Attic Reconstruction Research Articles

Attic reconstruction techniques in cholesteatoma surgery: a comparative analysis of cartilage versus bone pate

Background Cholesteatoma surgery involves canal wall down (CWD) and canal wall up (CWU) mastoidectomy. CWU is associated with higher cholesteatoma recurrence, often linked to attic retraction pockets. Attic reconstruction with cartilage or bone pate lacks comparative evidence. Aims/Objectives To compare the effectiveness of cartilage and bone pate in attic reconstruction during CWU mastoidectomy for cholesteatoma. Material and Methods We conducted a retrospective study at King Abdullah University Hospital (KAUH) in Jordan, analyzing surgeries performed from 2011 to 2021. Patients who underwent CWU mastoidectomy with attic reconstruction using tragal cartilage with perichondrium or bone pate were included. Results Of 48 patients analyzed, 26 had cartilage graft attic reconstruction, and 22 received bone pate. Recurrent cholesteatoma occurred in 19.23% of the cartilage group but none in the bone pate group (p = .001). Ear discharge was observed in 19.23% of the cartilage group and 18.18% of the bone pate group, while tympanic membrane perforations and external auditory canal cholesteatoma were more prevalent in the cartilage group. Conclusions and Significance Our study indicates that bone pate results in significantly lower cholesteatoma recurrence than cartilage grafting in CWU mastoidectomy attic reconstruction. Bone pate offers stability and favorable long-term outcomes for outer attic wall repair.

A narrative review of the management of pars flaccida tympanic membrane retractions without cholesteatoma.

Review the effectiveness of surgical and non-surgical management strategies for isolated pars flaccida and combined pars tensa and flaccida tympanic membrane retractions in preventing progression or recurrence, improving hearing and preventing development of cholesteatoma. Narrative review. ENT and otology services worldwide. Patients with non-cholesteatoma tympanic membrane retractions. Changes in retraction (progression or resolution, or development of a known sequela such as perforation). Eight full text papers are included: three randomised controlled trials and five case series or cohort studies of more than five patients (a total of 238 ears). Data exists for the use of conservative management, ventilation tubes, laser tympanoplasty, cartilage and fascia tympanoplasty, lateral attic reconstruction as well as mastoid procedures. Few high-quality studies on the management of isolated and combined pars flaccida retractions exist. For isolated pars flaccida retractions deemed to require surgical intervention, this review suggests that lateral attic reconstruction and cartilage tympanoplasty carries least risk of recurrence.

The Emerging Surgical Concepts and Principles of Attic and Postero-Superior Wall Reconstruction by Auricular Cartilage and Free Fibro-Periosteal Tissue in Middle Ear Surgery. An Exposition on Surgical Experiences, Observations and Mistakes.

In middle ear surgeries, addressing the pathologies (cholesteatoma, retractions or tympanosclerosis) in attic or postero-superior area, are associated with difficulties like reconstruction of attic and postero-superior canal wall after clearing the disease. There are various graft materials available for such attic reconstruction in intact canal -wall surgeries. We describe our experience of attic and postero-superior canal wall reconstruction in combined approach tympanoplasty (CAT) using free auricular cartilage and free fibro-periosteal tissue and to present our results in anatomical and functional perspectives. This retrospective observational study was conducted in a tertiary care center which comprised 25 cases of combined approach tympanoplasty (with attic wall reconstruction) which were operated for attic cholesteatoma, tympanosclerosis or adhesive otitis media from January 2017 to December 2019 in our otolaryngology department. Outcomes were evaluated in audiological and morphological dimensions and paired "t" test (significant p value <0.05) was used to analyse the audiological data. A total of 25 cases (22 primary and 3 revision cases) were included in the study. Defect in attic and posterosuperior canal wall was caused by pathology (disease itself) in 2 cases, surgically created (intraoperatively to clear the disease) in 11 cases and both by pathology and surgically in 12 cases. 22 cases had successful graft uptake, with a morphological success rate of 88%, whereas graft failure was encountered in 3 cases. Complications observed were post-operative otorrhea (2 cases), recurrence (3 cases), no hearing improvement despite intact graft (1 case) and worsening of hearing post operatively in 1 case. Pre-operative ACT (Air conduction threshold) was 45.96 ± 12.47dB and the post-operative ACT was 38.61 ± 9.76dB (p value = 0.0246). Pre-operative ABG (Air-bone gap) was reduced from 30.58 ± 11.06dB to the post-operative ABG of 21.89 ± 6.24dB (p value = 0.0013). Reconstruction of postero-superior canal wall and attic defects in CAT using auricular cartilage and fibro-periosteal tissue (over mastoid cortex) is a novel method and associated with satisfactory morphological and audiological results. It is also effective in preventing postoperative retractions.

