INTRODUCTION
Cholesteatoma is a histopathologically benign entity but locally very aggressive,
being an important cause of chronic otitis media and deafness.
Congenital or acquired, it consists of a chronic inflammatory process that results
in the migration of keratinized epithelium from the tympanic membrane to the middle
ear.
The accumulation of keratin plaques is the underlying factor in the etiology of cholesteatoma.
The characteristic clinical findings are purulent otorrhea, tympanic perforation extending
to the inner ear and erosion of the ossicles with hearing loss or deafness1.
Treatment consists of eradicating all middle ear tissue; however, relapse rates can
be high, from 8% to 50%2. Recurrence usually manifests with postoperative otorrhea3.
The mastoidectomy ablation area can be quite extensive and, to avoid complications,
its obliteration is important4. Obliteration can be achieved with the use of alloplastic materials or autologous
reconstruction. Lipofilling or adipose autograft is the most used method of obliterating
the mastoid cavity in the literature5,6.
The temporal fascia flap is an established surgical technique for mastoid reconstruction3. Descriptions of this flap for this purpose can be found in the literature.
In this clinical case, we discussed the surgical approach of a recurrent cholesteatoma,
which underwent reconstruction with a temporal fascia flap after radical excision
by the Otorhinolaryngology (ENT) service Plastic Surgery.
OBJECTIVE
This work aims to present the temporal fascia flap as a suitable surgical option for
the reconstruction of the mastoid cavity.
CASE REPORT
A 50-year-old male Caucasian patient was diagnosed with chronic otitis media cholesteatomatous
on the left.
The first manifestation of the disease occurred 4 years earlier, in May 2014, with
an episode of left suppurative otitis media, and after several relapses, it progressively
evolved into chronic otitis media.
During this period, he continued to be followed up in the ENT service of the Centro
Hospitalar e Universitário de Coimbra.
The disease had periods of remission and recurrence, gradually progressing to a lytic
lesion of the inner ear with cophosis.
He underwent multiple cycles of empiric and targeted antibiotics, washes and topical
corticosteroids. In the laboratory, the only microorganism identified was Pseudomonas
aeruginosa.
Imagiologically, maxillofacial computed axial tomography (CAT) described a polypoid
lesion extending to the external auditory canal.
Biopsy revealed inflammatory tissue with granulation and excluded a neoplastic lesion.
In December 2016, the patient underwent modified radical mastoidectomy and meatoplasty,
and in November 2017, open mastoidectomy with surgical cleaning, mastoid cavity reduction
with cartilage, tympanoplasty with perichondrium and fascia, and meatoplasty revision.
In July 2018, after a new recurrence and the cophosis was installed, a mastoidectomy
review and dead space obliteration with a temporal fascia flap were proposed.
Anatomical considerations
The parietotemporal fascia is an extension of the superficial muscular aponeurotic
system (SMAS) inferiorly and the galea aponeurotic superiorly.
In the temporal fossa, it is found superficial to the deep temporal fascia and the
temporal muscle. Above the temporal muscle, the parietotemporal fascia lies immediately
above the periosteum.
It is a thin fascia vascularized by the superficial temporal artery (TS).
The TS artery is a branch of the external carotid. It is a small-caliber artery, approximately
1-3 mm in diameter. A vein of a similar caliber usually accompanies it. These vessels
run anterior to the pinna, and the pulse can be easily palpated.
Along its course, the TS artery branches supply the parietotemporal fascia, helix,
temporal muscle, and scalp.
Pitanguy Line: the frontal branch of the facial nerve runs on an imaginary line 0.5 cm below the
tragus and 1.5 cm above the lateral border of the supercilium and is at risk of being
severed if the dissection is too deep. This imaginary line is called Pitanguy’s line
and is an anatomical reference that must be respected.
