Bondy's Modified Radical Mastoidectomy

Historical Background and Concept

• Radical mastoidectomy: removes tympanic membrane and ossicles; externalizes the entire middle ear - no hearing preservation
• Bondy's modification: externalizes the attic and mastoid while preserving the intact pars tensa, ossicular chain (malleus and stapes), and a functioning tympanic cavity - thus preserving hearing

1. An intact pars tensa with a defective pars flaccida (attic) perforation
2. Normal or functioning tympanic cavity beneath
3. Cholesteatoma confined to the epitympanum/attic region without invading the mesotympanum

Shambaugh Surgery of the Ear, p. 542

Indications

• Epitympanic (attic) cholesteatoma with an intact pars tensa and a good-hearing ear, where the tympanic cavity remains functional

1. Cholesteatoma extending into the attic, antrum, or mastoid process
2. Extensive destruction of the posterior canal wall with cholesteatoma invading the mastoid
3. Patients unwilling or unable to undergo staged (two-stage canal-wall-up) approach
4. Patients in circumstances where a second-stage procedure is impractical
5. Occasional otologic surgeons less experienced with the canal-wall-up technique
6. Recurrent cholesteatoma after prior surgery

• Acute otitis media with coalescent mastoiditis
• Persistent secretory otitis media or chronic allergic otitis media
• Tuberculous otitis media (chemotherapy is primary treatment)
• Relative: wide exposure of sigmoid sinus, dura, and facial nerve by aggressive disease

Shambaugh Surgery of the Ear, pp. 541-543

Key Distinctions: Bondy vs. Standard MRM

Surgical Technique

Incision

• First incision: from "12 o'clock" on the superior canal wall down the posterior canal wall in the incisura terminalis nearly to "6 o'clock," then at right angles outward ~2-3 mm to the conchal cartilage
• Second incision: from "12 o'clock" extending directly upward in the incisura terminalis toward the upper edge of the auricle
• Periosteum is elevated widely over the entire mastoid - failure to elevate periosteum sufficiently is a common cause of inadequate exposure

Atticotomy and Bone Removal

1. A self-retaining endaural retractor is inserted; wide retraction is essential
2. Atticotomy using a surgical cutting bur: removes the outer cortex just above and behind the meatus over a semilunar area, deepening toward the notch of Rivinus
3. The epitympanum is entered; the white smooth cholesteatoma sac is identified
4. The sac is carefully opened, contents evacuated by suction, and extensions explored with a blunt mastoid searcher
5. Bone cortex and overhang are removed with bur, curet, or rongeur until the entire cholesteatoma sac lies exposed
6. The entire matrix (epithelial lining) is removed - exceptions include:
   • Matrix firmly adherent to exposed dura or sigmoid sinus
   • Matrix over a semicircular canal fistula (fascia graft applied instead)
   • Matrix firmly attached to exposed facial nerve
   • Matrix extending to the stapes footplate (may defer to second-stage)

Bondy-Specific Step (Limited Cavity)

• Stay superior in the dissection - a limited intact canal wall procedure is performed
• Remove the superior and posterior canal wall until only a thin rim of bone remains over the ossicles
• A medium-sized bur, drawn medially to laterally, facilitates bone removal
• The final rim of bone is removed with a small curette to avoid traumatizing the intact ossicular chain
• With experience, this can be performed entirely from the canal side ("inside-out"), creating the smallest possible cavity

Meatoplasty

Shambaugh Surgery of the Ear, p. 808 (Appendix)

Intraoperative Image

Preoperative Assessment

• CT temporal bone (non-contrast): assesses scutum erosion, attic soft tissue, involvement of semicircular canals, cochlea, fallopian canal, dural plates, sigmoid sinus, and degree of mastoid sclerosis
• Gadolinium-enhanced MRI: adjunct to CT when tegmen erosion is extensive - defines meningoencephalocele, dural inflammation, intracranial infection
• MR angiography: if sigmoid sinus thrombosis is suspected
• Preoperative ear toilet: 1.5% acetic acid irrigations + antibiotic otic drops for several weeks before surgery to control active suppuration

Complications and Pitfalls

1. Incomplete removal of the posterior canal wall
2. Incomplete removal of the superior canal wall
3. High facial ridge (facial nerve not sufficiently skeletonized/lowered)
4. Inadequate meatoplasty

• Sensorineural hearing loss if the ossicular chain or labyrinth is traumatized
• Facial nerve injury - the vertical segment must be identified and protected; the chorda tympani is typically sacrificed
• Labyrinthine fistula - matrix over the LSCC must be handled delicately; a blue line or palpable depression indicates fistula
• "Sink trap" effect - if the mastoid tip extends below the level of the bony canal, a dependent recess forms that accumulates debris; prevented by removing lateral mastoid tip cells to create a shallower cavity
• Recurrent/residual cholesteatoma - the principal long-term risk, especially with the limited Bondy dissection; the sinus tympani is the most difficult area to inspect

Summary

• Shambaugh Surgery of the Ear, pp. 541-544, 808
• Cummings Otolaryngology Head and Neck Surgery, Chapter 31