Endoscopic Cartilage Umberlla Ossiculoplasty: As Total Ossicular Replacement Using Endoscope Holder.

The online version contains supplementary material available at 10.1007/s12070-021-02518-8.

Exclusive Two Handed Endoscopic Cartilage Type 3 Tympanoplasty with Endoscope Holders.

In present world of contemporary techniques of microscopic ear surgery and single handed endoscopic ear surgery, we propose the technique of two handed endoscopic tympanoplasty using endoscope holders. The aim of the study isto evaluate the functional and anatomical results of our technique of endoscopic type 3 cartilage tympanoplasty using endoscope holder. It is aRetrospective Non Randomized Clinical Study. A total of 67 endoscope holder assisted exclusively two handed endoscopic type 3 cartilage tympanoplasties performed from December 2014 to March 2017 with our technique were included in the study. Patients with pars tensa retractions and perforations with absent incus were included in the study. Those with cholesteatoma were excluded from the study. Full thickness tragal cartilage disc of 3 × 3mm dimensions with a circular slot of 1mm to fit onto the head of the stapes was used for reconstruction. Tympanic membrane reconstruction was done along with attic reconstruction, using sliced tragal cartilage of 0.5mm thickness. Patients were assessed at 6, 12 and 24months for graft status. In early follow up period ranging from 24 to 52months, the graft take up was seen in 64 ears with three perforations giving a success rate of 95.52%. The pre-operative air-bone gap was 42.6 ± 3.26dB and the post-operative air-bone gap at 6months, 1 and 2years was 18.36 ± 3.46dB, 19.42 ± 4.32dB and 19.53 ± 4.33dB respectively. The study reports good air-bone closure to 20dB postoperatively following type 3 endoscopic tympanoplasty using endoscope holder. Slotted cartilage graft is definitely an excellent option for ossiculoplasty in cases of absent incus providing a stable assembly. Level of evidence: Level 4.

Cholesteatoma Masquerading as Cerumen

Cerumen is composed of glandular secretions and desquamated epithelial cells. It protects and lubricates the external auditory canal. Impacted cerumen causes canal occlusion and pressure over the tympanic membrane, causing ear discomfort, conductive hearing loss, itching, etc. Up to 6% of the general population are affected with impacted cerumen, which includes 10% of children, more than 30% of the elderly and people with cognitive impairment. Persistent symptoms despite resolution of impaction and patient repeatedly should raise suspicion of alternative diagnosis and prompt for further evaluation. A 20-year-old female patient came with complaints of decreased hearing and ear discharge. On otoscopic examination of left ear, impacted cerumen was seen in the attic region. On removal of wax with the aid of oto-endoscopy, attic region was found to be filled with cholesteatoma debris. On pure tone audiometry, patient had mild conductive hearing loss of 30 db and computed tomography of left temporal bone revealed ill-defined soft tissue density in the middle ear (epitympanum) with erosion of head of malleus and short process of incus. Blunting of scutum was also seen. Attic reconstruction and type III tympanoplasty was performed. On histopathological examination, the section showed keratin flakes with bacterial colonies which were consistent with cholesteatoma. In conclusion, any case of impacted cerumen should not be ignored by otorhinolaryngologist. Further evaluation with thorough examination under otomicroscope/otoendoscope has to be done which can lead to different diagnosis and treatment plan.

Anterior Attico-antrostomy with Cortical Mastoidectomy and Attic Reconstruction with or without Ossiculoplasty Versus Canal Wall Down Mastoidectomy with Ossiculotympanoplasty using Tragal Cartilage sh

Anterior Attico-antrostomy with Cortical Mastoidectomy and Attic Reconstruction with or without Ossiculoplasty Versus Canal Wall Down Mastoidectomy with Ossiculotympanoplasty using Tragal Cartilage sh

Hearing results of tympanoplasty with attic reconstruction vs. obliteration in attic cholesteatoma