The auriculotemporal branch runs posterior to the artery and is a sensory nerve to
the scalp. This branch of the maxillary nerve (in turn, one of the branches in the
trigeminal cranial nerve - CN V) is often sacrificed in dissection, resulting in an
area of hypoesthesia of the scalp.
Surgical technique
ENT mastoidectomy review (Figures 1, 2 and 3)
Figure 1 - Revision of mastoidectomy by Otorhinolaryngology.###
Figure 1 - Revision of mastoidectomy by Otorhinolaryngology.###
Figure 2 - Revision of mastoidectomy by Otorhinolaryngology.###
Figure 2 - Revision of mastoidectomy by Otorhinolaryngology.###
Figure 3 - Revision of mastoidectomy by Otorhinolaryngology.
Figure 3 - Revision of mastoidectomy by Otorhinolaryngology.
Patient undergoing removal of epithelial and mucosal tissue from the petromastoid
emptying cavity. The limits were sharpened with a diamond bur, and the tympanic membrane
was removed.
Lifting of skin tissue from the external auditory canal (EAC).
Superficial parietotemporal fascia flap
To expose the fascia, make a “V”-shaped skin incision in the pre-auricular region
(Figure 4).
Figure 4 - A “V”-shaped skin incision in the pre-auricular region to expose the fascia.
Figure 4 - A “V”-shaped skin incision in the pre-auricular region to expose the fascia.
The scalp is dissected from the fascia similarly to a rhytidectomy. The intended plane
is immediately superficial to the superficial parietotemporal fascia.
In this step, care must be taken not to injure the follicles and cause alopecia.
After exposing the fascia and identifying the vascular pedicle, the flap is delimited
by making an incision to the desired plane, which is the posterior leaflet of the
deep temporal fascia.
Subsequently, the flap is lifted from distal to proximal, tapering as we approach
the vascular pedicle. In this step, care must be taken not to injure the frontal branch
of the facial nerve.
The auriculotemporal branch of the maxillary nerve is often sacrificed, resulting
in an area of scalp hypoesthesia.
The temporal fascia flap based on the superficial temporal vessels can be visualized
(Figures 5 and 6).
Figure 5 - Temporal fascia flap based on superficial temporal vessels.
Figure 5 - Temporal fascia flap based on superficial temporal vessels.
Figure 6 - Temporal fascia flap based on superficial temporal vessels.
Figure 6 - Temporal fascia flap based on superficial temporal vessels.
The “Inset” in the cavity obliterates all dead space (Figures 7, 8 and 9). Fibrin glue was used to promote adhesion.
Figure 7 - “Inset” into the cavity, obliterating all dead space.###
Figure 7 - “Inset” into the cavity, obliterating all dead space.###
Figure 8 - “Inset” into the cavity, obliterating all dead space.###
Figure 8 - “Inset” into the cavity, obliterating all dead space.###
Figure 9 - “Inset” into the cavity, obliterating all dead space.###
Figure 9 - “Inset” into the cavity, obliterating all dead space.###
The meatus of the EAC is left to epithelialize by the second intention, applying a
dressing with fat gauze.
The suture is performed in layers, and an aspiration drain is left and removed in
the immediate postoperative period (Figure 10).
Figure 10 - Immediate postoperative period.
Figure 10 - Immediate postoperative period.
This reconstructive technique presents a good final functional and aesthetic result
at 5 months postoperatively, with total epithelialization of the external auditory
meatus and no signs of recurrence (Figure 11).
Figure 11 - Good final functional and aesthetic result at 5 months after reconstruction with temporal
fascia flap.
Figure 11 - Good final functional and aesthetic result at 5 months after reconstruction with temporal
fascia flap.
Results
In the clinical case presented, the treatment was effective. Outwardly, only a fully
epithelialized meatus of the ear canal can be seen, with no suspicion of cholesteatoma
recurrence.
At the time of discharge from the Plastic Surgery consultation, 5 months after reconstruction
with a temporal fascia flap (Figure 11), the patient was doing well and had no clinical complaints. He had preserved facial
movements, demonstrating the integrity of the facial nerve, namely the frontal branch.
