Hammer and gouge mastoidectomy for acute mastoiditis - Vula ...

The 1 st assistant retracts the auricletowards himself, using both hands. The 3 rdfinger of the lower hand is pressed stronglyunder the mastoid tip in order to compressthe posterior auricular artery. The otherassistant is prepared to sponge/swab withmastoid sponges/swabs held in angularforceps. The surgeon incises theretroauricular crease down to bone fromleft to right, from the linea temporalis tothe inferior part of the crease, or vice versa(Figure 5). In the event of a retroauricularabscess, the abscess cavity may be enteredat this point or during periosteal elevation.Second Step: Periosteal ElevationFollowing haemostasis and ligation ofbleeding vessels, the mastoid is completelyexposed proceeding posteriorly to theincision, without elevating the anteriorcartilaginous canal. This is easy in thesuperior portion where the periosteumfrees itself, but becomes more laborioustoward the inferior and posteroinferiorportions where the muscular insertionsmust be sectioned with the elevator. Figure6 demonstrates how the cartilaginous canalhas been respected (Figure 6).Third Step: Exploration of BoneIn the absence of electrocoagulation, 2Kocher hemostats are applied to theperiosteum, one in front and one in back,assuring haemostasis. Two sharp toothedretractors are held by the assistant. One isplaced forward to retract the auricle in thecanal without separating it from the bone.The other embraces the posterior lip of thewound, retracting it backward to uncoverthe operative surface. A self-retainingretractor may also be employed. Aftercompleting the periosteal elevation, thesurgeon carefully examines the mastoidsurface for changes in form, colour, andsurface (Figure 7).Figure 7: Examine the mastoid surfaceFigure 6: Periosteal elevationForm: In adjoining illustration one seesthe crest of the linea temporalis, the spineof Henlé, and the sieve-like region, theretromeatal depression, and the bulge ofthe posterosuperior region. The anteriormastoid portion is free of all muscularinsertions. The muscles from the nape ofthe neck and the sternocleidomastoidmuscle are inserted into the posteriorportion of the mastoid. These two regionsare separated by the posterior externalpetrosquamous suture. With acutemastoiditis these landmarks may be absentand the mastoid may then present anevenly rounded bulge, having the4