INTRODUCTION: The aim of the study was to compare hearing results between tympanoplasty with attic wall reconstruction and attic obliteration. MATERIAL AND METHODS: A prospective study included 88 patients who were operated for chronic suppurative otitis media (CSOM) and cholesteatoma in the ENT Department University Clinic Center Banja Luka from 2006 to 2011. Analysis of variance (ANOVA) was conducted to assess the impact of two different techniques of tympanoplasty: attic wall reconstruction and attic wall obliteration on patients` hearing. Hearing outcome was measured comparing preoperative to postoperative pure-tone average (PTA) and postoperative air-bone gap (ABG). RESULTS: Cholesteatoma was found in 54 (61.4%) patients: 31 (35.2%) sinus cholesteatoma, 20 (22.7%) attic cholesteatoma, 3 (3.4%) tensa tympanic cholesteatoma, and 34 cases (38.6%) of CSOM. Lateral attic wall and ossicular chain reconstruction was performed in 33 cases with subsequent attic reconstruction if the long process of the incus and the incudo-stapedial joint were missing. A mixed between-within-subjects analysis of variance showed significant improvement of PTA postoperatively in comparison to preoperative levels: Wilk`s Lambda=0.33, F(1,86)=172.1, p<0.001. ANOVA showed significant improvement of ABG postoperatively in comparison to preoperative levels: Wilk`s Lambda=0.23, F(1,86)=286.3, p<0.001. Hearing improvement was measured in both cases, the ABG closure and mean PTA improvement was larger in the attic reconstruction compared to attic obliteration technique. CONCLUSION: Attic wall reconstruction with cartilage provides better postoperative hearing compared to attic obliteration. Attic reconstruction in revision cases for cholesteatoma recurrence is not recommended.

Cartilage ossiculoplasty in cholesteatoma surgery: hearing results and prognostic factors.

SUMMARYCartilage tympanoplasty is an established procedure for tympanic membrane and attic reconstruction. Cartilage has been used as an ossiculoplasty material for many years. The aim of this study was to evaluate hearing results of costal cartilage prostheses in ossicular chain reconstruction procedures in subjects operated on for middle ear cholesteatoma and to determine the presence of prognostic factors. Candidates for this study were patients affected by middle ear cholesteatoma whose ossicular chain was reconstructed with a chondroprosthesis. 67 cases of ossiculoplasty with total (TORP) or partial (PORP) chondroprosthesis were performed between January 2011 and December 2013. Follow-up examination included micro-otoscopy and pure tone audiometry. The guidelines of the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology Head and Neck Surgery were followed and pure-tone average (PTA) was calculated as the mean of 0.5, 1, 2 and 4 kHz thresholds. Statistical analysis was performed with ANOVA tests and regression models. Average air-bone gap (ABG) significantly improved from 39.2 dB HL (SD 9.1 dB HL) to 25.4 dB HL (SD 11 dB HL) (p < 0.001). Linear regression analysis showed that the only prognostic factor was the type of operation (p = 0.02). In fact, patients submitted to ICWT presented better post-operative ABG compared to CWDT. None of the other variables influenced the results. The present study proposes costal cartilage as material of choice when autologous ossicles are not available. The maintenance of the posterior canal wall was the only prognostic factor identified.

Atticotomy, Attic Reconstruction, Tympanoplasty with or Without Ossiculoplasty, Canal Plasty and Cortical Mastoidectomy as Part of Intact Canal Wall Technique for Attic Cholesteatoma.

To evaluate a technique of canal wall up mastoidectomy for limited attic cholesteatoma and to study practical considerations during surgery. Any person undergoing surgery for attic cholesteatoma was thoroughly examined during surgery and decision for doing this canal wall up (CWU) surgery will be taken on operating table. The patients were regularly followed up and microscopic, oto endoscopic and audiological assessments done at regular intervals. Revision surgery was done only if there were signs of recidivism or if ossiculoplasty was planned for second stage or placement of a prosthesis later was considered. Out of 100 cholesteatoma surgeries, 22 cases found suitable for the CWU technique. Only 1 out of 22 patients required revision surgery due to recurrence. Rest of the patients maintained healthy middle ear for more than a year. Prevention of medialisation of attic cartilage piece was found to be very important consideration. The CWU technique is a reliable method of management for limited attic cholesteatoma. Selection of subjects should be very meticulous.

Cartilage palisades in type 3 tympanoplasty: functional and hearing results.

