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"Bondy" mastoidectomy cholesteatoma modified radical

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Bondy's Atticotomy (Modified Radical Mastoidectomy - Bondy Procedure)

Historical Background

Gustav Bondy described his modification of the classical radical mastoidectomy in 1910, building on an observation by Körner (1899) that in certain cases of cholesteatoma, the pars tensa of the tympanic membrane and the ossicular chain remained intact and functional. Bondy recognized that when disease was limited to the pars flaccida and the attic, the surgeon could exteriorize that disease without disturbing the intact middle ear, thus sparing the patient's hearing.

Before Bondy's contribution, the standard radical mastoidectomy (Zaufa, 1890) sacrificed the entire tympanic membrane, lateral ossicular chain, and middle ear mucosa. Bondy's key insight - that pars flaccida cholesteatoma could simply be exteriorized rather than treated with full radical ablation - made his procedure one of the earliest ear operations to formally address hearing preservation.

Shambaugh Surgery of the Ear, p. 540
Cummings Otolaryngology, p. 2740

Definition and Core Concept

The Bondy procedure (also called Bondy's modified radical mastoidectomy or Bondy's atticotomy) is a canal-wall-down exteriorization operation in which:

The superior and a portion of the posterior osseous meatal wall (i.e., the lateral attic wall) are removed
The attic and antral cholesteatoma is exteriorized into a permanently open cavity accessible through the external meatus
The intact pars tensa, tympanic cavity, ossicular chain, and middle ear mucosa are left undisturbed
The cholesteatoma matrix on the lateral surface of the ossicular heads is maintained in place as a lining for the created cavity

The fundamental principle is limited dissection - only the disease-bearing attic is opened, and the mesotympanum is not entered.

Cummings Otolaryngology, p. 2741 ("Modified Radical Mastoidectomy")

Indications

The Bondy procedure is specifically indicated when:

Cholesteatoma is confined to the epitympanum (attic) and antrum
There is a pars flaccida perforation with cholesteatoma limited to the attic region
The pars tensa is intact and hearing is preserved
The tympanic cavity and ossicular chain are uninvolved by disease
The cholesteatoma sac is small to moderate in size and limited laterally (lateral to the incus and malleus head)

When disease has spread into the mesotympanum, mastoid tip cells, or facial recess, the more comprehensive modified radical mastoidectomy (complete mastoidectomy + tympanoplasty) is preferred over the Bondy approach.

Surgical Anatomy Relevant to the Procedure

Before understanding the technique, the following landmarks are critical:

Notch of Rivinus: The superior defect in the tympanic ring - the natural entry point into the epitympanum. The surgeon uses a narrow periosteal elevator along the superior osseous meatal wall to locate it.
Middle fossa dura (tegmen): Lies just superior to the attic. The surgeon tracks the pink color through bone as the tegmen is approached during drilling.
Facial nerve: The tympanic segment runs in the fallopian canal at the floor of the epitympanum; the vertical (mastoid) segment is housed within the posterior bony facial ridge. Three landmarks locate it: the bony horizontal semicircular canal above, the tympanomastoid suture in the posterior meatal wall, and the digastric ridge in the mastoid tip.
Bridge: The remaining superior osseous meatal wall that bridges the notch of Rivinus after the atticotomy groove is created.
Facial ridge: The posterior osseous meatal wall deep portion housing the posterior bend and vertical facial nerve.

Surgical Technique (Step-by-Step)

1. Incision - Endaural Approach

The classical Bondy technique uses an endaural incision, made in two steps:

First incision: Beginning at "12 o'clock" on the superior canal wall, about 1 cm from the outer edge, it extends down the posterior canal wall in the incisura terminalis nearly to "6 o'clock," then turns outward 2-3 mm to the edge of (but not into) the conchal cartilage.
Second incision: Starting again at the same "12 o'clock" point, extends directly upward in the incisura terminalis to a point halfway between the meatus and the upper edge of the auricle. This vertical limb can be extended further superiorly without encountering important structures except the temporalis muscle and superficial temporal vessels.

Both incisions are first through skin only, then deepened to include periosteum, with the knife angled to avoid plunging into the bony canal.

2. Periosteal Elevation and Exposure

A broad periosteal elevator is directed posteriorly to elevate periosteum over the entire mastoid process, and anteriorly over the posterior root of the zygoma only. Wide elevation ("mobilizing the incision," as Lempert emphasized) is essential to obtain adequate exposure. The Shambaugh self-retaining endaural retractor is then inserted, exposing bone above and behind the osseous meatus from the posterior zygomatic root to 2-3 cm behind the suprameatal spine of Henle, and from the temporal line to the lower mastoid.

3. Atticotomy - Bone Removal

A surgical cutting bur removes the outer cortex just above and behind the meatus over a semilunar area - this is the atticotomy proper. As the groove is deepened:

The pink color of middle fossa dura shining through the bone signals proximity to the tegmen
The notch of Rivinus is located by passing a narrow elevator inward along the superior osseous meatal wall
The epitympanum is entered just before the groove reaches the depth of the notch
If the preoperative diagnosis is correct, the white, smooth wall of the cholesteatoma sac is identified at this point (care is taken not to mistake the dura for the sac wall)

4. Opening and Evacuating the Cholesteatoma Sac

The sac is opened cautiously, and:

Cholesteatoma contents are removed by suction and instrumentation
Extensions anteriorly, superiorly, and posteriorly are explored with a blunt mastoid searcher
Bone cortex and overhanging bone are removed with cutting bur, curet, or rongeur until the entire sac lies exposed

Important intraoperative decisions:

