Wullsteins Osteoplastic Flap

Sabrina Wullstein has popularized the creation of an epitympanic osteoplastic flap.13 This elegant procedure gives wide exposure of the epitympanum and mastoid antrum. Variations in the technique are more popular in the United States and Europe.14,15

The osteoplastic flap approach is begun like an anterior atticotomy, as previously described. The scutum is thinned but not drilled away as in the atticotomy. The scutum, the lateral epitympanic

Atticotomy

FIGURE 7-5 The external ear canal is enlarged as in the anterior atticotomy to the level of the tegmen with thinning of the lateral attic wall, the scutum. The bone cuts for the osteoplastic flap are outlined. The anterior, superior, and posterior bone cuts are made with a pointed diamond bur, using the tegmen as a guide. The posterior inferior cut at the fossa incudis is made with a small round diamond bur from lateral to medial to minimize the potential of injury to the incus or facial nerve.

FIGURE 7-5 The external ear canal is enlarged as in the anterior atticotomy to the level of the tegmen with thinning of the lateral attic wall, the scutum. The bone cuts for the osteoplastic flap are outlined. The anterior, superior, and posterior bone cuts are made with a pointed diamond bur, using the tegmen as a guide. The posterior inferior cut at the fossa incudis is made with a small round diamond bur from lateral to medial to minimize the potential of injury to the incus or facial nerve.

wall, is cut as an osteoplastic flap using a file-pointed diamond bur. Beginning anterior to the malleus, a vertical cut is made up to the level of the tegmen. The second cut is made from the anterior bone cut back to the aditus, following the tegmen. The third bone cut is from the tegmen down to the fossa incudis. The bone in the fossa incudis is cut from lateral to medial using a small round diamond bur, reducing the potential risk to the incus and facial nerve (Fig. 7-5). Once the bone cuts are complete, the lateral attic wall is elevated to expose the epitympanum and mastoid antrum. Anterior and posterior bony shelves are created that will support the bone flap after removal of cholesteatoma (Fig. 7-6). The osteoplastic flap is replaced using Gelfoam to support the bone flap abutting the anterior and posterior bony buttresses and prevent it from contacting the ossicular chain. The bone flap may be placed lateral to its normal position to create a larger attic space if desired.

Wullstein's technique has not been popular in the United States, though a variation of her approach has been. The scutum is removed as previously described for the anterior atticotomy. Small bony buttresses are preserved above the eustachian tube and at the fossa incudis. After the cholesteatoma is removed, the lateral attic wall is reconstructed with a free cartilage or bone graft allowing re-aeration of the mastoid14,15 (Fig. 7-7). This technique is useful if the ossicular chain is intact. Over time, however, patients with persistently poor eustachian tube function may develop a secondary attic retraction pocket cholesteatoma.

Osteoplastic Flap Attic Retraction Pocket

Fascia

FIGURE 7-7 The lateral attic wall, osteoplastic flap, is replaced or may be reconstructed with cartilage. Filling the epitympanum with absorbable packing and fascia graft supports it.

Fascia

FIGURE 7-7 The lateral attic wall, osteoplastic flap, is replaced or may be reconstructed with cartilage. Filling the epitympanum with absorbable packing and fascia graft supports it.

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