Mastoidectomy

Introduction

If a doctor has discussed mastoidectomy with you or a family member, you are probably dealing with long-standing ear problems — repeated infections, ongoing discharge, a growth called a cholesteatoma, or hearing loss that has not improved with medicines. The idea of surgery on the ear can feel worrying, especially when it involves bone close to the brain, the facial nerve, and the hearing organs. This guide is written to help you understand what mastoidectomy is, why it is done, the different ways it can be performed, what recovery looks like, and what to expect for your hearing in the months and years after.

Mastoidectomy has been performed for more than a century, and modern techniques are far more refined than older versions. Surgeons today work with microscopes or endoscopes, high-speed drills, and detailed CT imaging that lets them plan the operation in detail before they begin. The main aims of the surgery are to clear disease completely, protect important structures around the ear, and — where possible — preserve or improve hearing.

What Is Mastoidectomy?

Mastoidectomy is the surgical removal of infected or diseased air cells inside the mastoid bone. The mastoid is the bony bump you can feel behind your ear. It is part of the temporal bone of the skull and is filled with a honeycomb-like network of small air-filled spaces called mastoid air cells. These spaces connect with the middle ear, which sits behind the eardrum.

When chronic infection or a cholesteatoma (an abnormal collection of skin cells) develops in the middle ear, it can spread into these mastoid air cells. The bone itself can become eroded. Because the mastoid sits very close to the inner ear, the facial nerve, the lining of the brain, and large blood vessels, untreated disease in this area can cause serious problems. Mastoidectomy removes the diseased cells and creates a clean, dry, safe ear.

The operation is almost always performed by an ENT surgeon (also called an otolaryngologist), often one who has additional training in ear surgery, known as an otologist or neurotologist. It is usually done under general anaesthesia through an incision behind the ear, although in some cases the surgeon may use an approach through the ear canal.

Why Is Mastoidectomy Performed?

Mastoidectomy is not used for ordinary ear infections that come and go. It is reserved for situations where disease in the middle ear or mastoid bone has become persistent, destructive, or dangerous. The most common reasons surgeons recommend mastoidectomy include:

• Chronic suppurative otitis media (CSOM). This is long-standing middle ear infection that does not heal with antibiotics and ear drops, often with a hole in the eardrum and ongoing discharge.
• Cholesteatoma. A cholesteatoma is a growth of skin cells trapped behind the eardrum or in the mastoid. It is not a cancer, but it slowly enlarges and erodes the bones of hearing and the surrounding skull base. Surgery is the only effective treatment.
• Acute mastoiditis with complications. When an acute middle ear infection spreads into the mastoid bone and does not settle with intravenous antibiotics, surgery may be needed.
• Complications of ear disease. These include facial nerve weakness, dizziness from inner ear involvement, hearing loss caused by erosion of the middle ear bones, infection spreading to the lining of the brain (meningitis), or abscess formation.
• Access for other surgery. Mastoidectomy is sometimes performed not for disease but to give the surgeon access to structures deeper in the ear — for example, during cochlear implant surgery, removal of certain tumours, or repair of fluid leaks from the brain lining.

The decision to operate is based on examination of the ear (often with a microscope), a hearing test, and a CT scan of the temporal bone that shows the extent of disease and the anatomy around it.

Who Is a Candidate?

Most adults and children with the conditions listed above can be considered for mastoidectomy, but the timing, urgency, and type of surgery vary. Surgeons usually weigh:

• How long the disease has been present and whether it has responded to medical treatment
• Whether a cholesteatoma is present (cholesteatoma almost always requires surgery)
• The current state of hearing in both ears
• Whether complications have already occurred or are likely
• Overall fitness for general anaesthesia
• For children, age, ear anatomy, and impact on school and language development

In an only-hearing ear (where the other ear has very poor hearing), surgeons usually plan even more cautiously, because any change in hearing on the operated side could have a big impact on daily life.

Alternatives to Mastoidectomy

Before recommending mastoidectomy, ENT specialists usually try less invasive options, depending on the underlying problem.

