Eur Arch Otorhinolaryngol (2010) 267:1705–1711
DOI 10.1007/s00405-010-1308-x
OTOLOGY
Piezosurgery® versus microdrill in intact canal wall
mastoidectomy
Angelo Salami · Renzo Mora · Massimo Dellepiane ·
Barbara Crippa · Valentina Santomauro ·
Luca Guastini
Received: 1 January 2010 / Accepted: 7 June 2010 / Published online: 25 June 2010
© Springer-Verlag 2010
Abstract Piezosurgery® is a recently developed system
for cutting bone with microvibrations. The objectives of the
present study were to report our experience with the piezo-
electric device in the intact canal mastoidectomy, and to
compare the results with traditional method by means of
microdrill. A non-randomized controlled trial was under-
taken on 60 intact canal wall mastoidectomy performed
using the piezoelectric device (30 patients) or the microdrill
(30 patients). Before 1 month and 1 year after surgery, all
the patients underwent the following instrumental examina-
tions: otomicroscopic evaluation of the tympanic mem-
brane and external auditory duct, bone conduction
threshold audiometry, tympanometry, transient-evoked
otoacoustic emissions with linear click emission, distortion
product otoacoustic emissions, auditory brainstem response
(ABR) by MK 12-ABR screener with natus-ALGO2e
(Amplifon, Milan, Italy), and electronystamographic
recording. The piezoelectric device is proved to be eVective
in sclerotic and pneumatic mastoid, with an excellent con-
trol and without side eVects on the adjacent structures of the
middle and inner ear (lateral sinus, facial nerve, and/or dura
mater). The operation time has been the same as compared
with microdrill, and the average hospital stay was signiW-
cantly (p < 0.05) shorter. Postoperatively, all patients had
uneventful recovery with no evidence of audiovestibular
deWcit or side eVects. Our experience highlights the safety
of the piezoelectric device on the anatomic structures of the
middle and inner ear, and demonstrates its eYciency in
terms of cutting precision and healing process.
A. Salami · R. Mora (&) · M. Dellepiane · B. Crippa ·
V. Santomauro · L. Guastini
ENT Department, University of Genoa,
Via Dei Mille 11/9, 16147 Genoa, Italy
e-mail: renzomora@libero.it
Keywords Inner ear function · Mastoidectomy ·
Otologic surgery · Piezoelectric device · Piezosurgery® ·
Vestibular function
Introduction
Mastoidectomy is one of the commonly performed proce-
dures in the Welds of otology and neurotology. Multiple
diVerent procedures exist, each with their own indications,
advantages, and disadvantages [1].
Piezosurgery® (Mectron Medical Technology, Carasco,
Genoa, Italy) is a recently developed system for cutting bone
with microvibrations. The piezoelectric device uses low-
frequency ultrasonic waves (24.7–29.5 kHz). The applied
power can be modulated between 2.8 and 16 W, and the
machine is programed in accordance with the density of the
bone. The microvibrations which are created in the piezo-
electric hand-piece cause the inserts to vibrate linearly
between 60 and 210 . The amplitude of the ultrasonic waves
allows a clean, precise, and selective cut when the insert
works on mineralized tissue; yet, it is ineVective on soft
tissue (higher frequency waves need to be utilized) [2–7].
The equipment consists of two hand-pieces, two inserts,
and two peristaltic pumps connected to the control unit
(Fig. 1); appropriate inserts have been created: the width,
the thickness, and the angle of the insets vary in relation to
the power that is applied, the bone density and the surgical
techniques that they are used for (some are coated with dia-
mond in various grades) [2–7] (Fig. 2).
The objectives of the present study were to report our
experience with the piezoelectric device in the intact canal
mastoidectomy, to evaluate the eYciency and applicability
of the piezoelectric device, and to compare the results with
traditional method by means of microdrill.
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1706
Fig. 1 The main unit (black arrow) with the two hand-pieces (blue
arrow), two inserts (red arrow), and two peristaltic pumps (green
arrow)
Fig. 2 The speciWc insets: OT7 (bone saw) (red arrow), OP3 (small
and large) inserts (bone scalpel for osteoplasty) (blue arrow), and OT4
(round cylindrical bone scalpel coated with diamond) (green arrow)
Materials and methods
The study was conducted according to the Revised Declara-
tion of Helsinki and the Good Clinical Practice Guidelines.
All procedures were carried out in accordance with the
local ethics committee’s protocol. A non-randomized
controlled trial was undertaken on 60 intact canal wall
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Eur Arch Otorhinolaryngol (2010) 267:1705–1711
mastoidectomy performed using the piezoelectric device
(30 patients) or the microdrill (30 patients). The study was
conducted at the ENT Department of the University of
Genoa (Italy), between September 2008 and December
2009. The patients (26 males and 34 females), aged
between 34 and 67 years, were divided into two numeri-
cally equal and homogeneous groups (groups A and B).
After signing an informed consent, all patients were oper-
ated on by the same team of surgeons.
All the patients presented a chronic active otitis media
with pain, hearing loss, constant otorrhea, and perforation
