Patients  Consecutive sample of children (≤18 years old) who had undergone modified radical mastoidectomy performed by the author from 1995 to 2005.

Intervention  Z-meatoplasty technique used as part of modified radical mastoidectomy.

Main Outcome Measure  Development of postoperative stenosis of the external auditory meatus that required additional surgery.

Results  A total of 28 children and 29 ears were treated with modified radical mastoidectomy during the study period. The Z-meatoplasty was used in 24 ears, and 3 (12.5%) required revision meatoplasty for meatal stenosis. Twenty-one ears (87.5%) treated with Z-meatoplasty had excellent healing and cosmesis without stenosis, during a mean follow-up period of 40 months.

Conclusion  The Z-meatoplasty is an effective technique for use during modified radical mastoidectomy to treat children with cholesteatoma.

Figures in this Article

Modified radical mastoidectomy remains an effective procedure to remove or exteriorize cholesteatoma. Such “canal-wall down” procedures are usually used in patients who have extensive cholesteatoma or recurrence of cholesteatoma after intact canal-wall tympanomastoid surgery.1 Modified radical mastoidectomy is also used to treat ears with impending complications (lateral semicircular canal fistula or fallopian canal erosion) or anatomic issues that limit the intact canal-wall approach (eg, poor mastoid pneumatization, anteriorly placed lateral dural sinus, or low-lying middle fossa plate). Host factors, such as deafness in the contralateral ear, potential for poor postoperative follow-up, and ongoing eustachian tube dysfunction may favor the canal-wall down approach to treat cholesteatoma.2

Meatoplasty is a key part of the modified radical mastoidectomy procedure. A large external auditory canal meatus allows ventilation of the mastoid cavity as well as access for examination and debridement of the entire cavity. Removal of soft tissue and the cartilage of the external auditory canal and concha will enlarge the meatus, but meatoplasty procedures can be complicated by stenosis, infection, and pinna deformity.

I have used the Z-meatoplasty to enlarge the external auditory meatus of children undergoing modified radical mastoidectomy. This procedure uses an incision that runs in 3 dimensions to reduce the potential for stenosis. Two skin flaps are transposed after removal of cartilage and soft tissue to reduce the raw surface area and amount of exposed cartilage.

The technique is described, my results reported, and the advantages of this procedure are discussed.

Medical records of children (age, ≤18 years) who had undergone mastoidectomy performed by the author from 1995 to 2005 were reviewed. Patients who had modified radical mastoidectomy were identified. Demographic information including age at surgery, sex, side of surgery, and duration of follow-up was recorded. The method of meatoplasty was recorded (Z-meatoplasty or other). Indications for surgery, and whether surgery was primary or revision, were also recorded. Complications of Z-meatoplasty were analyzed, specifically the need for revision meatoplasty.

This study was reviewed by the institutional review board at Johns Hopkins University School of Medicine (Baltimore, Md) and was considered exempt under Department of Health and Human Services category 45CFR 46.404.

The meatoplasty is performed after all mastoid dissection and tympanoplastic surgery has been completed. All procedures were performed through a postauricular incision. A skin incision is made along the posterior and inferior conchal borders, along the posterior ear canal meatus (Figure 1). A flap of conchal skin is lifted just above the perichondrial layer, based posterosuperiorly (Figure 2). The skin of the posterior cartilaginous ear canal is then dissected off underlying cartilage and soft tissue, and then this canal skin flap is released superiorly to create an inferiorly based flap of ear canal skin (Figure 3). The conchal cartilage is excised, and underlying soft tissue is either excised or incised to create a large meatus (Figure 4). The conchal skin flap is rotated medially and tacked with absorbable suture to the soft tissue on the deep surface of the pinna, and the flap of posterior canal skin is rotated almost 90° and sutured to the skin edge of the inferior conchal cut (Figure 5). The cavity is filled with antibiotic ointment through the meatus (Figure 6). A loose nonadherent packing can be used if hemostasis is required. The postauricular incision is then closed.

Place holder to copy figure label and caption
Figure 1.