Medical management

For chronic ear infections without cholesteatoma, treatment may begin with regular cleaning of the ear under a microscope (aural toilet), topical antibiotic and steroid ear drops, oral antibiotics where appropriate, and management of risk factors such as allergic rhinitis or smoking. Some ears settle with prolonged medical care and never need surgery.

Tympanoplasty alone

If the disease is limited to the middle ear and eardrum — for example, a simple hole in the eardrum without active mastoid infection — the surgeon may perform a tympanoplasty (eardrum repair) without opening the mastoid bone. Whether this is enough depends on the findings on examination and CT scan.

Ventilation tubes (grommets)

For recurrent middle ear fluid or infections, particularly in children, small ventilation tubes placed in the eardrum may control the problem without the need for mastoid surgery.

Watchful waiting

For very small, stable, contained disease in patients who are not fit for surgery, careful observation with regular examination is sometimes chosen. This is generally not appropriate for cholesteatoma, which tends to grow over time.

Whether a non-surgical approach is enough is a clinical decision made by the surgeon after full assessment. Once disease has spread into the mastoid bone or a cholesteatoma is present, alternatives to surgery are limited.

Types of Mastoidectomy

Mastoidectomy is not a single operation. It is a family of related procedures, and the right type depends on how much disease is present and where it sits. The main types are described below. Your surgeon will explain which one is planned for your ear and why.

Cortical (simple) mastoidectomy

This is the most limited form. The surgeon removes the outer (cortical) layer of the mastoid bone and the air cells behind the ear, but does not enter the middle ear space. It is used for acute mastoiditis, to drain infection, or as a step in other operations such as cochlear implantation. The bony wall of the ear canal is left untouched.

Canal-wall-up (intact canal wall) mastoidectomy

Here the surgeon clears the mastoid air cells while preserving the back wall of the ear canal. The middle ear and mastoid remain separate spaces. This approach keeps the ear looking and feeling more normal and tends to allow easier hearing rehabilitation. It is often combined with tympanoplasty (repair of the eardrum and middle ear bones). Because the disease is reached through a narrower route, there is a higher chance that residual or recurrent disease may need a second operation, often planned about a year later as a “second-look” procedure.

Canal-wall-down (modified radical) mastoidectomy

In this version, the surgeon removes the back wall of the ear canal so that the mastoid cavity and the ear canal become one continuous open space. This makes it easier to see and clear all disease in one operation and is often used when cholesteatoma is extensive. The eardrum and hearing bones are repaired where possible. The trade-off is that the patient is left with a larger ear cavity that needs occasional cleaning by an ENT specialist for life, and water precautions are usually long-term.

Radical mastoidectomy

This is the most extensive form. The mastoid, middle ear, and ear canal are made into a single open cavity, and the eardrum and hearing bones are not reconstructed. It is reserved for severe disease, certain tumours, or situations where reconstruction would not be safe. Hearing in the operated ear is usually significantly reduced after this operation, although hearing aids or other devices can sometimes help.

Endoscopic and combined approaches

In recent years, many surgeons use small endoscopes during ear surgery, either alone or with the microscope. Endoscopes can let the surgeon see around corners inside the middle ear and may help remove disease while preserving more normal anatomy. Whether an endoscopic, microscopic, or combined approach is used depends on the surgeon’s training and the specific case.

The choice between canal-wall-up and canal-wall-down is one of the most discussed decisions in ear surgery. Surgeons consider the extent of disease, the condition of the other ear, the patient’s ability to attend long-term follow-up, lifestyle factors such as swimming, and the patient’s own preferences after the options are explained.

Preparing for Mastoidectomy

Once surgery is planned, your ENT team will guide you through preparation. Common steps include:

• Detailed assessment. A full ear examination, hearing test (audiogram), and CT scan of the temporal bones. In some cases, an MRI is added, particularly to check for recurrent cholesteatoma or complications.
• Anaesthesia review. Blood tests, ECG if needed, and a meeting with the anaesthetist to check fitness for general anaesthesia and review any other medical conditions.
• Medication check. Blood-thinning medicines such as aspirin, clopidogrel, or warfarin may need to be paused or adjusted before surgery, only under your doctor’s guidance.
• Treating active infection. If the ear is actively discharging, the surgical team may use antibiotic drops and microsuction cleaning in the days or weeks before surgery to make the ear as dry as possible.
• Fasting. You will be asked not to eat or drink for a set number of hours before the operation.
• Hair and skin preparation. A small area of hair behind the ear may be shaved on the day of surgery.
• Discussion of goals. The surgeon will go over what the operation aims to achieve, what type of mastoidectomy is planned, whether hearing reconstruction is included, the likely impact on hearing, and the chance that a second-stage operation may be needed.