in the tympanic membrane on the aVected side. Preopera-
tive CT scan revealed a cholesteatoma of the meso- and
hypotympanum, involving the ossicular chain and the mas-
toid cells. No patients presented facial nerve or other neur-
opathies or vestibular symptoms.
As exclusion criteria, we have considered a history of
otologic surgery, diabetes, immunosuppression, and/or
allergic rhinosinusitis.
All the patients underwent the following tests before and
1 year after surgery: otomicroscopic evaluation of the
tympanic membrane and external auditory duct, bone con-
duction threshold audiometry, tympanometry, transient-
evoked otoacoustic emissions (TEOAEs), distortion
product otoacoustic emissions (DPOAEs), auditory brain-
stem response (ABR), and electronystamographic (ENG)
recording. The subjective parameters of our assessment of
piezoelectric surgery were its reliability, precision, safety in
soft tissues, ease of use, operative time, and average hospital
stay.
All the operations were carried out under general anes-
thesia with orotracheal intubation, using an operatory
microscope having a focal length of 200 mm. The neces-
sary steps of surgery were performed as dictated by the
diagnostic needs of each case.
In group A, formed by 16 males and 14 females (mean
age 44.1 years), under general anesthesia, the patients
underwent intact canal wall mastoidectomy using the pie-
zoelectric device; in group B, formed by 10 males and 20
females (mean age 46.9 years), the patients were submitted
to intact canal wall mastoidectomy with microdrill.
In group A, after a retro-auricular incision and the expo-
sition of the mastoid cortex, the piezoelectric device was
used in all the surgical steps: the mastoid cortex was
removed through three linear osteotomies performed with
OT7 (bone saw) insert along the linea temporalis, parallel
to external ear canal and from mastoid tip to sinodural
angle (Fig. 3).
These osteotomies were done to create a bony specimen
like a pyramid, with its triangular base in high and the apex
in bass (Fig. 3).
After having removed the bony specimen (Fig. 4), the
other surgical steps have been done by removing bone in
Eur Arch Otorhinolaryngol (2010) 267:1705–1711
Fig. 3 The mastoid cortex has been removed through three linear
osteotomies performed along the linea temporalis, perpendicular to
external ear canal and from mastoid tip to sinodural angle
Fig. 4 The mastoid cortex has been removed through a cortical bony
specimen like a pyramid, with its triangular base in high and the apex
in bass: the arrow highlights the absence of lesions on the lateral sinus
layers, as traditional methods: the thinning of the bone of
the external ear canal wall, infero-lateral to the buttress and
the short process of the incus (the lateral limit of the facial
recess was exposed by further inferior extension of the
osteoplasty at the level of the chordal eminence), was done
with OP3 (bone scalpel for osteoplasty) insert, and skelet-
onization of the canal facial nerve was allowed with OT4
(round cylindrical bone scalpel coated with diamond). The
OP3 and OT4 inserts were linearly moved with a light
pressure.
After the intact canal wall mastoidectomy, the piezoelec-
tric device was used (with OP3 insert) in atticotomy and
close tympanoplasty: with a light pressure, OP3 insert was
linearly moved along the middle ear bone; after inspection
and removal of any adhesions and bony spicule of the
1707
Fig. 5 Final reposition of the cortical bony specimen and the good
esthetic result
middle ear bone, small pieces of gelfoam were placed onto
the hypotympanic Xoor.
The cortical bony specimen was replaced in the mastoid
cortex as Wnal step (Fig. 5).
In group B, after a retro-auricular incision and the expo-
sition of the mastoid cortex, intact canal wall mastoidec-
tomy was done using microdrill.
Statistical analysis was performed using t test: probabil-
ity values at less than 0.05 were regarded as signiWcant; the
results were reviewed and approved by the Institutional
Review Board of the University of Genoa, Italy. Results for
each group are expressed as mean § standard deviation
(SD).
Results
In group A, the piezoelectric device is proved to be eVec-
tive in sclerotic and pneumatic mastoid: the device allowed
a rapid and easy intra-operative management and a precise
and safe cut; the diVerent angles and diameters of the
inserts allowed therapeutic success in all the phases of the
operations. It was possible to preserve the bone of the pos-
terior external ear canal wall without side eVects to the
chorda tympani or to the facial nerve. The further use
toward the hypotympanum along the course of the chorda
tympani opened the inferior part of the facial recess: if nec-
essary, complete skeletonization of the facial nerve or even
decompression was performed without damaging the sur-
rounding structures. The operating Welds were blood-free,
with perfect intra-operative visibility without any sign of
surgical damage to soft tissues such as facial nerve, lateral
sinus, dura mater, and/or vascular formations. After unin-
tentional contact with the facial nerve, no patient experi-
enced side eVects. Lateral sinus, dura mater, and facial
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1708 Eur Arch Otorhinolaryngol (2010) 267:1705–1711

