RESPONSE TO “OSSICULAR CHAIN PRESERVATION IN EPITYMPANIC CHOLESTEATOMA SURGERY

Abstract

To the Editor: We would like to thank the colleagues for their comments about our article. Gruppo Otologico’s experience has been fundamental for the development, refinement, and diffusion of middle ear surgery techniques, and their attention to our work is an honor for us. We will reply point-by-point to be as clear as possible. 1) Actually, in our article (1), 56.5% of ossicular chain preservation is reported using the exclusive endoscopic transcanal tympanoplasty. The more are the subsites involved, the less is the likelihood of ossicular chain preservation. Subsite B (medial attic) is the most frequently associated with ossicular chain removal. Our colleagues address the fact that in a study involving 230 patients, the ossicular chain preservation rate was 100%, regardless of the epitympanic location. In our experience, cholesteatoma, which involved medial attic (type B), was present in 12 patients (52%) of 23. Only in 2 cases we were able to safely remove the pathology without removing the ossicular chain but only because of 45-degree endoscopic view. In a big population like 230 patients in some cases, cholesteatoma might involve the medial attic, and it seems to us very unlikely that all this patients have been operated without ossicular chain removal. How did they visualize the pathology laying medially to the ossicles? Did they perform a blind removal? How did they check the radicality of their removal? Would this be consistent with the absence of residual pathology in the middle ear? Because the scientific honesty of such a prestigious institution is not to be questioned, some realistic reasons of these results have to be found. Notably, reading the material and methods subheading of the article by Sanna et al. (2), we noticed that the inclusion criteria of the retrospective review were “patients with cholesteatoma who underwent modified Bondy technique.” This kind of inclusion criteria is at high risk of selection bias. The risk would be that the patients who had ossicular chain removal during that kind of surgery for medial attic localization or for extended pathologies were excluded because they did not eventually underwent a Bondy modified technique, who, by definition (2), provides intact ossicular chain and pars tensa preservation. In this way, the sentence, regardless of the location in the epitympanum, would rather be not considering the location in the epitympanum. However, if the exact location in the epitympanum was not considered, results of that study could be referred neither to cholesteatoma medial to the attic nor to those involving several subsites, the latter being treated by more extended operations other than Bondy and, hence, excluded a priori from the study. In the same way, if we analyze the results of our study considering all the patients except those with medial attic involvement, the ossicular preservation rate would be 100% because the 10 patients who had ossicular chain removal also had type B involvement. 2) We also would clarify that our recurrence rate in the middle ear was 8.6% (2 of 23) and not 13% (3 of 23). In fact, as specified in our article, 1 patient had a pearllike residual, which, also in the article by Sanna et al. (2), was considered apart from middle ear pathology recurrence. 3) Our experience with the exclusive endoscopic transcanal tympanoplasty, as stated in the title of our article, must be considered preliminary. Long-term results are necessary to confirm the realiability of this technique. Anyway, in the authors’ opinion, the advantages of mastoid preservation and absence of external incisions and retroauricular tissue dissection should be considered in the choice of the best approach to treat cholesteatoma. Daniele Marchioni, M.D. Matteo Alicandri-Ciufelli, M.D. Gabriele Molteni, M.D. Domenico Villari, M.D. Daniele Monzani, M.D. Livio Presutti, M.D. Otolaryngology-Head and Neck Surgery Department University Hospital of Modena Modena, Italy