This is also the time to ask questions. Useful ones include: What type of mastoidectomy is planned, and why? Will the hearing bones be repaired in the same operation or later? What outcome can I realistically expect for my hearing? Will I need a hearing aid afterwards? Will I need to avoid water in the ear long-term?

What Happens During Mastoidectomy

Mastoidectomy is almost always performed under general anaesthesia, so you will be fully asleep. The operation usually takes between two and four hours, sometimes longer for complex disease.

The general steps are:

1. Positioning and preparation. You are positioned with the operated ear facing up. The area is cleaned and draped.
2. Incision. Most surgeons make an incision in the skin crease behind the ear (postauricular). In some cases, an approach through the ear canal (endaural or transcanal) is used. The incision behind the ear usually heals into a fine scar that is hidden by the ear and hair.
3. Exposing the mastoid bone. Soft tissues are lifted to expose the surface of the mastoid.
4. Drilling. Using a high-speed drill under a microscope or endoscope, the surgeon carefully removes the outer bone and opens the mastoid air cells. Drilling continues until all diseased cells are cleared and key landmarks — the bony covering of the facial nerve, the inner ear, the brain lining, and the sigmoid sinus (a large vein) — are clearly identified and protected.
5. Addressing middle ear disease. If a cholesteatoma or other disease extends into the middle ear, the surgeon removes it. The condition of the hearing bones (ossicles) is checked. Damaged ossicles may be repaired with the patient’s own tissue or a small prosthesis — this part of the operation is called ossiculoplasty.
6. Eardrum repair (tympanoplasty). A hole in the eardrum is closed using a graft, often taken from the lining of the muscle above the ear (temporalis fascia) or from cartilage in the outer ear.
7. Decision about the canal wall. The surgeon decides whether to preserve or take down the back wall of the ear canal, based on what is found during surgery.
8. Facial nerve monitoring. A device that monitors the facial nerve is often used during the operation as an extra safety measure.
9. Closure. The wound behind the ear is closed in layers with stitches, often dissolvable. A dressing and sometimes a soft head bandage are applied. Packing may be placed in the ear canal.

The first few days

You can expect:

• Some pain or pressure around the ear, usually well controlled with simple painkillers
• A dressing or head bandage for one to a few days
• A blocked or muffled feeling in the operated ear because of packing and swelling
• Possibly some dizziness, especially when moving the head quickly
• Mild bleeding or staining of the dressing
• Tiredness from the anaesthetic

Your team will explain how to keep the wound clean and dry, when you can wash your hair, and which medicines to take.

The first few weeks

During this period:

• The ear canal packing is gradually absorbed or removed at follow-up visits
• Discharge from the ear is common as packing dissolves — this usually settles
• Hearing in the operated ear often sounds worse initially because of packing, swelling, and fluid; this is expected and is not a final result
• You will need to keep water out of the ear — cotton balls smeared with petroleum jelly, or a swimming cap, can help during showers
• Heavy lifting, straining, nose blowing, and air travel are usually restricted for a period decided by your surgeon
• Most adults return to office-type work within one to two weeks; physically demanding jobs may need longer
• Children may return to school within one to two weeks but should avoid swimming, contact sports, and rough play until the surgeon allows

The first few months

Healing of the eardrum graft and settling of the inner ear can take two to three months or more. A hearing test is usually done several weeks to months after surgery to assess the new baseline. If a canal-wall-down or modified radical procedure was performed, the open cavity will continue to settle and form a stable lining over several months.

Long-term follow-up

Even after the ear feels healed, regular follow-up is important. For canal-wall-down cavities, periodic cleaning under a microscope by an ENT specialist is usually needed for life. For canal-wall-up surgery, follow-up imaging or a planned second-look operation may be used to check for any hidden recurrence of cholesteatoma.