Table 1 Surgical operation time, hospital stay, and number of compli-
cations in each patient’s group
Patient’s group
A (n = 30) B (n = 30)
Average operation time 78.4 § 7.41 80.2 § 8.03
(min) (mean § SD)
Average hospital stay 3.1 § 0.31 4.1 § 0.28
(days) (mean § SD)
No. of complications 1 3
nerve had been exposed in 2/30 (6.6%), 1/30 (3.3%), and
3/30 (10%) patients, respectively (Fig. 4).
The chronic otitis media eroded the middle ear ossicles,
causing ossicular chain discontinuity in 23/30 (76.6%)
patients. Erosion or absence of malleus was found in 24/30
(80%) cases, the incus in 25/30 (83.3%) cases, and the sta-
pes in 7/30 (23%) cases.
The cortical specimen, suitable to be reinserted in the
mastoid cortex, allowed no obvious retraction or depression
in the postauricular area.
In the group A, the operation time has been the same as
compared with microdrill (78.4 § 7.41 vs. 80.2 § 8.03);
the average hospital stay was signiWcantly (p < 0.05) lower
(3.1 § 0.31 vs. 4.1 § 0.28); the dry-up time range from 3 to
6 weeks (mean 4.3 weeks). Among 30 cases followed for
1 year, 29 (97%) maintained a dry and safe ear. Intermittent
otorrhea with perforation of the tympanic membrane
occurred in one patient (3%). In the group B, the dry-up
time range from 3 to 7 weeks (mean 4.9 weeks). Among 30
cases followed for 1 year, 27 (90%) maintained a dry and
p value safe ear. Intermittent otorrhea with perforation of the tym-
panic membrane occurred in three patients (10%) (Table 1).
In group B, the microdrill allowed a rapid and easy intra-
>0.05 operative management. Dura mater and facial nerve had
been exposed in 2/30 (6.6%) and 1/30 (3%) patients,
<0.05 respectively, without injury. The chronic otitis media
eroded the middle ear ossicles, causing ossicular chain dis-
– continuity in 21/30 (70%) patients. Erosion or absence of
malleus was found in 23/30 (76.6%) cases, the incus in 22/30
(73.3%) cases, and the stapes in 6/30 (20%) cases.
In the group A, 1 year after surgery, all the patients pre-
sented no worsening of their mean air and bone audiometric
threshold at 250 dB (27.1 § 2.56, 13.6 § 1.35 vs. 34.5 §
3.22, 14.1 § 1.38), 500 dB (26.9 § 2.71, 15.9 § 1.42 vs.
34.9 § 3.42, 16.1 § 1.44), 1,000 dB (27.7 § 2.89, 19.5 §
1.81 vs. 34.1 § 3.27, 19.7 § 1.89), 2,000 dB (31.1 § 3.11,
18.9 § 1.82 vs. 36.5 § 3.44, 21.2 § 2.01), and 4,000 dB
(30.1 § 3.02, 20.1 § 1.98 vs. 34.6 § 3.39, 20.6 § 1.99). In
all the patients with hearing improvement, the TEOAEs
revealed an improvement from “Fail” to “Pass” and otoa-
coustic distortion products, which were previously absent,
were evoked at frequencies of the tonal Weld normally
examined (Table 2).
The ABR responses were normal, and ENG recording
revealed a normoreXexia in all the patients (Table 2).
In the group B, 1 year after surgery, all the patients pre-
sented no worsening of their mean air and bone audiometric
threshold at 250 dB (27.3 § 2.57, 13.8 § 1.37 vs. 34.2 § 3.21,

