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Otorhinolaryngology focuses on the ear, nose, and throat. Learn about the diagnosis and treatment of hearing loss, sinusitis, tonsillitis, and voice disorders.
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Once the diagnosis of mastoid disease is confirmed, the conversation shifts to treatment. While antibiotics are the first line of defense for acute infections, they are often not enough to cure chronic mastoiditis or cholesteatoma. In these cases, surgery—specifically a mastoidectomy—is the definitive treatment.
There isn’t just one type of mastoid surgery. The procedure is tailored to the severity of the disease and the specific anatomy of the patient. The surgeon’s primary goal is always to make the ear safe and dry. Preserving hearing is a secondary but important goal. This section explains the different types of mastoidectomy procedures, what happens during the operation, and the other surgical steps that are often combined with it.
A cortical or simple mastoidectomy is typically performed for acute mastoiditis that hasn’t responded to antibiotics. It is the most conservative approach.
In this surgery, the surgeon makes an incision behind the ear to expose the mastoid bone. Using a high-speed surgical drill, they open the outer shell of the bone and clean out the infected air cells. It is like cleaning out the rooms of a honeycomb. The surgeon removes the pus and the soft, rotten bone but leaves the back wall of the ear canal intact.
This procedure drains the infection and allows the antibiotics to work effectively. Because the anatomy of the ear canal and middle ear is preserved, the appearance of the ear canal remains normal, and hearing is usually not affected by the surgery itself. Children commonly undergo this procedure to rescue their ear from a severe, sudden infection.
For chronic disease or cholesteatoma, a more extensive surgery is needed. The “Canal-Wall-Up” procedure is a common choice. In this operation, the surgeon drills out the mastoid disease but works cautiously to preserve the bony wall that separates the ear canal from the mastoid cavity.
By keeping this wall up, the ear canal retains its normal shape. This is beneficial because the patient can continue to swim and get the ear wet after healing without much difficulty. It also makes fitting a hearing aid easier in the future if needed.
The downside is that it is technically harder to see every hidden corner of the disease. A slight increase in the risk of leaving a small piece of cholesteatoma behind could potentially lead to a recurrence. Because of this, patients often need a “second look” surgery 6 to 12 months later to check for any regrowth.
This is the “gold standard” for extensive or recurrent cholesteatoma. In a Canal-Wall-Down procedure (also known as a Radical or Modified Radical Mastoidectomy), the surgeon makes a strategic decision to remove the bony wall between the ear canal and the mastoid.
By removing the wall, the surgeon merges the ear canal and the mastoid cavity into one large, open bowl. This provides the surgeon complete, unobstructed access to the disease. There are no hidden corners for the cyst to hide in. It has the highest success rate for permanently curing the disease.
The result is a larger ear opening (meatus). The new “bowl” is lined with skin. The main advantage is safety: the disease is gone and unlikely to return. The disadvantage is that the bowl requires maintenance. It does not clean itself like a normal ear canal. The patient must visit the ENT doctor once or twice a year to have the wax and dead skin vacuumed out. Furthermore, patients with a mastoid bowl often need to keep water out of their ear indefinitely, as the open cavity can get dizzy if cold water enters it.
Mastoidectomy is rarely done alone. It is almost always combined with a tympanoplasty. Since the infection usually started in the middle ear and traveled to the mastoid, the eardrum is often damaged or has a hole in it.
After cleaning the mastoid bone, the surgeon repairs the eardrum. They use a graft—usually a piece of muscle lining (fascia) or cartilage taken from the patient’s own ear—to patch the hole. The surgery rebuilds the wall between the outer world and the middle ear, helping to waterproof the ear and improve hearing.
Chronic infection and cholesteatoma often erode the tiny hearing bones (malleus, incus, and stapes). Once the disease is removed, the surgeon checks these bones. If the “bridge” of bones is broken, sound cannot travel to the inner ear.
In an ossiculoplasty, the surgeon rebuilds this bridge. They might reshape the patient’s own bone remnants or use a microscopic prosthetic implant made of titanium or plastic. This implant connects the new eardrum to the inner ear, restoring the transmission of sound. After the disease disappears, this step is crucial for providing the patient with functional hearing.
Mastoid surgery is performed under general anesthesia. The patient is completely asleep and feels no pain. Facial nerve monitors are used throughout the case—these are small electrodes placed on the face that alert the surgeon if they are working too close to the facial nerve, adding a layer of safety.
The surgery typically takes 2 to 4 hours. Most of the work is done under a microscope. At the end of the surgery, the ear is usually packed with a dissolvable sponge or antibiotic gauze to hold everything in place. A bandage is wrapped around the head to prevent swelling. Most patients go home the same day or stay just one night in the hospital.
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The “best” surgery depends on the extent of your disease. If you have a large, aggressive cholesteatoma, a canal-wall-down approach is safer. If it is a limited infection, a canal-wall-up approach is preferred to preserve normal anatomy.
It is possible. If the disease destroyed the hearing bones, surgery attempts to fix them, but perfect hearing isn’t always restored. A hearing aid can be fitted once the ear is fully healed.
A mastoid bowl is the open space created when the wall between the ear canal and mastoid is removed. It looks like a larger ear canal opening and requires periodic cleaning by a doctor.
All surgery has risks, but serious complications like facial paralysis or deafness are rare. Surgeons use advanced monitoring and microscopes to minimize these risks significantly.
Usually, no. Mastoidectomy involves drilling bone away, not adding plates. If hearing bones are replaced, tiny titanium implants might be used inside the middle ear, but not on the skull surface.
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