To evaluate the functional and hearing outcomes using full thickness broad cartilage palisades for tympanic membrane reconstruction in type 3 tympanoplasty with titanium prostheses. The retrospective study performed at a tertiary referral institute included 30 patients with posterior mesotympanic retraction pockets or tympanic membrane perforations requiring tympanic membrane and type 3 ossicular reconstruction. Patients with disease extending beyond the aditus requiring canal wall down mastoidectomy were excluded. Disease removal from posterior mesotympanic and epitympanic recesses was confirmed using angled endoscopy and ossicular reconstruction was performed using titanium partial or total ossicular replacement prostheses. Tympanic membrane reconstruction was done, with or without attic reconstruction, using full thickness broad cartilage palisades harvested from the tragus with perichondrium attached laterally. Patients were assessed at 24 and 48weeks for graft status and any evidence of implant extrusion. Hearing evaluation was done using subjective assessment and pure tone audiometry. In total, 27 out of 30 patients had intact and completely healed grafts at 48weeks postoperatively (a success rate of 90%) showing full union and epithelialization of palisades, and with three patients displaying small defects. The mean pure tone air bone gap pre- and postoperatively was 32.4 and 8.8dB, respectively, with most patients reporting satisfactory postoperative hearing. No evidence of implant extrusion was found in the 48-week period. Tympanic membrane reconstruction using full thickness palisades of tragal cartilage provides good functional and hearing outcomes in type 3 tympanoplasty with titanium prostheses.

Cartilage Palisades in Type 3 Tympanoplasty: Functional and Hearing Results

Objectives: Evaluate functional and hearing outcomes with use of full thickness broad cartilage palisades for tympanic membrane reconstruction in type 3 tympanoplasty using titanium prosthesis. Methods: The retrospective study done at a tertiary referral institute included 30 patients with posterior mesotympanic retraction pockets or tympanic membrane perforations requiring tympanic membrane and a type 3 ossicular reconstruction. Patients with disease extending beyond aditus requiring canal wall down mastoidectomy were excluded. Disease removal from posterior mesotympanic and epitympanic recesses was confirmed using angled endoscopy and ossicular reconstruction performed using titanium partial or total ossicular replacement prosthesis. The tympanic membrane reconstruction was done, with or without attic reconstruction, using full thickness broad cartilage palisades harvested from the tragus with attached perichondrium laterally. Patients were assessed at 12 and 24 weeks for graft status and any evidence of implant extrusion. Hearing evaluation was done using subjective assessment and pure tone audiometry. Results: Twenty-seven out of 30 patients had intact and completely healed grafts postoperatively at 24 weeks (success rate of 90%) displaying full union and epithelization of palisades, with 3 patients displaying small defects. The mean pure tone air bone gap pre and postoperatively was 32.4 dB and 8.8 dB respectively, with most patients reporting satisfactory postoperative hearing. No evidence of implant extrusion was found in the 24 week period. Conclusions: Tympanic membrane reconstruction using full thickness palisades of tragal cartilage provides good functional and hearing outcomes in type 3 tympanoplasty using titanium prosthesis.

Attic Reconstruction in Pediatric Canal Wall‐up Mastoidectomy

Objective: 1) To evaluate 3 methods: conchal cartilage, tragal cartilage, and bone pate, for primary attic reconstruction (scutumplasty) in pediatric canal wall-up mastoidectomies in terms of recurrence rates and formation of retraction pockets. Method: All patients undergoing attic reconstruction following a canal wall up mastoidectomy were evaluated from a single surgeon prospective pediatric otological database maintained over a 10-year period. The reconstruction of the scutum defects was done using bone pate, conchal and tragal cartilage. The outcome measures were postoperative retraction pocket formation and recurrence of cholesteatoma. Results: A total of 120 patients underwent primary attic reconstruction following canal wall-up mastoidectomy over a 10-year period. The overall recurrence rate was 9.83% (n = 12). Fifty-one patients underwent attic reconstruction with tragal cartilage, while 33 were reconstructed using conchal cartilage and 36 with bone pate. The recurrence rate with various reconstruction methods was 5.8% (n = 2), 15.1% (n = 5), and 13.8% (n = 5) for tragal, conchal, and bone pate, respectively. Cholesteatoma recurrence rates with the use of tragal cartilage for reconstruction of the scutum were significantly lower as compared to that of conchal cartilage ( P = .034, chi square = 3.308) and bone pate ( P = .046, chi square = 2.834). Conclusion: The use of the tragal cartilage for scutum reconstruction is associated with the least recurrence rate for pediatric cholesteatoma. The easy accessibility, stability, and good long-term results with the use of the tragal cartilage makes it an ideal material for outer attic wall reconstruction in pediatric canal wall up mastoidectomies.