Table 2 Audiologic results

Frequency t=1 t=2 p value
(mean § SD) in the patients
underwent intact canal wall Liminal tonal 250 A 34.5 § 3.22 27.1 § 2.56 <0.05
mastoidectomy with the audiometry (n = 30)
piezoelectric device, before B 14.1 § 1.38 13.6 § 1.35 –
(t = 1) and 1 year after (t = 2) the 500 A 34.9 § 3.42 26.9 § 2.71 <0.05
surgical treatment B 16.1 § 1.44 15.9 § 1.42 –
1,000 A 34.1 § 3.27 27.7 § 2.89 –
B 19.7 § 1.89 19.5 § 1.81 –
2,000 A 36.5 § 3.44 31.1 § 3.11 –
B 21.2 § 2.01 18.9 § 1.82 –
4,000 A 34.6 § 3.39 30.1 § 3.02 –
B 20.6 § 1.99 20.1 § 1.98 –
TEOAE Present n=6 n = 29 <0.05
Absent n = 24 n=1
DPOEA Present n = 18 n = 29 <0.05
Absent n = 12 n=1 –
Tympanometry (type A) n=0 n = 22 <0.05
n number of patients, A audio-
ABR Normal n = 30 Normal n = 30 –
metric air threshold, B audiomet-
ric bone threshold, hyper ENG Hyper n=0 n=0 –
labyrinthic hyperreXexia, Normo n = 30 n = 30 –
normo labyrinthic normoreXex- Hypo n=0 n=0 –
ia, hypo labyrinthic hyporeXexia

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Eur Arch Otorhinolaryngol (2010) 267:1705–1711 1709

Table 3 Audiologic results

Frequency t=1 t=2 p value
(mean § SD) in the patients
underwent intact canal wall Liminal tonal 250 A 34.2 § 3.21 27.3 § 2.57 <0.05
mastoidectomy with microdrill, audiometry (n = 30)
before (t = 1) and 1 year after B 14.4 § 1.41 13.8 § 1.37 –
(t = 2) the surgical treatment 500 A 34.5 § 3.38 26.9 § 2.71 <0.05
B 16.4 § 1.51 15.7 § 1.39 –
1,000 A 34.2 § 3.28 27.5 § 2.81 –
B 19.4 § 1.76 19.3 § 1.76 –
2,000 A 36.8 § 3.47 30.9 § 3.09 –
B 21.4 § 2.05 18.7 § 1.81 –
4,000 A 34.4 § 3.37 30.3 § 3.05 –
B 20.9 § 2.03 20.3 § 1.99 –
TEOAE Present n=7 n = 27 <0.05
Absent n = 23 n=3
DPOEA Present n = 19 n = 27 <0.05
Absent n = 11 n=3
n number of patients, A audio- Tympanometry (type A) n=0 n = 21 <0.05
metric air threshold, B audiomet- ABR Normal (n = 30) Normal (n = 30) –
ric bone threshold, hyper ENG Hyper n=0 n=0 –
labyrinthic hyperreXexia,
Normo n = 30 n = 30 –
normo labyrinthic normoreXexia,
hypo labyrinthic hyporeXexia Hypo n=0 n=0 –

