1. OSTEOPLASTIC TECHNIQUE :
Canal wall reconstruction is more practical for anatomic and physiologic reason and can be performed by various techniques. To avoid the possible risk of residual cholesteatoma, we have adopted a variation of combined approach Tympanoplasty .The posterior meatal wall is temporarily cut out with a micro surgical saw and is re-implanted after clearance of the pathology.

Procedure : Post aural incision is given and the soft tissue retracted. Cortical mastoidectomy with posterior tympanotomy and lateral atticotomy is carried out. Posterior bony meatal wall and lateral attic wall are cut out with an oscillating saw and the segment of the meatus is removed (fig.1). Please note the V cuts which make realignment later more accurate and convenient.

Pre requisites of radical mastoid are met. All procedures of elimination of disease and reconstruction of middle ear can be performed. The canal wall is repositioned as seen in the figure 2.

Risks : Injury to the dura, facial nerve and ossicular chain. Especially in Superior cut to incus and malleus and in inferior cut to stapes. Excessive thinning of posterior bony meatal wall can result in necrosis of the re-implanted segment.

Advantages : No cavity, single stage disease clearance and ossicular reconstruction. Better visualization of the Sinus tympani and facial recess.

This approach was adopted in our institute on young patients with extensive cholesteatoma. Using this approach an adequate disease clearance can be given as the hidden areas of middle ear are accessible. In one of the patients primary hearing reconstruction was done using titanium TORP. As the skin tube of the external auditory canal is not divided the reimplanted bone, fascial graft have ample vascularity to heal well without post operative granulations as seen in figure 3.

Fig.1 : Posterior canal wall being removed .	Fig. 2 : Intraoperative image of repositioning of bony fragment and securing the meatal wall.

2.OBLITERATION OF MASTOID CAVITIES
Management of extensive cholesteatoma and its squelae has been a challenge. The disease being aggressive, many of our patients require a canal wall down (CWD) procedure with its attendant cavity problems in post op..Various approaches have been adopted to resolve this problem. One among them is the obliteration of cavity.

Fig.3 : Post op oto endoscopic image of healed neotympanum with an intact posterior canal wall.	Fig. 4 : Disfigured external auditory with wide meatoplasty
Fig. 5 : Intraoperative images showing inferiorly based periosteal flap and superiorly based periosteal flaps

Reduction of a cavity is determined by the size of the cavity. For small cavities a free graft of connective tissue of suitable size taken from the surface of the mastoid process suffices to fill the cavity. Superiorly or inferiorly pedicled connective tissue flaps as seen in figure 5 are used for large mastoid cavities as described by Guilford. This flap consists of soft tissue from the surface of the mastoid process (excluding the skin) and a part of the aponeurosis of the SCM muscle. Soft tissue including the Periosteum are divided and freed. A long flap must contain more of the aponeurosis and mass of SCM muscle. Initially the flap swells and reduces to its original state after 8-10 days. Broad based pedicle is used for adequate venous drainage. Dissection of the flap is done meticulously to avoid compromising the vascularity. Any bleeder is controlled by bipolar under irrigation and monopolar diathermy is avoided in all ear operations at MCV. The bone edges are smoothed down so that congestion does not occur in the shifted flap.. Flap must be provided with epithelial covering from the external auditory canal since the additional blood supply and protection increases the take up rate.

Contra indications : Granulating Osteitis, Labyrinthitis, Labyrinthine fistula, Otogenic complications, Childhood cholesteatoma.

If the cavity is large both superiorly and inferiorly based flaps are used. In inferiorly based flap length of flap can be increased by dividing the flap transversely while keeping the proximal attachment intact retaining the vascularity of the flap. A well saucerised cavity with a pedicle based flap has been successful in management of CWD mastoid cavity. Once again we leave external canal skin tube intact (as in Osteoplastic operation) and this brings additional blood supply. Well healed obliterated cavity without meatoplasty is seen in figure 6.