Clinical Results of Atticoantrotomy with Attic Reconstruction or Attic Obliteration for Patients with an Attic Cholesteatoma

ObjectivesWe aimed to investigate the clinical results of atticoantrotomy in patients with an attic cholesteatoma.MethodsNinety-eight ears in 98 patients were operated on using atticoantrotomy between October 2002 and December 2006. A retrospective review of the otology database (operative findings and methods, postoperative physical examination and pre- and postoperative audiometry) was performed.ResultsThere were 58 female and 40 male patients with a mean age of 40 yr. The cholesteatoma was limited to the attic region in 24 patients (24.5%); attic with antrum in 18 (18.4%); and attic with antrum and middle ear in 56 (57.1%). Attic obliteration was performed in 59 patients (60.2%), attic reconstruction in 39 (39.8%) and ossicular reconstruction was performed in 59 (60.2%). The mean preoperative and postoperative air-bone gaps were 29.2±13.5 dB and 25.0±15.4 dB, respectively (P=0.01) and the mean preoperative and postoperative high-tone bone conduction levels were 14.5±9.7 dB and 15.23±14.0 dB, respectively (P=0.411). A recurrent cholesteatoma was detected in 3 ears (3%) and revision surgery was performed on these patients.ConclusionAtticoantrotomy showed a low recurrence rate and no deterioration in hearing levels. If there is a intact malleus head or body of incus, attic reconstruction was possible and this procedure could lead to improved hearing. However, postoperative retraction occurred in 18% of patients, a problem that will need to be solved in the future.

Cartilage tympanoplasty: literature review

There has been renewed interest in the use of cartilage for middle-ear reconstructions. The aim of the present review is to examine the indications, techniques and surgical outcomes of cartilage tympanoplasties reported in the literature. There have been concerns regarding weakening of cartilage struts, from histological studies involving explants; as a result, cartilage struts for ossiculoplasty have not gained popularity. On the other hand, cartilage tympanoplasty is now an established procedure for tympanic membrane and attic reconstruction. The commonest techniques involve cartilage palisades and composite cartilage-perichondrial island grafts. There are many variations on the shape, size and thickness of the cartilage grafts. The perceived benefit of cartilage tympanoplasty is to prevent retraction pockets at the grafted site, even though many otologists accept that this technique may not deal with the causal factors involved in the retraction process. Concerns that the stiffness and mass of cartilage grafts may adversely affect hearing have not been substantiated in clinical reports thus far.

Lateral Attic Reconstruction Technique

To provide an estimate of the reliability of a preventive surgical approach named lateral attic reconstruction (LAR) technique for the treatment of Type II epitympanic retraction pockets. From a cohort of 25 adult patients presenting with a Type II epitympanic retraction pocket, 2 groups were randomly formed: a first one, with 15 patients who underwent LAR technique, and a second one, in whom (10 patients) only observation was planned and was therefore used as control. University hospital as tertiary referral center. Selection criteria for composing the 2 groups of study were the presence of a Type II epitympanic retraction pocket and a normal audiogram. The surgical procedure (LAR) consisted of a retroauricular approach, removal of a small piece of tragal cartilage, cleansing of the epitympanic pocket until denudation of the ossicular components, and placement of the cartilage graft to reconstruct the lateral epitympanic wall. All the patients were controlled at different postoperative or postobservation times (1, 3, 6, and 12 mo) via otomicroscopic examination, pure-tone audiometry, and tympanometry. All operated patients showed a normal anatomic pattern starting from the first postoperative control (1 mo) with a normal or near-normal hearing threshold and a Type A or As tympanogram in most cases. Lateral attic reconstruction technique has proved to be a reliable preventive technique for impeding a Type II epitympanic retraction pocket to worsen because it was observed in a percentage, although small (33.3%), of patients in whom a wait-and-scope policy was applied.

Reconstruction of outer attic wall defects using bone paté: long-term clinical and histological evaluation