The Z-meatoplasty combines a conchal incision with an incision into the superior ear canal. A, Schematic of skin incision that is made along posterior and inferior margin of concha, continued at the posterior ear canal meatus, and down into the superior cartilaginous ear canal. B, Incision planned for right ear.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Skin elevation and cartilage. A, Conchal skin flap is lifted. B, Exposing cartilage that is subsequently excised.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

The skin of the posterior ear canal is dissected from underlying cartilage and soft tissue.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

The conchal cartilage has been removed and underlying soft tissue excised.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

The conchal skin flap is rotated into the meatus and sutured to raw undersurface of the pinna. The flap of posterior canal skin is rotated 90° and sutured to the edge of the conchal cut.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Completed meatoplasty; the mastoid cavity is filled with antibiotic ointment.

Graphic Jump Location

Oral antibiotics are administered for 5 to 7 days after surgery. If a meatal packing is placed, it is removed during the first postoperative week.

Twenty-eight children and 29 ears underwent modified radical mastoidectomy during the study period. Twenty patients were male, and 8 were female. Surgery was performed on 17 left ears and 12 right ears. The median age of the patients at surgery was 10 years (range, 2.5-16 years).

All modified radical mastoidectomy procedures were performed for cholesteatoma. Eight were primary procedures for cholesteatoma, with extensive disease or anatomic factors dictating the need for canal-wall down surgery. Twenty-one procedures were revision procedures (either second or third operations), and canal-wall down surgery was performed for recurrence or persistence of cholesteatoma. The mean length of follow-up was 40 months (range, 5-78 months), but 2 patients were lost to follow-up approximately 2 years after surgery.

Twenty-four (83%) of these 29 ears had Z-meatoplasty performed. Five ears had been previously treated with other methods of meatoplasty, all of which had left the conchal anatomy unsuitable for Z-meatoplasty. Three (12.5%) of the 24 ears that were treated with Z-meatoplasty required additional surgery to revise the meatus during the follow-up period. One of these ears had a postoperative perichondritis that resolved with local care and oral antibiotics, and 1 developed a keloid at the meatus. All 3 ears that required revision developed stenosis within 2 months of surgery. Aside from the 1 patient with postoperative infection and the other with hypertrophic scar formation, no other factors were identified to predict failure of the Z-meatoplasty technique.

The appearance of the meatus and pinna after Z-meatoplasty is shown in Figure 7. These ears are easy to examine and debride with the use of simple otologic tools and an operating microscope.

Place holder to copy figure label and caption
Figure 7.

Five years after Z-meatoplasty/modified radical mastoidectomy.

Graphic Jump Location

Successful control of cholesteatoma and chronic infection with open cavity mastoid procedures requires a well-ventilated, accessible mastoid cavity. Creation of a large meatus is a key component of such surgery. Meatoplasty requires removal of soft tissue and cartilage while avoiding raw tissue surfaces that may lead to granulation tissue and stenosis. Techniques of meatoplasty have included some combination of transposed skin flaps, removal of conchal cartilage, removal of cartilage from the tragus or the floor of the ear canal, and use of conchomastoid sutures or meatal packing to maintain a large meatal diameter.36

The Z-meatoplasty has been described as a method to enlarge the external auditory meatus by rotating 2 skin flaps after removal of conchal cartilage and soft tissue.7 This technique reduces the amount of raw surface by primary closure of the rotated flaps. The need for packing is reduced, and conchomastoid sutures are unnecessary because the large meatus is tension-free. Murray et al8 describe the use of this technique in 32 patients, after canal-wall down mastoid surgery that was performed using an endaural incision. There was no stenosis seen in this series, although 1 patient required revision of a hypertrophic scar.

The success rate for meatoplasty of any method, specifically with regard to restenosis, is not well documented in the literature. The wide variety of techniques described to enlarge the external auditory meatus suggests that restenosis may be more common than the literature suggests. One series of patients who had undergone canal-wall down mastoidectomy in New Guinea, where postoperative follow-up is minimal, reports a 12% to 20% rate of revision meatoplasty.9 Aggressive postoperative treatment of granulation may reduce the rate of stenosis after meatoplasty.

To my knowledge, the series reported herein is the first series of children treated with Z-meatoplasty and the first series that reports the use of Z-meatoplasty with the postauricular mastoid approach. The 88% success rate and excellent cosmesis are comparable with or perhaps better than other techniques of meatoplasty. This technique should be considered for use in children who require canal-wall down mastoid surgery to control cholesteatoma.

Correspondence: David E. Tunkel, MD, Johns Hopkins Outpatient Center, Room 6231, 601 N Caroline St, Baltimore, MD 21287-0910 (dtunkel@jhmi.edu).

