Is Cortical Mastoidectomy Necessary in Myringoplasty for Chronic Otitis Media?

INTRODUCTION

Chronic otitis media (COM) continues to be a major public health problem and one of the leading causes of conductive hearing loss in low- and middle-income countries.¹ It is characterized by long-standing inflammation of the middle-ear cleft, often resulting in tympanic-membrane perforation and recurrent otorrhea.² The main goals of surgery are to eradicate infection, achieve a dry ear, and improve hearing.³

Myringoplasty, the surgical repair of the tympanic membrane, remains the cornerstone of treatment for inactive mucosal COM. Although success rates exceed 85 %, failures may occur due to poor Eustachian-tube function or inadequate middle-ear aeration.⁴ To improve ventilation, many surgeons perform cortical mastoidectomy along with myringoplasty, assuming it enhances graft uptake and reduces reczurrence.⁵ However, several studies have shown conflicting results, with no consistent improvement in hearing or graft success.^6-8

The current study was designed to compare postoperative graft uptake and hearing outcomes between myringoplasty alone and myringoplasty with cortical mastoidectomy, to clarify whether the additional procedure offers any measurable advantage in patients with inactive mucosal COM.

MATERIAL AND METHODS

This prospective cohort study was conducted at the Department of Otorhinolaryngology, Shridevi Institute of Medical Sciences and Research Hospital, Tumakuru, between July 2023 and December 2024, following approval from the Institutional Ethics Committee and adherence to the Declaration of Helsinki (2013).⁹ Informed consent was obtained from all participants.

Eighty-six patients aged ≥ 15 years with inactive mucosal COM and central tympanic-membrane perforation were included. Patients with cholesteatoma, prior ear surgery, or systemic illnesses affecting healing were excluded. Participants were divided into Group A (myringoplasty alone) and Group B (myringoplasty with cortical mastoidectomy).

Preoperative evaluation included oto-microscopy, pure-tone audiometry, and HRCT of the temporal bone when indicated. All procedures were performed under general anesthesia via a post-auricular approach using an operating microscope. The temporalis fascia was used for grafting in all cases. In Group B, the mastoid cortex was drilled to exenterate air cells and widen the aditus [Figure 1].

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Figure 1:

Temporalis fascia graft harvested.

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Postoperatively, Figure 2 shows patients received oral antibiotics and were reviewed at 2 weeks, 6 weeks, and 3–5 months. Primary outcomes were graft uptake and hearing gain (change in mean air-conduction threshold). Secondary outcomes included operative time, blood loss, and complications. Data were analyzed using SPSS v25 (IBM Corp., Armonk, NY, USA); p< 0.05 was considered statistically significant.

RESULTS

Of the 86 patients, 43 underwent myringoplasty alone, and 43 underwent myringoplasty with cortical mastoidectomy. The mean age was 33.2 years, with a slight male predominance (53.5 %).

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Figure 2:

Postauricular wound.

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Hearing improvement: Both groups demonstrated significant postoperative improvement (p < 0.001). Mean pure-tone average (PTA) improved from 28.86 ± 13.53 dB to 15.37 ± 3.16 dB in Group A, and from 24.40 ± 12.29 dB to 15.49 ± 4.91 dB in Group B. Mean hearing gain was 13.49 dB and 8.91 dB, respectively, with no significant inter-group difference (p = 0.09).

Graft uptake: Overall graft success was 90.7 % — 86.05 % in Group A and 95.33 % in Group B (p = 0.17) [Figures 3 and 4].

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Figure 3:

Group wise post operative graft uptake

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Operative parameters: Mean duration of surgery was 64.2 minutes in Group A and 96.4 minutes in Group B (p < 0.001). Mean blood loss was 32.5 mL versus 51.2 mL (p < 0.001). No major complications occurred.

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Figure 4:

Group wise mean postoperative ear PTA. PTA: Pure-tone average

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Follow-up: All patients achieved a dry ear at 5 months; over 90 % reported subjective hearing satisfaction.

DISCUSSION

The findings of this study confirm that myringoplasty alone achieves excellent functional and anatomical results in most cases of inactive mucosal COM. The slight improvement in graft uptake in the mastoidectomy group was not statistically significant, aligning with the results of Kamath et al.⁶ and Kaur et al.⁷ who reported similar success rates with both procedures.

The role of cortical mastoidectomy has been debated for decades. Proponents argue it improves middle-ear ventilation and eradicates residual disease⁵, while opponents believe it adds operative morbidity without substantial benefit.^8-10

Our results showed that mastoidectomy increased operative time and blood loss, with no significant hearing advantage — consistent with modern series and meta-analyzes.

The present study reinforces that the primary determinant of surgical success lies in proper disease control, meticulous grafting technique, and postoperative care, rather than the addition of mastoidectomy. Routine mastoidectomy is thus unnecessary for inactive, dry ears with well-aerated mastoids, but may be useful in recurrent or sclerotic cases.

Limitations include the modest sample size and short follow-up period, which preclude assessment of long-term recurrence. Larger multicentric studies are warranted to refine surgical selection criteria and confirm these outcomes.

CONCLUSION

Both procedures provide excellent hearing restoration and graft uptake. Cortical mastoidectomy offers no statistically significant advantage over myringoplasty alone in inactive mucosal COM and should be reserved for patients with poor mastoid aeration or recurrent discharge.