Hammer and gouge mastoidectomy for acute mastoiditis - Vula ...

Thirteenth Step: Exploration of DeepSubantral Region (Retrofacial Groove)Between the deep antrum and mastoid tipthere remains a bony, often cellular, masswhich it is wise to remove. The antrum isthus continued below by a deep verticaltrench. Exploration of this regionsometimes reveals large cells located verydeep in the bone. This resection may beperformed with the gouge, using verticalblows first in front of the sinus then againstthe posterior wall of the canal which mustbe preserved. The curette, directed fromabove downwards, may be used. It iscontrolled by the index finger of the left ofhand to avoid injury to the lateral sinus ora too deep curettage towards the facialnerve anteriorly. If the deep subantralregion is narrow and the lateral sinusprominent, it is preferable to use a narrowjawedcurved rongeur (Figure 22).Fourteenth Step: Exploration andCleansing of Operative Cavity (Figures23, 24)The cavity is thoroughly explored andcleared of loose or adherent bony spicules.The edges and bottom are smoothed with acurette or rongeur. Suspicious areas areexplored with a blunt probe which locatespreviously unnoticed cells and determinesthe presence of inflammatory granulationson the dura mater.Figure 23: Cleaned cavityFigure 22: Using a narrow-jawed curvedrongeur in the deep subantral regionThe instrument is held in the right handwith the jaws parallel to the anterior aspectof the mastoid; this permits safe progressinto the deeper regions between the facialnerve in front and the lateral sinus at theback.Figure 24: Schematic representation ofanatomy of final cavity10