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The Laryngoscope

Lippincott Williams & Wilkins, Inc.

© 2003 The American Laryngological,
Rhinological and Otological Society, Inc.

How I Do It
A Targeted Problem and Its Solution

Modified Bondy’s Technique for

Epitympanic Cholesteatoma
Mario Sanna, MD; Manoj Agarwal, DLO RCS, DLO(Cal); Tarek Khrais, FRCS(I), HSDM;
Giuseppe Di Trapani, MD

INTRODUCTION widely expose the sinodural angle and mastoid

Localized epitympanic cholesteatoma with normal or tip (Fig. 2).
near normal hearing gives the otologist an opportunity to 3. Once the mastoidectomy is completed, poste-
achieve both aims of otologic surgery: a dry, safe ear and rior epitympanotomy is performed. Care is
preservation of hearing. Clinical acumen coupled with the taken not to touch the ossicles with the rotat-
availability of modern radiologic technology allows the ing burr during this step. This is imperative to
surgeon to recognize this group of cholesteatoma early. avoid any postoperative sensorineural hearing
This clinical scenario is an ideal setting to perform a loss because the ossicular chain is intact. To
modified Bondy’s technique, the steps of which are de- identify the ossicles as early as possible, the
scribed in the following paragraphs. operating table is rotated away from the
INDICATIONS 4. Next, attention is directed toward the canal
1. Epitympanic cholesteatoma in normal or good wall, which may need a canaloplasty. The
hearing ear with an intact tympanic membrane meatal skin is elevated, folded medially, and
and ossicular chain (Fig. 1). protected using an aluminum strip while dril-
2. Epitympanic cholesteatoma in the better or only ling the canal walls.
hearing ear with slightly compromised ossicular
5. The facial ridge must be lowered to the level of
the tympanic annulus. The most medial part of
An important prerequisite for performing modified the facial bridge is removed using a curette
Bondy’s technique is that the preoperative air-bone gap (Fig. 3). The use of a curette reduces the
should not exceed 25 dB (calculated as the difference be- chances of dislocating the intact ossicular
tween the average of the air and bone-conduction thresh- chain as compared with use of a rotating burr.
olds at 0.5, 1, 2, and 4 kHz).1 The same instrument is used for removing the
anterior and posterior buttresses. Care is
SURGICAL STEPS taken to open the anterior epitympanum as far
1. A standard postauricular incision is made, and anterior as possible.
the soft tissues are handled in regular fashion. 6. Once adequate exposure of the mastoid and
A large piece of temporalis fascia is harvested epitympanum is obtained, removal of cho-
for grafting. lesteatoma is initiated. Again, care is taken to
2. A transcortical mastoidectomy is performed to avoid excessive manipulation of the ossicular
chain for the reasons mentioned above.
7. The posterosuperior annulus is partially de-
This article supported by a grant from Associazione Studio Aggior-
namento Basicranio. tached from the tympanic sulcus, and the tym-
From the Gruppo Otologico, Piacenza, Italy. panic cavity is inspected for the presence of any
Editor’s Note: This Manuscript was accepted for publication July 23, cholesteatomatous extension that can be
2003. removed.
Send Correspondence to Dr. Mario Sanna, Gruppo Otologico, Via
Emmanueli 42, 29100 Piacenza, Italy. E-mail: mario.sanna@ 8. Once the cholesteatoma is removed completely,
gruppootologico.com a wide conchomeatoplasty is performed. The

Laryngoscope 113: December 2003 Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma
Fig. 1. Coronal computed tomography scan of the right temporal
bone without contrast showing presence of localized epitympanic
cholesteatoma lateral to the ossicles: an ideal case for modified
Bondy’s technique.

conchal cartilage obtained is used for the

following steps. Fig. 3. Operative sketch of the right side demonstrating removal of
9. A piece of cartilage is place in the attic and the most medial part of the facial bridge, with use of a curette to
pushed as far anteriorly as possible, medial to minimize the chances of ossicular disruption. Note the movement of
the body of the incus and the head of the mal- the curette is directed away from the ossicles.
leus (Fig. 4). If the anterior epitympanum is
widely exposed, the cartilage is pushed as far
as the orifice of the eustachian tube. The car- body of the incus and the head of the malleus
tilage is placed to avoid any possible retrac- over the previously placed cartilage. The other
tions in this area in the future. Another piece tongue is inserted lateral to the long process
of cartilage may be placed lateral to the long of the incus and medial to the handle of the
process of the incus and medial to the handle of malleus by pushing it under the tympanic
the malleus (Fig. 5). This cartilage prevents membrane.
retraction in the posterosuperior quadrant of
the grafted tympanic membrane.
10. A longitudinal cut is made in the temporalis
fascia. One tongue is inserted medial to the

Fig. 2. Operative sketch of the right side demonstrating transcor-

tical mastoidectomy with the cholesteatoma visible in the epitym- Fig. 4. Operative sketch of the right side demonstrating the place-
panum. Note the wide exposure of the mastoid tip and sinodural ment of cartilage in the attic medial to the incudomalleolar joint as
angle. far anterior as possible.