Matrix firmly attached to the exposed facial nerve may be intentionally left rather than risk nerve injury
Matrix extending into the mesotympanum and covering the stapes footplate may be left at the initial operation to avoid opening the vestibule (risking labyrinthitis) - a second-stage procedure can later remove it after the ear is dry

5. Taking Down the Bridge and Facial Ridge

The remaining superior osseous meatal wall (the bridge over the notch of Rivinus) is removed in small bites with a narrow rongeur after first elevating meatal skin
Using a small (000) curet, the anterior and posterior buttresses (spines of Rivinus) are taken down, always working outward away from the facial canal
The tympanic segment of the facial nerve is kept in constant view throughout
Ossicles are inspected: wherever cholesteatoma envelops or extends onto the medial surface of the malleus head or incus, these ossicles must be removed. If matrix is only lateral to ossicles, it may be removed or left, and the ossicles preserved.
The posterior osseous meatal wall (facial ridge) is taken down carefully with a drill or curet under the operating microscope, working parallel to - never across - the facial nerve direction, until the surgical cavity is flush with the intact tympanic membrane.

The step most often performed poorly is taking down the facial ridge. Unnecessary nerve exposure should be avoided because a Bell's palsy-type paresis occurs more often with nerve exposure. This is generally reversible but can leave residual weakness with synkinesis.

Shambaugh Surgery of the Ear, p. 543

6. Preparation of the Meatal Plastic Skin Flap

A pedicled plastic skin flap from the skin and periosteum of the entire superior osseous meatal wall is turned back to cover the facial ridge and the floor of the completed operative cavity.

7. Meatoplasty and Packing

The endaural incision is partially closed with 1-2 sutures, but the final meatal opening is packed wide open - to 3-4 times the original size - so that when fully healed, the meatus is twice the former size and the exteriorized cavity can be easily inspected and kept clean through the external meatus.

8. Endomeatal (Transcanal) Atticotomy Variant

For a small cholesteatoma sac that is lateral to the incus and malleus head in a patient with a large external meatus, an endomeatal (transcanal) atticotomy may be performed:

A stapes-type meatal flap extended forward superiorly and outwardly is raised, followed by removal of the meatal rim to exteriorize the sac
The surgeon then either dissects and removes the sac intact, or leaves the matrix and exteriorizes it as a small Bondy radical cavity
If the cholesteatoma proves larger than anticipated intraoperatively, the surgeon proceeds to a full endaural incision and atticotomy

Bondy vs. Classic Radical Mastoidectomy

Feature	Bondy Procedure	Classic Radical Mastoidectomy
Tympanic membrane	Intact pars tensa preserved	Removed entirely
Ossicular chain	Preserved (unless involved)	Removed
Middle ear mucosa	Undisturbed	Stripped
Eustachian tube	Not obliterated	Obliterated
Hearing	Often preserved/good	Sacrificed
Cavity extent	Limited attic + antrum	Entire temporal bone
Cholesteatoma type	Confined to attic/epitympanum	Extensive

Why the Bondy Procedure Lost Favor

The Bondy procedure, though hearing-sparing in the short term, had significant drawbacks that led to its decline:

Recurrent or persistent aural discharge from incomplete removal of infected mastoid air cells - the mastoid tip cells are not exenterated, and persistent infection occurred
Continued bone erosion from cholesteatoma matrix left in the attic (due to osteolytic enzymes produced by the matrix)
Squamous debris accumulation from incomplete tip cell removal and high facial ridge, causing recurrent infection

These failures prompted the evolution toward the modified radical mastoidectomy (complete mastoidectomy + tympanoplasty), which adds complete exenteration of all mastoid air cells, low facial ridge takedown, and tympanoplasty - achieving a self-cleaning dry cavity in 95% of cases.

Shambaugh Surgery of the Ear, pp. 543-544

Skin Grafting of the Bondy Cavity

Primary split-thickness skin grafting immediately after surgery is generally not recommended (Shambaugh's experience with ~100 fenestration operations). When a graft took by primary intention, the resulting epidermal lining was closely applied to bone without a connective tissue layer, led to excessive desquamation, was prone to breakdown, and showed a tendency to invade crevices requiring later revision.

The preferred approach is to allow the cavity to heal by granulation, then optionally apply a skin graft 2-3 weeks later when the cavity is lined by healthy granulations - providing the desired subepithelial connective tissue base.

Modern Legacy: The "Modified Bondy" Technique

The Bondy approach has been refined in modern otology. Sanna et al. (2009) described the Modified Bondy Technique, refining surgical steps and reporting long-term outcomes. In current practice, the term "Bondy mastoidectomy" or "limited canal-wall-down mastoidectomy" refers to a procedure where, for disease limited to the superior dissection:

A limited intact canal wall procedure is performed, staying superior
The antrum is identified
A Bondy mastoidectomy (limited cavity) can be performed if the ossicular chain is intact, with the superior dissection confined to the epitympanum and antrum
Shambaugh Surgery of the Ear, p. 4371 (block 7)

Summary

Bondy's atticotomy is a canal-wall-down, hearing-preserving exteriorization procedure for attic cholesteatoma confined to the epitympanum, in which the superior and part of the posterior canal wall are removed to create an open cavity, while the intact pars tensa, ossicular chain, and mesotympanum are deliberately left undisturbed. Its genius lay in recognizing that limited disease required limited surgery. While it has largely been superseded by the complete modified radical mastoidectomy with tympanoplasty (which addresses its recurrence problems), the Bondy concept remains foundational in understanding the continuum of open-cavity ear surgery, and modified versions continue to be used for select cases of small, localized attic cholesteatoma.

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