title: A randomized, blinded study of canal wall up versus canal wall down mastoidectomy determining the differences in viewing middle ear anatomy and pathology.
abstract: OBJECTIVE
  Canal wall down and intact canal wall tympanomastoidectomy represent two surgical approaches to middle ear pathology. The authors hypothesize that there is a difference in the ability to view structures in the middle ear between these two methods.
  
  
  BACKGROUND
  Depending on the individual, many surgeons have used the two different techniques of intact canal wall and canal wall down tympanomastoidectomy for approaching the middle ear. However, opinions conflict as to which approach provides the best visualization of different locations in the middle ear. This study prospectively evaluated temporal bones to determine the differences in visualizing structures of the middle ear using these two approaches.
  
  
  METHODS
  Twelve temporal bones underwent a standardized canal wall down tympanomastoidectomy using a reversible canal wall down technique. All bones were viewed in two dissections: intact canal wall and canal wall down preparations. Four points previously had been marked on each temporal bone in randomly assigned colors. These points include the sinus tympani, posterior crus of stapes, lateral epitympanum, and the Eustachian tube orifice. An observer blinded to the purpose of the study, color, and number of locations recorded the color and location of marks observed within the temporal bones. Randomized bones of two separate settings were viewed such that each bone was viewed in both the canal wall down and the intact canal wall preparations.
  
  
  RESULTS
  A significant difference was noted in the ability to observe middle ear pathology between the intact canal wall versus canal wall down tympanomastoidectomy, with the latter showing superiority (p < 0.001). Of the four subsites, the sinus tympani, posterior crus of stapes, and lateral epitympanum were observed more frequently with the canal wall down. There was no significant difference in the ability to observe the Eustachian tube orifice between the two techniques.
  
  
  CONCLUSIONS
  Statistical analysis shows good reproducibility and randomization of this study. The canal wall down tympanomastoidectomy allowed for superior viewing of the three locations, sinus tympanic, posterior crus of stapes, and lateral at the tympanum, as they were marked in the study. This study shows the potential for improved visualization via the canal wall down tympanomastoidectomy. A significant amount of literature written by individuals and otology group practices is available retrospectively comparing the advantages and disadvantages of intact canal wall versus canal wall down mastoidectomy procedures for approaching middle ear pathology. In the interest of objectively evaluating the differences between these two approaches, we have studied temporal bones in a prospective randomized, blinded study comparing the two. Twelve bones were used and observed twice, once in each of 2 sessions. All bones were viewed in two dissections: intact canal wall and canal wall down mastoidectomy. Four points were marked on each temporal bone in three different colors applied in a randomized order to eliminate observer expectation. The four points marked include sinus tympani, posterior crus of the stapes footplate, lateral epitympanum, and Eustachian tube orifice. Both intact canal wall and canal wall down bones were provided randomly to the observer at each viewing session. Before the observer was allowed to see the dissections, those requiring replacement of the canal for the first session of the study had this done in a method using native posterior bony canal. Temporal bones were presented to an expert otologist in a randomized fashion with each temporal bone being placed in a temporal bone bowl holder and specialized framework, allowing for rotation and repositioning approximating the experience in an operating room setting. For each temporal bone, the observer filled in a questionnaire describing his or her observations by denoting both location and color of marks observed. (ABSTRACT TRUNCATED)
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
authors.forename: G F
authors.initials: GF
authors.lastname: Hulka
authors.forename: J T
authors.initials: JT
authors.lastname: McElveen
mesh_terms: D004311:Double-Blind Method; D004424:Ear Canal / Q000473:pathology / Q000601:surgery*; D004432:Ear, Middle / Q000033:anatomy & histology* / Q000473:pathology*; D006801:Humans; D008416:Mastoid / Q000601:surgery*; D013701:Temporal Bone / Q000473:pathology / Q000601:surgery; D014433:Tympanoplasty