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Posterior tympanotomy versus posterior atticotomy in creating well-ventilated middle ear cleft pros and cons

Background Cortical mastoidectomy is considered a cornerstone step in the surgical management of noncholesteatomatous chronic suppurative otitis media. It comprises the canal wall-up technique, preserving the posterior and superior bony canal walls. The goal of cortical mastoidectomy is mainly to ventilate the middle ear cleft besides eradication of diseased mastoid air cells. The ventilation of the middle ear cleft has no way except through the aditus ad antrum and patent epitympanic diaphragm besides well-functioning Eustachian tube. This way of ventilation is usually affected in chronic infected ears by edematous and polypoid mucosa, leading to its obstruction. Traditional practice used to perform posterior atticotomy to overcome this problem, exposing the incudomalleolar complex and to excise edematous and polypoid mucosa. This technique may be ineffective in many cases owing to multiple factors, so posterior tympanotomy may acts as an alternative pathway to bypass obstructed aditus ad antrum and epitympanic diaphragm. Aim The aim was to compare the effectiveness of both posterior tympanotomy and posterior atticotomy in achieving well-ventilated middle ear cleft in noncholesteatomatous chronic suppurative otitis media and to identify advantages and disadvantages of both techniques. Patients and methods A prospective, comparative, randomized study was conducted from March 2019 to December 2020. A total of 40 patients experiencing safe non chronic suppurative otitis media CSOM with central perforation were included. Patients have been randomized into two groups of 20 patients each (groups A and B). The patients in group A underwent cortical mastoidectomy and posterior atticotomy, whereas the patients in group B underwent cortical mastoidectomy and posterior tympanotomy. Regular follow-up visits were done every 2 months for at least 6 months for both groups. Results In group A, 12 patients were doing well throughout the follow-up period with intact graft and ventilated middle ear, 4 patients had retracted grafts, 2 patients had retraction pockets, and 2 patients had recurrent tympanic perforation and discharge. In group B, 17 patients were doing well with intact grafts and ventilated middle ear, and 3 patients had mild tympanic retraction. Conclusion The authors found that posterior tympanotomy is an effective and viable alternative ventilation pathway to middle ear cleft bypassing obstructed aditus ad antrum with better address to the epitympanic diaphragm and less complications in patients with CSOM.