Submitted for Publication: February 17, 2006; final revision received March 29, 2006; accepted April 22, 2006.

Author Contributions: Dr Tunkel had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Financial Disclosure: None reported.

Previous Presentation: This study was presented in part at the annual meeting of the Society for Ear, Nose, Throat Advances in Children; December 4, 2005; Baltimore.

Lambert  PRDodson  EEHashisaki  G Intact canal wall versus canal wall down mastoidectomy.  In: Lalwani  AK, Grundfast  KM, eds.Pediatric Otology and Neurotology. Philadelphia, Pa: Lippincott-Raven; 1998:663-670
Jackson  CGGlasscock  MENissen  AJSchwaber  MKBojrab  DI Open mastoid procedures: contemporary indications and surgical technique. Laryngoscope 1985;951037- 1043
PubMed
Fisch  U Tympanoplasty, Mastoidectomy, and Stapedectomy.  New York, NY: Thieme; 1994:190-192
Suskind  DLBigelow  CDKnox  GW Y modification of the Fisch meatoplasty. Otolaryngol Head Neck Surg 1999;121126- 127
PubMed
Eisenman  DJParisier  SC Meatoplasty: the cartilage of the floor of the ear canal. Laryngoscope 1999;109840- 842
PubMed
Raut  VVRutka  JA The Toronto meatoplasty: enhancing one's results in canal wall down procedures. Laryngoscope 2002;1122093- 2095
PubMed
Fagan  PAjal  M Z-Meatoplasty of the external auditory canal. Laryngoscope 1998;1081421- 1422
PubMed
Murray  DPJassar  PLee  MSWVeitch  DY Z-meatoplasty technique in endaural mastoidectomy. J Laryngol Otol 2000;114526- 527
PubMed
Garap  JPDubey  SP Canal-down mastoidectomy: experience in 81 cases. Otol Neurotol 2001;22451- 456
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

The Z-meatoplasty combines a conchal incision with an incision into the superior ear canal. A, Schematic of skin incision that is made along posterior and inferior margin of concha, continued at the posterior ear canal meatus, and down into the superior cartilaginous ear canal. B, Incision planned for right ear.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Skin elevation and cartilage. A, Conchal skin flap is lifted. B, Exposing cartilage that is subsequently excised.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

The skin of the posterior ear canal is dissected from underlying cartilage and soft tissue.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

The conchal cartilage has been removed and underlying soft tissue excised.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

The conchal skin flap is rotated into the meatus and sutured to raw undersurface of the pinna. The flap of posterior canal skin is rotated 90° and sutured to the edge of the conchal cut.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Completed meatoplasty; the mastoid cavity is filled with antibiotic ointment.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

Five years after Z-meatoplasty/modified radical mastoidectomy.

Graphic Jump Location

Tables

References

Lambert  PRDodson  EEHashisaki  G Intact canal wall versus canal wall down mastoidectomy.  In: Lalwani  AK, Grundfast  KM, eds.Pediatric Otology and Neurotology. Philadelphia, Pa: Lippincott-Raven; 1998:663-670
Jackson  CGGlasscock  MENissen  AJSchwaber  MKBojrab  DI Open mastoid procedures: contemporary indications and surgical technique. Laryngoscope 1985;951037- 1043
PubMed
Fisch  U Tympanoplasty, Mastoidectomy, and Stapedectomy.  New York, NY: Thieme; 1994:190-192
Suskind  DLBigelow  CDKnox  GW Y modification of the Fisch meatoplasty. Otolaryngol Head Neck Surg 1999;121126- 127
PubMed
Eisenman  DJParisier  SC Meatoplasty: the cartilage of the floor of the ear canal. Laryngoscope 1999;109840- 842
PubMed
Raut  VVRutka  JA The Toronto meatoplasty: enhancing one's results in canal wall down procedures. Laryngoscope 2002;1122093- 2095
PubMed
Fagan  PAjal  M Z-Meatoplasty of the external auditory canal. Laryngoscope 1998;1081421- 1422
PubMed
Murray  DPJassar  PLee  MSWVeitch  DY Z-meatoplasty technique in endaural mastoidectomy. J Laryngol Otol 2000;114526- 527
PubMed
Garap  JPDubey  SP Canal-down mastoidectomy: experience in 81 cases. Otol Neurotol 2001;22451- 456
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 2

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles