Successful Debridement and Flap Reconstruction for Left Mastoid Ulcer

Chief Complaints

A 68-year-old female patient with a body mass index (BMI) of 21 presented to the Plastic and Reconstructive Surgery Department at PACE Hospitals, Hitech City, Hyderabad, with a one-week history of an ulcer behind the ear. She reported that the condition began 15 days earlier as a swelling at the same site, which was associated with pus discharge. She underwent incision and drainage (I&D) at an outside hospital, following which she developed a persistent ulcer at the affected area.

The patient was a known case of hypertension and diabetes mellitus and was on regular treatment for both conditions. She had a history of percutaneous transluminal coronary angioplasty (PTCA). She had also undergone previous surgical procedures, including tubectomy and hysterectomy. There was no history of any known drug or food allergies.

On examination, the patient was conscious, coherent, and cooperative. There was no evidence of pallor, icterus, cyanosis, clubbing, lymphadenopathy, or pedal edema. Her vital signs were stable. Local examination revealed an ulcer over the left mastoid region.

Upon admission to PACE Hospitals, the patient underwent a comprehensive evaluation, including a detailed review of her medical history and a thorough physical examination by the Plastic and Reconstructive Surgery team. The patient presented with a non-healing ulcer behind the left ear for one week duration, associated with a prior history of swelling and pus discharge at the same site, for which incision and drainage had been performed at an outside hospital. Clinical examination revealed an ulcer over the left mastoid region, suggestive of a post-infective non-healing wound.

A complete diagnostic workup was carried out, including laboratory investigations and tissue analysis. Tissue obtained from the ulcer site was sent for culture and sensitivity, which showed no bacterial growth after incubation. General clinical assessment indicated a stable systemic status without signs of active systemic infection. Her known history of diabetes mellitus, PTCA, and hypertension was also taken into consideration, as these conditions can contribute to delayed wound healing.

Based on the confirmed findings, the patient was advised to undergo a Left Mastoid Ulcer Treatment in Hyderabad, India, under the expert care of the Plastic and Reconstructive Surgery team.

After a thorough evaluation by Dr. Kantamneni Lakshmi, Senior Consultant Plastic, Reconstructive & Aesthetic Surgeon, and in coordination with cross-consultations from Dr. Shiva Shankar Marri (Dermatologist) and Dr. Tripti Sharma (Endocrinologist), a comprehensive assessment was carried out to determine the most appropriate management plan for the patient diagnosed with a left mastoid ulcer.

Based on the clinical findings of a non-healing ulcer over the left mastoid region following prior swelling, pus discharge, and incision and drainage performed at an outside hospital, along with the patient’s comorbid conditions, including diabetes mellitus, hypertension, and history of PTCA, it was determined that surgical management with thorough wound debridement and rotational flap cover was the most appropriate treatment approach. This decision was made after careful evaluation of the wound status, infection risk, and the need for definitive soft tissue coverage to promote optimal healing and prevent further complications.

The patient and her family members were counselled in detail regarding the condition, the need for surgical intervention, and the associated risks and benefits. They were also informed about the importance of glycemic control, infection prevention, and adherence to postoperative care to ensure successful wound healing and recovery.

Following the diagnosis, the patient was scheduled to undergo Debridement with Flap Cover Procedure in Hyderabad at PACE Hospitals, under the supervision of the expert Plastic and Reconstructive Surgery team.

The surgical procedure involved the following steps:

• Anaesthesia and Patient Preparation: The procedure was performed under general anaesthesia under strict aseptic precautions. The patient was positioned appropriately, and the operative site over the left mastoid region was thoroughly painted and draped in a sterile manner to maintain surgical field sterility.

• Wound Assessment and Debridement: The ulcer over the mastoid area was carefully assessed. All necrotic, slough, and unhealthy tissues were thoroughly debrided to achieve a clean and viable wound bed. Tissue samples were sent for culture and sensitivity to identify any underlying infection.

• Flap Planning and Design: Based on the size of the defect (approximately 1.5 × 2.5 cm), a local rotation flap was planned to achieve adequate coverage while maintaining vascularity and minimizing tension at the repair site.

• Flap Elevation and Inset: The designed rotation flap was carefully elevated, ensuring preservation of its blood supply. The flap was then rotated and positioned into the defect, achieving proper alignment and complete coverage of the wound area. The flap was secured in place using appropriate suturing techniques.

• Hemostasis and Wound Closure: Meticulous hemostasis was achieved to prevent post-operative bleeding. The surgical site was closed in layers using appropriate sutures, and an aseptic dressing was applied. The procedure was completed uneventfully with no intraoperative complications.

Postoperatively, the patient was managed with intravenous fluids for hydration and circulatory support, intravenous medications for infection control, intravenous medications for pain management, and gastric protective measures for stress-related ulcer prevention. Ongoing treatment was continued for control of blood sugar levels and blood pressure in view of underlying diabetes mellitus and hypertension. Specialist consultations were obtained for evaluation of skin-related itching and optimization of metabolic control. The postoperative period remained uneventful with stable recovery and healthy flap condition. At discharge, the patient was stable and advised strict wound care and proper control of comorbid conditions to ensure optimal healing.

Upon discharge, the patient was advised oral medications for the prevention of infection at the surgical site, reduction of gastric irritation, and relief from postoperative pain. Medications were also prescribed to improve nutritional status and support wound healing. Treatment was continued for control of blood sugar levels in view of diabetes mellitus and for regulation of blood pressure due to hypertension. Additional medications were advised for the management of scalp and neck itching, skin irritation, and allergic symptoms. Further, in view of the past history of PTCA, appropriate cardiac protective therapy was considered for the prevention of thrombotic complications and long-term cardiovascular risk reduction. The overall aim of the prescribed medications was to promote wound healing, prevent infection, maintain metabolic and cardiovascular stability, and ensure smooth postoperative recovery.

The patient was advised to follow a diabetic diet. She was instructed on proper wound care and to keep the surgical site clean and protected. She was also advised to avoid applying pressure on the wound site to promote optimal healing. In addition, mechanical combing was recommended once weekly as part of scalp care instructions.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms like fever, increasing pain, swelling or discharge from the wound, or any signs of altered consciousness, uncontrolled blood sugar levels, or any other unexpected postoperative complications.

The patient was advised to return for a follow-up consultation with the Consultant Plastic, Reconstructive & Aesthetic Surgeon in Hyderabad at PACE Hospitals after 2 days for dressing and review with prior appointment in the Plastic Surgery OPD. She was also advised to attend the Dermatology OPD for review after 2 weeks and the Endocrinology OPD for review after 1 week with FBS and PPBS reports for further evaluation and management.

This case highlights successful surgical management of a left mastoid ulcer using debridement and flap cover under general anaesthesia. The postoperative course was uneventful with good wound healing and stable recovery. Multidisciplinary care and appropriate wound management contributed to an optimal clinical outcome.