Hammer and gouge mastoidectomy for acute mastoiditis - Vula ...
Hammer and gouge mastoidectomy for acute mastoiditis - Vula ...
Hammer and gouge mastoidectomy for acute mastoiditis - Vula ...
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The 1 st assistant retracts the auricletowards himself, using both h<strong>and</strong>s. The 3 rdfinger of the lower h<strong>and</strong> 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 angular<strong>for</strong>ceps. 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 <strong>and</strong> 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 <strong>and</strong> 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 <strong>and</strong> one in back,assuring haemostasis. Two sharp toothedretractors are held by the assistant. One isplaced <strong>for</strong>ward 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 <strong>for</strong> changes in <strong>for</strong>m, colour, <strong>and</strong>surface (Figure 7).Figure 7: Examine the mastoid surfaceFigure 6: Periosteal elevationForm: In adjoining illustration one seesthe crest of the linea temporalis, the spineof Henlé, <strong>and</strong> the sieve-like region, theretromeatal depression, <strong>and</strong> the bulge ofthe posterosuperior region. The anteriormastoid portion is free of all muscularinsertions. The muscles from the nape ofthe neck <strong>and</strong> the sternocleidomastoidmuscle are inserted into the posteriorportion of the mastoid. These two regionsare separated by the posterior externalpetrosquamous suture. With <strong>acute</strong><strong>mastoiditis</strong> these l<strong>and</strong>marks may be absent<strong>and</strong> the mastoid may then present anevenly rounded bulge, having the4