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

InstrumentationGouges and chisels should be keptextremely sharp, so as to ensure controlledbone resection. Blunt instrumentationrequires undue force to be applied, andgouges/chisels may slip off bone andplunge and damage critical structures suchas brain, lateral sinus, facial nerve, innerear, and carotid artery. For the bone workthe surgeon requires the following:Curved periosteal elevatorMalletThree gouges: Large, medium, smallFlat chiselCurettesRongeurs/bone nibblers (small,medium and large)Retractors (2), ideally self-retractingCanal elevator/McDonalds dissectorBlunt probeMicroinstruments: Curved needle,Plester knife, sickle knife, curetteSuction tipsPosition of PatientThe patient is laid supine with the headturned towards the normal ear.Position of Surgeon and AssistantsThe surgeon stands on the side of theaffected ear. Two assistants are stationedon the other side, facing the surgeon. The1 st assistant is nearest to the head. The 2 ndassistant is exactly opposite the surgeon.Operative FieldThe mastoid, auricle, and preauricularregions are extensively swabbed withtincture of iodine. The patient is covered tothe neck with a sterile sheet. The operativefield is isolated by four towels. Over themis placed a fenestrated sheet, the orifice ofwhich encircles the auricle and mastoid.AntibioticsNo antibiotics are required formastoidectomy for uncomplicatedcholesteatoma, other than when there issecondary infection (mastoiditis).BIPP PasteBIPP Paste can be prepared and used toimpregnate ribbon gauze. This can be usedto pack the mastoid cavity or ear canal, andbecause of its antiseptic properties, may beleft in place for a few weeks.Bismuth subnitrate 20% w/w, iodoform40% w/w, paraffin liquid 40% w/w (w/w =weight for weight)Figure 1: Instruments for bone work2