14.4 § 1.41), 500 dB (26.9 § 2.71, 15.7 § 1.39 vs. 34.5 §
3.38, 16.4 § 1.51), 1,000 dB (27.5 § 2.81, 19.3 § 1.76 vs.
34.2 § 3.28, 19.4 § 1.76), 2,000 dB (30.9 § 3.09, 18.7 §
1.81 vs. 36.8 § 3.47, 21.4 § 2.05), and 4,000 dB (30.3 §
3.05, 20.3 § 1.99 vs. 34.4 § 3.37, 20.9 § 2.03). In all the
patients with hearing improvement, the TEOAEs revealed
an improvement from “Fail” to “Pass” and otoacoustic dis-
tortion products, which were previously absent, were
evoked at frequencies of the tonal Weld normally examined
(Table 3).
The ABR responses were normal, and ENG recording
revealed a normoreXexia in all the patients (Table 3).
At the endpoint, with regard to the bone conduction
threshold audiometry, comparison between the two groups
showed no signiWcant (p > 0.05) best results in group A at
the 250, 500, 1,000, 2,000, and 4,000 Hz frequencies
(Table 4).
Discussion
In the surgical treatment of chronic otitis media with
cholesteatoma, the main goals for surgery are to eliminate
cholesteatoma and bone disease in order to produce a dry
and safe ear, to prevent recurrent disease, and to restore
serviceable hearing [8].
Among the pathogenic factors that are responsible for a
surgical failure, a bad mastoid and tympanic cavity aeration is
very important; recent studies have shown that there is a gas
exchange function between the mastoid and blood vessels
through the middle ear mucosa: this function plays a very
important role in the regulation of middle ear pressure [9].
The overall complication rate of mastoid surgery is
around 1–16% [1]. After chronic ear surgery, injuries
include: facial nerve and vascular damages, tegmen inju-
ries, canal dehiscence, and cholesteatoma recurrence [1].
Furthermore, after surgery, a Wbrous tissue may partially or
completely substitute the mastoid air reserve and results in
retraction of the mastoid skin and/or tympanic membrane
into the cavity [1, 9].
Comparative histologic studies between the piezoelectric
devices, saw and bur, highlighted the superiority of the pie-
zoelectric device in terms of safety, cutting precision, and
protection of anatomic structures and, consequently, a bet-
ter healing process [2]. After Piezosurgery® the new bone
formation was better and more rapid than with saw and bur:
the new tissue was primarily composed by bone, while after
osteotomies with bur and saw the new tissue presented less
advanced stages of healing with the central areas of the
osteotomies Wlled with non-mineralized Wbrovascular tissue
[2]. The less invasive action of the piezoelectric device and
the better new bone formation allow the preservation of the
mastoid mucosa and its function in regulating middle ear
pressure by transmucosal exchange function: for these rea-
sons, postoperatively, all patients had uneventful recovery.
Instead, traditional motorized instruments generate a sig-
niWcant increase of heat with an alteration of the healing
bony response [10].

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1710 Eur Arch Otorhinolaryngol (2010) 267:1705–1711

In contrast to the results of low-power ultrasonic devices

Table 4 Liminal tonal audiometry results (mean § SD) in the patients underwent intact canal wall mastoidectomy with the piezoelectric device (group A) and with microdrill (group B), before

30.1 § 3.02
20.1 § 1.98

30.3 § 3.05
20.3 § 1.99
used in the recent past and conventional devices (saw, bur),
microscopic examination of an anatomic specimen of the

>0.05
t=2
operative site showed no signs of coagulative necrosis after
the piezoelectric cut [2, 9]. The presence of live osteocytes

34.6 § 3.39
20.6 § 1.99

34.4 § 3.37
20.9 § 2.03
of normal dimension and morphology on the cut surfaces
highlighted the reduced trauma of the piezoelectric cut,

>0.05
4,000

t=1
with a complete absence of harmful eVects [2]. In the group
A, the lower dry-up time range highlights the absence of a
31.1 § 3.11
thermal eVect on the surface cut and shows a better healing
18.9 § 1.82

30.9 § 3.09
18.7 § 1.81
process.