The objective was to evaluate the long-term clinical outcome of the bony outer attic wall reconstruction (scutumplasty) by using autogenous bone paté in a series of patients who underwent canal wall up (CWU) mastoidectomy for middle ear cholesteatoma. In addition, an histological analysis of bone paté graft specimens taken during the second-look procedure 12 months after the first surgery, was carried out. A series of 134 ears from 128 patients with cholesteatoma who underwent staged CWU mastoidectomy and attic reconstruction with bone paté, between 1995 and 2000 inclusive, was retrospectively analyzed. In ten randomly selected ears, biopsies from the newly built outer attic wall were taken during the second-look operation and were microscopically analyzed. At the second stage operation, the bone paté graft was found normal in 64.9% of cases. In 39 (29.1%) patients there was a remarkable hypertrophy of the bone paté which was subsequently thinned out by using a diamond burr. A partial resorption of the bone paté was observed in 4.4% of ears and a total resorption in 1.4%. Residual cholesteatoma was found in 13.4% of ears. At the last follow-up visit, recurrent cholesteatoma was observed in 5.2% of ears. Self cleaning attic retraction pocket occurred in 4.4% of ears. Twelve months after implantation, histologic examination on the newly built bone showed a well-structured bony tissue. In particular, osteoblasts lined bone trabeculae with signs of an active tissue remodeling. In conclusion, the reconstruction of the outer attic wall should be considered a fundamental step when performing a CWU procedure in order to prevent attic retractions and recurrences of cholesteatoma. In our experience, autogenous bone paté graft has demonstrated good long-term results in outer attic wall reconstruction being adaptable, well tolerated, stable and of low cost.

How we do it: Free conchal cartilage revisited for primary reconstruction of attic defects in combined approach tympanoplasty

Keypoints * There are concerns over the efficacy of free cartilage autografts in attic reconstruction (scutumplasty) for combined approach tympanoplasty (CAT). * Our operative technique uses free conchal cartilage autografts and an additional piece of conchal cartilage to buttress the reconstruction. * Of the 16 cases where this technique was used, there were two cases (13%) of failure of the attic reconstruction and a keratin pearl (residual disease) in one case (6%). This compares favourably with comparable series using a variety of reconstruction techniques.

One Stage Canal Wall Up Tympanoplasty with Attic Reconstruction Assisted with Otoendoscope for a Small Attic Cholesteatoma

One Stage Canal Wall Up Tympanoplasty with Attic Reconstruction Assisted with Otoendoscope for a Small Attic Cholesteatoma

초기 중이 진주종의 치료

Chronic otitis media with cholosteatoma had been one of the most prevalent forms of otological disease. However, recently, the incidence of chronic otitis media have decreased owing to better economic status and health care. Thus, cases of middle ear surgery have also decreased relatively in number. So it seems that otologists nowadays should be engaged in revision surgery of the middle ear and management of early cholesteatoma. While the incidence of extensive or complicated cholesteatoma has dramatically decreased for last decades, the early staged or less extensive cholesteatoma and retraction pockets are more frequently found. Especially localized adhesive otitis media, usually posterior tympanic membrane, is one of the most difficult dilemmas for the otologist. There are several controversial issues for managing patients with early cholesteatoma : 1 ) conservative care or surgical treatment 2) techniques of surgery 3) whether or not mastoidectomy. So surgery for early cholesteatoma is thought to be reconstructive rather than destructive and it can be a prophylactic operation. I proposed a strategy for the management of early cholesteatoma which was based on safe marsupialization of retraction pocket or cholesteatoma, preservation of the mucosa, adequate ventilation, and prevention of retraction pocket. In case of attic retraction pocket or cholesteatoma, atticotomy with scutumplasty was made. On the other hand, the procedure to remove posterior annular bone and posterior scutum to allow access tympanic sinus and posterior attic space designated as posterior sinusectomy with reconstruction were applied to sinus retraction pocket or cholesteatoma. Early tensa retraction cholesteatoma would be managed as the combination of atticotomy and posterior sinusectomy. So I preferred the term “atticosinoplasty” which includes attic reconstruction with scutumplasty after atticotomy and posterior sinusectomy. If the disease seems to extend to mastoid, endoscopes were introduced transmeatally. If cholesteatoma occupies in mastoid, complete mastoidectomy is made, and sometimes mastoid cavity is obliterated to eliminate the cavity problems. During the last 7 years, I managed surgically 208 cases of attic or sinus cholesteatoma, so-called early cholesteatoma, among which there were 45 cases of atticosinoplasty. I analysed 45 cases with atticosinoplasty with special reference to period of postoperative care and hearing result, as compared to cases with mastoid obliteration and open cavity mastoidectomy. In conclusion, I personally think that middle ear cholesteatoma has a possibility of different clinical entity rather than a kind of chronic otitis media, eustachion tube dysfunction can not be always a prerequisite of middle ear cholesteatoma but it can be a secondary phenomenon, and finally surgury for early cholesteatoma is reconstructive rather than destructive ant it can be a prophylactic operation. (J Clinical Otolaryngol 2002;13:13–19)