The use of mastoid pressure dressings following otologic surgery is a common practice. Many styles of commercially available or improvised pressure dressings are available. The primary purpose of all such dressings is to prevent postoperative wound hematomas or seromas. Either complication may cause the patient pain, necessitate drainage, or increase the risk of postoperative wound infection. Does the routine use of mastoid pressure dressings, however, decrease the risk of postoperative complications? Although placing a mastoid pressure dressing is a relatively simple endeavor, one must balance potential efficacy with considerations of cost, both in time and monetary expense, and potential risk of pressure-induced complications such as headache and focal skin necrosis (Fig. 1).1
Several studies have shown that mastoid dressings do not prevent postoperative hematomas. Rowe-Jones et al. conducted a prospective trial in patients undergoing tympanoplasty, tympanomastoid, or middle ear surgery via the endaural or postauricular approach.2 Following wound closure, 50 patients were randomized to each study arm to either receive a pressure dressing or not. The pressure dressings consisted of Melolin (a cotton-polyester nonadhesive pad) and gauze over the pinna, a further layer of cotton-wool, and a circumferential 4-inch crepe (lightly woven fabric) bandage. The pressure dressings were changed at 24 hours and discontinued at 48 hours. Patients were then evaluated in the postoperative recovery room 24 hours postoperatively and at their first postoperative appointment 1 to 3 weeks after surgery. There was no difference in the rate of hematoma in the dressing versus no dressing group (2.0% each). There was no statistically significant difference in the rate of minor wound complications, such as in infection, dehiscence, or hematoma, in the dressing versus no dressing group (18% vs. 8%, respectively).
Castelli et al. also performed a prospective, randomized study in 420 cases of postauricular tympanoplasties or tympanomastoidectomies.3 There were 212 cases included in the pressure dressing group and 208 cases in the no-pressure dressing group. Pressure dressings consisted of a circumferential head bandage with five 6 × 6-cm gauze pads and cotton wool over the mastoid and auricle with a ribbon gauze over the eyebrow. The dressing remained in place for 3 days postoperatively. The wounds in both groups were inspected daily for 5 days and 3 weeks postoperatively. There were three cases of pinna bruising in the pressure dressing group and no cases in the no-pressure dressing group (P < .05). There were 70 cases of minor skin erythema in the pressure dressing group and no similar erythema in the no-pressure group (P < .05). There were no hematomas or wound infections in either group.
A retrospective review was performed by Lou et al. evaluating the efficacy of mastoid pressure dressings in 92 pediatric cochlear implant patients.4 There were 44 patients who had a mastoid dressing placed and 48 patients who were not treated with a mastoid dressing. Pressure dressings consisted of three crepes laid over the surgical site and pinna, covered with circumferentially placed ribbon gauze, and were removed 24 to 48 hours postoperatively. Patients within each group also had two different types of postauricular incision, an inverted J incision and a smaller minimally invasion incision. Subgroup analysis was performed for each type of incision in both the pressure dressing and no-pressure dressing groups. There was no statistically significant difference in hematoma formation or other wound complications between the two groups. Only the mastoid pressure dressing with the inverted J incision group had a higher complication rate (33.3% vs. 8.8%, P = .014).
Using a pressure transducer, Hill et al. measured the average pressure exerted by mastoid dressings.5 A mastoid dressing using two crepe bandages secured with zinc oxide tape was placed over the pressure transducer in 10 patients undergoing middle ear surgery via the endaural approach. Pressure was measured in the operating room and at each subsequent hour for 18 hours. The mean starting pressure of the dressing was over 38 mm Hg only during the first hour of placement, after which it declined to 24 mm Hg at 18 hours after placement. The amount of pressure delivered is much lower than typical arterial and arteriolar blood pressures.
BEST PRACTICE SUMMARY
The available evidence does not support the routine use of a mastoid pressure dressing to prevent hematoma formation following otologic surgery. Surgeons should adhere to principles of good hemostasis and appropriate would closure to prevent postoperative wound complications. There is, however, no literature studying other potential benefits of mastoid dressings, such as collecting postoperative drainage, protecting the wound from trauma (particularly important in young children), and psychological benefits to patients and family. For these reasons, loose mastoid dressings may be indicated and beneficial.
LEVEL OF EVIDENCE
In this review, there are two level Ib studies, two level IIb studies, and one level IV study.