Risks of mastoidectomy surgery may include:
. Changes in taste from sacrifice of chorda tympani nerve
. Hearing loss or deafness/sensorineural hearing loss
. Worse hearing (conductive loss) immediately after surgery is common due to ossicular discontinuity
. Infection that persists or keeps returning, including loss of reconstructed bony canal wall or exposure of bone in canal wall
. Noises in the ear (tinnitus)
. Facial paralysis – reported 0.6-3.6%
. Vertigo – 5-10% of cholesteatomas form lateral semicircular canal fistula
. Recurrence of cholesteatoma – 1.5%
. Need for further surgeries, including a planned surgery for re-evaluation of the ear and possible reconstruction of ossicles (bones that transmit sound from the eardrum to inner ear).
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. Facial nerve injury
Facial nerve paralysis is the most dreaded complication of mastoidectomy. The incidence of this complication is fortunately exceeding low (~0.1%). Revision surgery, operator experience, extensive disease, osseous dehiscence of the nerve all increase the risk of an iatrogenic facial nerve injury. A transient facial weakness can be seen in the immediate postoperative period from local anesthetic, which enters the middle ear space adjacent to the facial nerve. This typically resolves within a period of 2-4 hours. Postoperative facial nerve paralysis that does not resolve after a few hours should be taken back to the operating room for exploration. A partial-thickness injury can be decompressed or observed, while a full-thickness injury should be repaired with a primary anastomosis or interposition graft. Drilling in the direction of the nerve with a diamond burr using copious irrigation significantly reduces the risk of a facial nerve injury.
. Hearing loss
A temporary conductive hearing loss is very common after mastoidectomy, as blood, serous fluid, and packing frequently fill the middle ear space. In the setting of chronic otitis media with cholesteatoma, the ossicles are frequently eroded or absent, which results in a preoperative significant conductive hearing loss. Depending on the extent of the cholesteatoma and surgeon preference, an ossicular chain reconstruction with autologous materials or implants can allow for improvement in conductive hearing loss. A significant sensorineural hearing loss is rarely encountered in patients undergoing surgical intervention for chronic otitis media. Sensorineural hearing loss may arise from the high-speed drill contacting an intact ossicular chain, labyrinthine fistula, or noise exposure from the drill.
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Vertigo and/or dizziness is frequently seen in patients undergoing otologic surgery. A number of factors contribute to these symptoms including the type and duration of anesthesia, cool irrigation adjacent to the labyrinth, and possible manipulation of the ossicles. Permanent vestibular symptoms are quite rare after mastoidectomy. An iatrogenic injury to the labyrinth is fortunately quite rare (0.1%). A labyrinthine fistula, especially involving the lateral semicircular canal, typically results in severe room-spinning vertigo that typically lasts up to 72 hours.
Labyrinthine injury carries an additional risk of sensorineural hearing loss. If a fistula is identified, intraoperatively suctioning over the area should be avoided and the opening should be covered with fascia immediately. Packing the fistula with bone wax or other materials may increase the risk of hearing loss or vertigo, especially in the setting of inflammation or infection.
. Change in taste
The chorda tympani nerve travels through the middle ear space from its origin along the mastoid portion of the facial nerve. This nerve may need to be sacrificed if it is encased in cholesteatoma or inflammatory tissue. This nerve is typically removed in patients undergoing revision surgery or a canal wall down procedure. Patients typically notice an altered sensation of taste, typically described as a metallic or sour taste on the affected side. This sensation may be persistent but often resolves over a period of months.
. Mastoid cutaneous fistula
Mastoid cutaneous fistulas are rarely encountered after mastoidectomy. This may be seen in patients who have undergone multiple postauricular incisions or have poor wound healing. This defect can be closed with local advancement or rotational flaps.
. Dural injury
Dural exposure without injury can be observed without repair. A suspected dural injury from drilling or a microinstrument should be carefully inspected even if a cerebrospinal fluid leak is not identified. A partial or nearly full-thickness dural injury should be repaired with either fascia, cartilage, autologous bone, or bone cement depending on the extent and size of the injury. If bone cement is used, it should be covered with fascia after it has dried. Failure to repair this may result in an encephalocele. A cerebrospinal fluid leak involving the middle fossa plate typically abates if the dura is closed primarily or is covered with a graft. Posterior fossa dural plate injuries can be more challenging to close and may require mastoid obliteration with fat or bone cement. Caution is advised using nonautologous materials in an infected field. A cerebrospinal fluid leak often necessitates admission, elevation of the head of the bed, and, in refractory cases, placement of a lumbar drain.
. Vascular injury
The sigmoid sinus is one of the initial landmarks used to mastoid surgery. This large vessel can be injured with a drill or microinstruments. Injury typically results in copious venous bleeding. Since the sigmoid sinus is a low-flow system, gentle pressure with a moist cottonoid with Gelfoam or Surgicel over the injured area frequently results in the cessation of bleeding. Care must be taken not to displace packing into the sinus lumen with resultant embolization. An arterial injury to the petrous carotid artery should be taken to interventional neuroradiology immediately. Gentle continuous pressure is required over the vessel until the bleeding is controlled. Temporary or permanent occlusion may be necessary if the vessel injury cannot be repaired primarily.
About Iranian Surgery
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For more information about the cost of Mastoidectomy in Iran and to schedule an appointment in advance, you can contact Iranian Surgery consultants via WhatsApp number 0098 901 929 0946. This service is completely free.