Approaches to Middle ear and Mastoid surgery

Endomeatal (Transcanal or Transmeatal) Approach:

• Not used commonly in children owing to relatively small ear canal
• This incision is used when the mesotympanum and hypotympanum are the surgical sites
• A posterior tympanomeatal flap is raised to enter into the middle ear. The flap includes skin over the medial two-thirds of the bony external auditory canal.

Indications:

1. Exploratory tympanotomy
2. Underlay or Inlay myringoplasty
3. Ossiculoplasty (Ossicular reconstruction)
4. Stapedotomy and Stapedectomy (Otosclerosis surgeries)

Endaural Approach (Lempert or Heerman incision):

• Commonly used in infants and young children
• Accessibility of epitympanum and postero-superior part of mesotympanum
• Temporalis fascia graft can be easily obtained

Indications:

1. Excision of osteomas and exostoses of ear canal
2. Large tympanic membrane perforation
3. Atticoantrotomy for Attic cholesteatomas
4. Modified radical mastoidectomy

Postaural Approach (Wilde’s incision):

In children, the incision is shorter and horizontal to avoid injury to the facial nerve as mastoid is not well developed and the stylomastoid foramen (from where facial nerve emerges) lies superficially

Indications:

1. Cortical mastoidectomy
2. Modified radical and radical mastoidectomy
3. Tympanoplasty (when perforation extends anterior to handle of malleus)
4. Decompression of facial nerve
5. Endolymphatic sac surgery