There were no further episodes of recurrence such as otorrhea or suspicions of disease
progression such as vertigo or headache.
DISCUSSION
The temporal fascia flap is a versatile flap, generally used in head and neck reconstruction7.
It aims to obliterate dead space and increase vascularization of the affected anatomical
area, consequently improving the supply of antibiotics. This is the main advantage
compared to other non-vascularized reconstructive options, such as adipose autograft
or the use of alloplastic material8.
The temporal fascia flap is an effective technique in the plastic surgeon’s arsenal
to reconstruct the temporal region with good long-term results9. In this sense, it presents itself as an adequate technique to obtain obliteration
of the middle ear and mastoid, especially important in patients with locally advanced
disease who require extensive mastoidectomy.
It also has advantages compared to other reconstructive options, namely the temporal
myofascial flap. The main disadvantage of this flap is the excessive volume of the
flap and less plasticity when compared to the temporal fascia flap.
As it is a fascial flap, the sequelae, such as the aesthetic deformity caused to the
donor area, are minimal, and the scar is inconspicuous on the scalp.
The advantage of approaching pathologies in multidisciplinary teams is also highlighted,
as is the role of Plastic, Reconstructive and Aesthetic Surgery as a last-line reconstructive
surgical specialty in a multipurpose hospital.
CONCLUSION
In the clinical case presented, the treatment choice proved to be effective in achieving
the proposed objective of obliterating the mastoid cavity without recurrences and
with the least possible morbidity.
This work was also intended to briefly present the surgical technique to make its
execution reproducible and simple.
REFERENCES
1. Vartiainen E. Factors associated with recurrence of cholesteatoma. J Laryngol Otol.
1995;109(7):590-2.
2. Rutkowska J, Özgirgin N, Olszewska E. Cholesteatoma Definition and Classification:
A Literature Review. J Int Adv Otol. 2017;13(2):266-71.
3. Hung T, Leung N, van Hasselt CA, Liu KC, Tong M Long-term outcome of the Hong Kong
vascularized, pedicled temporalis fascia flap in reconstruction of mastoid cavity.
Laryngoscope. 2007;17(8):1403-7.
4. Skoulakis C, Koltsidopoulos P, Iyer A, Kontorinis G. Mastoid Obliteration with Synthetic
Materials: A Review of the Literature. J Int Adv Otol. 2019;15(3):400-4.
5. Çath T, Çelik C, Olgun L. Subtotal Petrosectomy and Blind Sac Closure of the External
Auditory Canal: Single-Center Experience with 44 Cases. Turk Arch Otolaryngol. 2014;52(3):81-6.
6. Pyle GM, Wiet RJ. Petrous Apex Cholesteatoma: Exteriorization vs. Subtotal Petrosectomy
with Obliteration. Skull Base Surg. 1991;1(2):97-105.
7. Demirdover C, Sahin B, Vayvada H, Oztan HY. The versatile use of temporoparietal fascial
flap. Int J Med Sci. 2011;8(5):362-8.
8. Yung M. The Use of Temporoparietal Fascial Flap to Eliminate Wound Breakdown in Subtotal
Petrosectomy for Chronic Discharging Ears. Otol Neurotol. 2016;37(3):248-51.
9. Karimnejad K, Akhter AS, Walen SG, Mikulec AA. The temporoparietal fascia flap for
coverage of cochlear reimplantation following extrusion. Int J Pediatr Otorhinolaryngol.
2017;94:64-7.
1. Coimbra Hospital and University Center, Plastic Surgery and Burns, Coimbra, Portugal.
Corresponding author: João Baltazar Ferreira, Praceta Professor Mota Pinto, Coimbra, Portugal, Zip Code 3004-561, E-mail: joao_cbf@msn.com
Article received: October 19, 2020.
Article accepted: April 23, 2021.
Conflicts of interest: none.