Risks and Complications

Mastoidectomy is generally safe in experienced hands, but as with any surgery near important structures, there are risks. Knowing them in advance helps you make informed decisions and recognise problems early.

Hearing-related risks

• Change in hearing. Hearing may improve, stay the same, or worsen after surgery. This depends on the type of operation, the condition of the hearing bones, and whether reconstruction is possible.
• Sensorineural hearing loss. Rarely, the inner ear can be affected, leading to a permanent drop in hearing in the operated ear.
• Tinnitus. New or worsened ringing in the ear can occur but often improves over time.

Balance and inner ear

• Dizziness. Short-term dizziness is common in the first days after surgery. Long-term vertigo is uncommon but possible if the inner ear has been involved by disease.

Nerve injury

• Facial nerve weakness. The facial nerve runs through the temporal bone close to the surgical area. Temporary weakness can occur from swelling or local anaesthetic. Permanent injury is rare with modern technique and facial nerve monitoring.
• Taste changes. A small nerve that carries taste from the front of the tongue (the chorda tympani) runs through the middle ear and is sometimes stretched or divided during surgery, leading to a metallic taste or numb feeling on one side of the tongue. This usually improves over weeks to months.

Wound and infection

• Bleeding, wound infection, and delayed healing are uncommon but possible.
• Continued or recurrent ear discharge can occur, especially if disease control is incomplete.

Recurrence of disease

• Cholesteatoma can return, particularly in children and in canal-wall-up procedures. This is why long-term follow-up and sometimes second-look surgery are planned.

Rare but serious risks

• Cerebrospinal fluid (CSF) leak from the lining of the brain
• Injury to large blood vessels near the mastoid
• Infection spreading to the brain or its coverings

Surgeons reduce these risks through detailed preoperative imaging, careful technique, intraoperative monitoring, and structured follow-up.

Hearing After Mastoidectomy

Hearing is one of the most common concerns for patients. It deserves its own section because outcomes vary widely.

In many cases, hearing in the operated ear was already affected by the underlying disease — for example, by fluid, a hole in the eardrum, or erosion of the hearing bones. Mastoidectomy itself is primarily aimed at clearing disease and making the ear safe; hearing reconstruction is a separate goal that may be done in the same operation or as a planned second stage.

Possible hearing outcomes include:

• Improvement. When the eardrum is repaired and the hearing bones are reconstructed successfully, hearing often improves compared to before surgery.
• Stable hearing. Some ears end up with hearing similar to before, particularly when the focus was disease clearance.
• Mild worsening. A small drop in hearing can occur, especially in canal-wall-down procedures, because of changes in the shape of the ear canal and cavity.
• Significant loss. In radical mastoidectomy or where the inner ear is involved, hearing in the operated ear may be substantially reduced.

If hearing remains a problem after the ear has fully healed, options such as conventional hearing aids, bone-conduction devices, and other implanted hearing devices can be considered. These decisions are made with an audiologist and ENT surgeon after testing.

Life After Mastoidectomy

Most people who recover from mastoidectomy notice an improvement in day-to-day comfort: less or no ear discharge, fewer infections, and reduced worry about the ear. Adjustments often include:

• Water care. Long-term water precautions are common, especially after canal-wall-down surgery. This may mean using earplugs or a swimming cap, or avoiding diving.
• Regular ear cleaning. Open mastoid cavities benefit from periodic microsuction cleaning by an ENT specialist, often every six to twelve months.
• Hearing rehabilitation. If hearing remains reduced, hearing aids or implants can help, and quiet environments may be easier than noisy ones for some time after surgery.
• Air travel. Once fully healed, air travel is usually safe, though some people experience pressure sensations.
• Sports. Most non-contact sports can be resumed. Contact sports and water sports may need ongoing precautions.
• Awareness of recurrence. New discharge, pain, hearing change, dizziness, or facial weakness should be reported to your ENT team rather than waiting for the next routine appointment.

Many patients describe a sense of relief once the chronic ear problem is resolved, even if hearing in that ear is not perfect. Quality-of-life improvements are often substantial.