Laryngoscope 113: December 2003 Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma
avoid inadvertent opening of the temporoman-
dibular joint.2 Similarly, caution is necessary
while drilling the posterior external canal wall
to avoid any injury to the facial nerve, which is
particularly vulnerable to injury in the postero-
inferior quadrant.3
7. Inspection of the tympanic cavity is mandatory to
ensure complete removal of the disease process.
8. Modified Bondy’s technique is mainly indicated
for localized epitympanic cholesteatoma and not
recommended for more extensive cholesteatoma.

During the period between December 1983 and De-
cember 2002, we performed a total of 153 surgeries using
the surgical technique described above. Some of these
cases have been reported previously.4,5 Of these, 57 cases
had a follow-up of 3 years (36 months) or more. The mean
follow-up was 86.6 (range 36 –196)months. Dry cavity was
achieved in 54 (94.7%) cases. The remaining three (5.3%)
cases had an occasional episode of otorrhea, which was
controlled with local medication. There was no single in-
stance of recurrence or reoperation. The air-bone gap was
Fig. 5. Operative sketch of the right side demonstrating the place- preserved or improved in comparison with the preopera-
ment of cartilage between the long process of incus and the handle
of the malleus. tive level in 43 (75.4%) cases. Nine (15.8%) cases showed a
drop of air-bone gap of more than 10 dB but less than 20
dB in comparison with the preoperative level, whereas
11. The remaining part of the fascia covers the five (8.8%) cases showed a drop of more than 20 dB but
exposed bony surface of the mastoid cavity as less than 30 dB. This small group of patients (n ⫽ 14)
far as possible. If necessary, another piece of exhibited the deterioration on long-term follow-up. There-
fascia may be harvested to cover the same. fore, this deterioration is probably attributable to tubal
12. The tympanomeatal flap is replaced over the dysfunction or ossicular fixation but definitely not to any
fascia, and the cavity is packed with an absorb- intra-operative factor. The bone conduction was measured
able gelatin sponge (Spongostan, Johnson & just before discharging the patient to assess the incidence
Johnson, Skipton, UK). of iatrogenic sensorineural hearing loss. It was main-
13. The wound is closed in layers, and pressure tained within 10 dB of the preoperative level in 55 (96.5%)
bandage is applied. cases. Two (3.5%) cases showed a deterioration of bone
conduction of more than 10 dB but less than 20 dB.
1. Adequate exposure of the sinodural angle and DISCUSSION
the mastoid tip is necessary to avoid recurrence. In 1910, Gustave Bondy described a technique that
2. A very deep sinodural angle should be obliterated attempted to provide a better outcome for his patients
using bone patè, cartilage, and temporalis fascia. suffering from cholesteatomatous otitis media. He treated
3. A extensively pneumatized mastoid tip should patients having epitympanic cholesteatoma with intact
be amputated to reduce the volume of the mas- pars tensa and intact ossicular chain using a modified
toid cavity. form of radical mastoidectomy wherein he removed the
4. As mentioned earlier, handling of the intact os- lateral attic wall and the posterior osseous wall.6 This
sicles should be avoided lest the surgeon cause a enabled him to remove the pathology without disturbing
sensorineural hearing loss. Extreme care should the intact ossicular chain, thus providing the patient with
be exercised in this region, and the direction of a safe, dry ear and preserved hearing. However, his tech-
the drilling and curetting should be away from nique was not without pitfalls. The high facial ridge and
the ossicles. incomplete removal of mastoid tip favored debris collec-
5. The anterior buttress should be removed com- tion, which meant repeated visits to the otologist for the
pletely to obtain a smooth continuation with the patients. There was also a possibility of leaving behind the
anterior wall of the external canal. This is nec- pathology because of the restricted access. Moreover, he
essary to avoid any bony overhang in this region did not perform any meatoplasty.
that could hamper the self-cleansing property of We, at the Gruppo Otologico, have been using the
the cavity. modified Bondy’s technique described above since 1983.
6. Caution is advisable while drilling the anterior We call it the modified Bondy’s technique because of the
external canal wall during the canaloplasty to following reasons:

Laryngoscope 113: December 2003 Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma
1. We put cartilage in the vicinity of the ossicles as achieves this end result in one stage is worth trying and
described above to reduce the chances of retraction. therefore strongly recommendable.
2. We inspect the middle ear to rule out any extension
of the cholesteatoma in the mesotympanum. BIBLIOGRAPHY
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quate aeration of the resultant cavity. panic annulus to the facial nerve: a direct anatomic exam-
ination. Laryngoscope 1999;109:1189 –1192.
5. Treatment of the deep sinodural angle and
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above is of paramount importance to achieve chain: the modified Bondy technique. Otolaryngol Head
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Philadelphia: WB Saunders, 1990.
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Laryngoscope 113: December 2003 Sanna et al.: Modified Bondy’s Technique for Epitympanic Cholesteatoma