What is the role of meatoplasty in mastoidectomy?

Meatoplasty in Mastoidectomy

Meatoplasty is an essential surgical technique performed during mastoidectomy to enlarge the external auditory meatus, ensuring adequate visualization, ventilation, and long-term access to the mastoid cavity for cleaning and surveillance.

Purpose and Indications

Meatoplasty serves critical functions in mastoid surgery:

• Provides adequate exposure of the mastoid cavity during canal wall-down (CWD) mastoidectomy procedures, allowing the surgeon to visualize and address disease comprehensively 1, 2
• Ensures long-term cavity ventilation and prevents moisture accumulation that could lead to chronic infection 3
• Facilitates postoperative surveillance by creating sufficient access for office-based cleaning and examination of the mastoid cavity 1, 4
• Prevents meatal stenosis, which occurs in approximately 12.5% of cases when meatoplasty is performed, requiring revision surgery if inadequate 1

Surgical Techniques

Z-Meatoplasty Technique

The Z-meatoplasty represents an effective modern approach:

• Creates a Z-shaped incision utilizing the endaural approach and superiorly based tympanomeatal flap, which provides excellent cosmetic results and functional outcomes 2
• Achieves 87.5% success rate in pediatric populations without requiring revision for stenosis during mean follow-up of 40 months 1
• Allows precise calculation of the external canal width and shape when performed at the beginning of the procedure via endaural approach 3

Endaural Approach Meatoplasty

This technique offers specific advantages:

• Permits removal of conchal cartilage as a whole piece with perichondrium, which can be preserved for middle ear reconstruction 3
• Produces broad mastoid exposure when performed early in the procedure, facilitating subsequent surgical steps 3
• Achieves stable, dry mastoid cavities in 98.6% of cases with intact eardrums in 97.76% at 3-year follow-up 3

Special Considerations

Oversized Meatus Correction

When previous CWD mastoidectomy creates an excessively large meatus:

• Reduction meatoplasty involves removing a wedge of skin and soft tissue superiorly to reduce meatal size after mastoid obliteration 4
• Enables use of standard hearing aids and over-the-counter ear plugs, eliminating the need for custom-molded devices 4
• Maintains cavity stability without chronic infection during average 22-month follow-up 4

Cochlear Implantation Context

In patients with CWD cavities and large meatoplasty requiring cochlear implantation:

• Pseudo-obliteration with conchal cartilage using multi-layered palisade reconstruction covering the electrode represents a safe alternative approach 5
• Prevents external canal overclosure while maintaining access and reducing cholesteatoma recurrence risk during mean 4.5-year follow-up 5

Common Pitfalls to Avoid

• Inadequate initial meatoplasty size leads to 12.5% revision rate for stenosis, emphasizing the importance of creating sufficient width initially 1
• Performing meatoplasty too late in the procedure makes it difficult to accurately calculate the required cartilage removal and future canal dimensions 3
• Creating excessively large meatus without considering future hearing aid or ear plug needs, particularly in patients who may require these devices 4