>0.05
The main advantage of the piezoelectric device is the
t=2

selective cut that recognizes tissue hardness and works only

on mineralized structures, without soft tissue damage [2–7].
36.5 § 3.44
21.2 § 2.01

36.8 § 3.47
21.4 § 2.05
Therefore, it was possible to make the cortical bony speci-
men, as the following surgical steps, without injuries to the
>0.05
2,000

t=1

non-mineralized structures, as lateral sinus, dura mater,

and/or facial nerve (Fig. 4). This evidence highlights the
27.7 § 2.89
19.5 § 1.81

27.5 § 2.81
19.3 § 1.76

capacity of the device to preserve the integrity of the mas-

toid mucosa and its important role in the regulation of mid-
>0.05
t=2

dle ear pressure. The cortical specimen, suitable to be

reinserted in the mastoid cortex, avoids retraction or
depression in the postauricular area (Fig. 5).
34.1 § 3.27
19.7 § 1.89

34.2 § 3.28
19.4 § 1.76

The micrometric oscillation allows easy control of the

>0.05

osteotomy procedure, increasing the tactile control of the

1,000

t=1

instrument and thus the cutting precision. A remarkable

feature of the piezoelectric device is its good manageabil-
26.9 § 2.71
15.9 § 1.42

26.9 § 2.71
15.7 § 1.39

ity, which makes it easy for the surgeon to create a straight

osteotomy line, without any learning period [2–7].
>0.05
t=2

We believe that in chronic otitis media surgery, the asso-

ciation between technical ability of a well-trained experi-
enced surgeon and new technology, as the piezoelectric
34.9 § 3.42
16.1 § 1.44

34.5 § 3.38
16.4 § 1.51

device, is major factor aVecting the outcome because the

>0.05

most important single factors for the failure of the surgery

t=1
500

in chronic otitis media are inadequate removal of cell tracts

meticulously and intraoperative complication (injuries to
27.1 § 2.56
13.6 § 1.35

27.3 § 2.57
13.8 § 1.37

lateral sinus, facial nerve, dura mater, etc.).

The absence of macrovibrations avoids cranial and inner
>0.05
t=2

ear vibrations, and this is reXected in our audiological

(t = 1) and 1 year after (t = 2) the surgical treatment

results that highlight the absence of side eVects on the inner

34.5 § 3.22
14.1 § 1.38

34.2 § 3.21
14.4 § 1.41

and middle ear. The postoperative audiologic data show, as

the absence of macrovibrations avoids cranial and inner ear
>0.05
t=1

vibrations, consequently side eVects [11].

250

In our patients, the postoperative presence of TEOAE

and DPOAEs highlights the absence of an ultrasound eVect
Audiometric bone threshold

Audiometric bone threshold

Audiometric air threshold

Audiometric air threshold

(ampliWcation, damage, etc.) on the inner ear and, in partic-

ular, on the cochlear outer hair cells [12].
The piezoelectric device uses low-frequency ultrasonic
waves (24.7–29.5 kHz), and does not damage the adjacent
inner ear tissue (higher frequency waves need to be
utilized) [12]. The literature reports ultrasound-induced
Group A

Group B

p value
Group

damage of vessels with ultrasound at a frequency of

750 kHz [13].

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Eur Arch Otorhinolaryngol (2010) 267:1705–1711
Because we have experienced a longer operative time by
performing mastoidectomy with the piezoelectric device in
the traditional method (removing bone in layers), we have
decided to remove the mastoid cortex through a bony spec-
imen. After having removed the bony specimen, the other
surgical steps have been done by removing bone in layers,
as traditional methods: for this reason, only four patients,
with an anterior sigmoid sinus (n = 2) or a low hanging
dura (n = 1), presented areas of the lateral sinus and of the
dura uncovered.
Conclusion
Our experience and the postoperative audiologic data show
the eYciency of the piezoelectric device in terms of safety,
cutting precision, and protection of anatomic structures of
the middle and inner ear, and conWrm its applicability in the
intact canal wall mastoidectomy.
ConXict of interest statement None of the authors have a Wnancial
relationship with any organization that sponsored the research.
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