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Incisions Used in Tympanomastoid Surgery

Three main incisions are used for tympanomastoid surgery, each with specific indications, advantages, and limitations. A fourth group - extended incisions for skull base access - is used for complex lateral cranial base work.

1. Transcanal (Endomeatal) Incision

The transcanal approach is performed entirely through the external auditory canal without any external skin incision. It is appropriate for procedures limited to the tympanic membrane and the posterior tympanic compartment.

Technique:

Canal incisions are made with a tympanomeatal flap
A posteriorly based flap (Rosen incision) is typical - the posterior canal skin is elevated and folded forward to expose the middle ear

Indications:

Myringotomy and grommet insertion
Stapedectomy / stapedotomy
Small posterior tympanic membrane perforations
Ossiculoplasty with limited disease
Small posterior glomus tympanicum tumors

Advantages: No external scar, least invasive, suitable for outpatient procedures

Limitation: Restricted posterior and mastoid access

Transcanal incision - posteriorly-based tympanomeatal flap with canal incisions

Transcanal incisions: (A) endaural view showing incision lines, (B) intracanal view, (C) exposure of the middle ear through the flap

2. Endaural Incision

The endaural incision was first described over 100 years ago. It has three segments:

Circumferential (meatal) limb - runs circumferentially around the canal entrance
Intercartilaginous limb - passes between the helical crus and the tragus (between the two cartilaginous portions)
Vertical (superior) limb - extends superiorly through the skin toward the temporalis fascia

Three segments of the endaural incision labeled 1, 2, 3 - Stanford Oto Surgery Atlas (Gralapp)

The three segments: (1) circumferential/meatal, (2) intercartilaginous, (3) vertical superior limb extending to temporalis fascia

Completed endaural exposure with retractors enabling tympanomastoid surgery - Stanford Atlas

Completed endaural exposure with retractors in place, giving direct access to the epitympanum and tympanomastoid compartment

Indications:

Tympanoplasty (especially anterior and total perforations)
Canalplasty for exostoses
Anterior atticotomy
Epitympanic procedures
Can be extended (Heermann modification) for mastoidectomy in narrow canals
Preferred when the external canal or meatus is abnormally small

Advantages:

Does not interrupt the majority of cutaneous innervation of the pinna → no postoperative hypesthesia of the auricle
Generally no mastoid dressing needed → ideal for day surgery
Auricle does not migrate anteriorly postoperatively (avoids collapsing canal)
Direct access to the epitympanum

Limitations:

Visible scar (between helical crus and tragus)
Limited posterior exposure compared to postauricular approach
Less commonly used today than postauricular due to scar visibility and restricted access when mastoid work is extensive

3. Postauricular Incision

The postauricular incision is the workhorse of tympanomastoid surgery. It is made in the postauricular sulcus (the crease behind the ear), running parallel to and approximately 5-8 mm behind the postauricular crease from above the auricle down to the mastoid tip.

Postauricular incision position relative to the postauricular crease, with two variants (A and B)

Postauricular incision: (A) more posterior variant, (B) closer to the crease; inset shows relationship to the postauricular crease and mastoid tip

Postauricular incision with retractor placement exposing the postauricular area and temporal muscle

Postauricular retractor placement after incision, exposing the temporalis muscle and mastoid cortex for drilling

Technique steps:

Incision through skin in the postauricular sulcus
Superior limb carried forward to allow the ear to rotate anteriorly
Identify temporalis fascia and linea temporalis
Periosteal incision along linea temporalis extended to the anterior aspect of the canal
Soft tissues rotate forward for full view down the canal to the middle ear
Periosteum is opened over the mastoid cortex to the mastoid tip

Indications:

Mastoidectomy (cortical, modified radical, radical)
Tympanoplasty with mastoid disease
Ossiculoplasty with extensive middle ear pathology
Cholesteatoma surgery
Cochlear implantation (modified postauricular with superior extension)
Any procedure requiring combined tympanomastoid access

Advantages:

Excellent exposure of the tympanomastoid compartment
Scar hidden behind the ear
Allows harvesting of temporalis fascia graft (through the same incision)
Allows periosteal graft harvest
Most versatile for complex cases

Limitations:

More invasive than endaural or transcanal
Risk of auricle migrating anteriorly postoperatively → possible collapsing canal
Cutaneous innervation of the pinna interrupted → temporary or permanent hypesthesia of auricle
Mastoid dressing usually required postoperatively

4. Extended and Skull Base Incisions

For lateral cranial base procedures, the postauricular incision is modified:

Incision	Access
Modified postauricular (with superior extension)	Temporal fossa; cochlear implantation
Extended postauricular	Tympanomastoid + upper neck + infratemporal fossa
Preauricular (lateral facial)	Upper neck and infratemporal fossa
Postauricular transtemporal	Middle fossa surface of temporal bone
Suboccipital	Posterior fossa

The figure below shows these variants:

Eight variants of ear/skull base incisions (A-H) including postauricular, extended postauricular, preauricular, suboccipital

Comparison Summary

Feature	Transcanal	Endaural	Postauricular
External scar	None	Yes (inter-cartilaginous)	No (hidden)
Mastoid access	None	Limited (Heermann extension)	Full
Epitympanum access	Limited	Excellent	Excellent
Postop dressing	None	Usually none	Usually required
Auricle hypesthesia	None	None/minimal	Yes
Graft harvest (temporalis fascia)	No	Yes (limited)	Yes (full)
Ideal for	Minor TM/ossicular work	Canal, epitympanum, anterior perforations	Mastoidectomy, cholesteatoma, cochlear implant

Sources:

Incisions and Approaches - Ento Key (Jackler's chapter on ear surgery)
Endaural Incision - Stanford Oto Surgery Atlas (Jackler & Gralapp)
Postauricular Incision - Stanford Oto Surgery Atlas
Illustrations: Gralapp / Stanford Oto Surgery Atlas (educational use)

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