Mastoidectomy in Children

Children can develop the same conditions that lead to mastoidectomy, including chronic ear infections and cholesteatoma. Some aspects are different from adults.

• Why surgery may be needed earlier. Cholesteatoma in children tends to grow more quickly and be more aggressive than in adults, which can lead to earlier surgery.
• Anaesthesia. Children tolerate modern anaesthesia well, but the team will discuss specific considerations beforehand.
• Choice of technique. Surgeons often try to preserve the ear canal wall in children where possible, partly because of the long lifetime impact of an open cavity. The trade-off is a higher chance of needing a planned second-look operation.
• Hearing and language. Hearing matters even more in children because of its role in language and school learning. Hearing tests are followed closely, and hearing rehabilitation is planned early if needed.
• Recovery and school. Children usually recover quickly from surgery itself but may need a few weeks off school and longer restrictions on swimming, contact sports, and rough play.
• Follow-up into adulthood. Children who have had mastoid surgery for cholesteatoma generally need long-term follow-up, sometimes into adulthood, to watch for recurrence.

Parents are usually closely involved in wound care, ear-drying precautions, and follow-up. The ENT team will guide you on what is normal during recovery and when to seek advice.

Frequently Asked Questions

Will I be able to hear normally after mastoidectomy?

The answer depends on the state of your ear before surgery and the type of mastoidectomy performed. Some people hear better than before, some stay about the same, and some have a small drop in hearing. Major hearing change is uncommon but possible. Your surgeon can give a more specific estimate based on your examination and CT scan.

Is mastoidectomy a major operation?

It is a specialised ear operation done under general anaesthesia, but it is performed regularly by ENT surgeons and is not considered high risk in routine cases. The depth of expertise of the surgical team matters more than the size of the incision behind your ear.

How long will I be in hospital?

Many patients are discharged on the same day or after one night. Longer stays may be needed if complications are being treated, if the surgery was extensive, or if the patient lives far from the hospital.

How long does recovery take?

Most adults return to light work within one to two weeks. Full healing of the eardrum and settling of hearing can take two to three months or more. People with open mastoid cavities continue to need occasional cleaning for life.

Will I need another operation?

In some cases, yes. A planned “second-look” operation, often around a year later, is sometimes done after canal-wall-up surgery for cholesteatoma to check for any disease that may have come back. Imaging is sometimes used as an alternative. Your surgeon will explain whether a second stage is part of your plan.

Can I swim after mastoidectomy?

Swimming is usually avoided for several weeks after surgery. After full healing, many people can swim with precautions such as earplugs or a swim cap, especially in the case of canal-wall-up surgery. People with open mastoid cavities are often advised to avoid getting water in the ear long-term. Your surgeon will give specific advice.

Will the scar be visible?

The incision is usually placed in the natural crease behind the ear and tends to fade into a fine line hidden by the ear and hair. In children, the scar generally becomes very inconspicuous as they grow.

What does follow-up involve?

Follow-up usually includes wound checks in the first weeks, microscopic cleaning of the ear canal as packing dissolves, hearing tests several weeks to months after surgery, and longer-term review at intervals decided by your surgeon. People with open cavities need lifelong periodic check-ups.

How do I choose the right surgeon?

Look for an ENT surgeon with specific experience in ear (otologic) surgery and the type of procedure being recommended. It is reasonable to ask how often they perform mastoid surgery, what their approach is to cholesteatoma, and how they handle hearing reconstruction. Meeting more than one surgeon before deciding is appropriate, particularly for complex cases.

Conclusion

Mastoidectomy is a well-established operation aimed at clearing chronic disease from the bone behind the ear, protecting nearby structures, and — where possible — supporting better hearing. It is not a single procedure but a family of techniques, and the right one depends on what is found in your particular ear. Modern surgery uses detailed imaging, microscopes and endoscopes, facial nerve monitoring, and careful reconstruction to make the operation as safe and effective as possible.

Recovery is gradual. The first weeks focus on wound healing and water precautions, the first months on settling of the ear and hearing, and the longer term on regular follow-up to make sure the ear stays clean, dry, and safe. With careful planning, an experienced surgical team, and good aftercare, mastoidectomy can resolve years of ear trouble and restore meaningful comfort and quality of life.