Incisions :

Postauricular Incisions:

This follows the curve of the postaural fold, beginning at the upper attachment of the auricle  and continuing either in or ½ cm behind the postaural fold downward to the tip of the mastoid.

 Since the incision usually cuts across the postauricular artery or its larger branches,digital pressure by the finger tips of the surgeons left hand on one side of the incision and the finger tips of an assistant on the other side will help to control excessive bleeding.

 The incision may first be scratched with two cross scratches to aid in accurate approximation when the wound is sutured.The blade of the scalpel is held perpendicular to the surfacenso as not to bevel the incision while skin , subcutaneous tissue and periosteum are incised.

Should a dehiscence of the cortex from a previous mastoidectomy or from disease be suspected,the incision should not be made in one stroke but shoulod be deepened very slowly and cautiously to avoid possible injury to the sigmoid sinus or dura.In newborns and infants, the mastoid is not developed and the postaural incision may sever the facial nerve…hence the incision should be horizontal just above the auricle, for the antrum lies in infants, almost directly above and slightly behind the meatus.

The lateral surface of he mastoid process is exposed using a periosteal elevator , as far forward as the  posterior root of the zygoma, and the suprameatal spine,care taken not to strip the skin and periosteum from the posterior and superion osseous meatal wall, as this this may induce postoperative Stenosis..A self retaining mastoid retractor is inserted under the periosteum, and spread carefully to avoid stripping the skin from the meatus.The attachment of the sternomastoid muscle  to the outer surface of the mastoid tip is cut across c tra leanly with a scalpel and these muslc fibres with any remaining shreds of periosteum are scrapped from the lateral surface of the mastoid process .Any remaining soft tissue bleeding points are controlled before bone work is begun.

External incisions
1. Endaural with extension in the intercartilagenous area superiorly and down the canal to join the canal wall incisions. This incision can be extended superiorly and then posterirly. With proper soft tissue elevation and retraction the epitympanum and a substantial part of the mastoid are exposed.
2. Postauricular approach. A behing the ear incision which is placed several millimeteres posterior to the postauricular crease and extends from the mastoid tip to the superior / anterior aspect of the auricle provides the best exposure for ear surgery involving the mastoid and /or antrum and epitympanum.
internal incisions

Incisions in the external auditory canal are essential in order to visualize the middle ear which is critical in the proper removal of cholesteatoma and in reconstruction of the tympanic membrane and the ossicular chain. There is a number of ways to perform these, however the principle is to access the middle ear by elevating the remnant tympanic membrane or annulus and reflecting it anteriorly.

Assume that the tympanic membrane is a clock and the following description can guide the incision placement
1. vascular strip incision. In this canal wall incision scheme there are two vertical incisions approximately at 12 o'clock and 6 o'clock with a horizontal incision joining the two vertical ones at a level 2 to 3mm lateral to the tympanic annulus.
2. another way to gain access to the middle ear is by making a triangular flap with oblique incisions starting approximately at 12 o'clock and 6 o'clock and joining posteriorly at 9 o'clock.
3. as in the first situation except that the incisions are performed entirely postauricularly, that is the external canal is entered from a postauricular route.
Once these incisions are made there is exposure by retraction of the soft tissues. The bony access begins only when soft tissue access is adequate and this is defined as the full visualization of: mastoid cortex, external auditory canal, linea temporalis superiorly along with the spine of henle and the associated superior area with the root of the zygoma. In addition the middle ear should be visualized well with direct vision.