Canal Wall Down Surgery Research Articles

A tailored approach in cholesteatoma surgery.

In recent years, new techniques have been added to cholesteatoma surgery, and established microsurgical approaches are being reconsidered. This study aims to present the importance of individualized decision-making for the selection of an intact canal wall (CWU) or canal wall down (CWD) surgical procedure for each patient. Using the "ChOLE" classification we categorized 264 operations retrospectively. 162 CWU and 102 CWD surgeries were performed. We focus to determine why a CWD procedure was chosen quite frequently despite some low-stage cases. Furthermore, we evaluated recidivism and hearing outcomes. Smaller cholesteatomas (Ch-stage 1a, 1b & 2a) were found in 182 patients (70%), ossicular chain status feasible for straightforward reconstruction (O-stage 0, 1 & 2) was present in 186 patients (70%), minor complications due to the cholesteatoma (L-stage 1) were infrequent with 28 cases (11%) and a well-pneumatized mastoid was found in 144 cases (55%). Recidivism rates were low (7%) without any difference in both groups and a mean follow-up time of 4 years and 8 months. In primary surgeries there was a significant difference (p < 0.05) in postoperative mean air-bone gap (ABG) between CWU (17dB) and CWD (27dB). The main goals of cholesteatoma surgery remain the avoidance of recidivism and optimal hearing rehabilitation. We recommend a tailored approach in the treatment of cholesteatomas and not a dogmatic one. Surgeons should not hesitate to perform a CWD procedure if required. Performed correctly it results in a dry ear and CWD surgery should remain in the skill set of the otologic surgeon.

Allograft bone vs. bioactive glass in rehabilitation of canal wall-down surgery

Canal wall-down (CWD) mastoidectomy creates a radical cavity that modifies the anatomy and physiology of the middle ear, thus preventing it from being self-cleaning and causing epidermal stagnation in the posterior cavities. Canal wall-down tympanomastoidectomy with reconstruction (CWDTwR) can obliterate such radical cavities. The main objective of this study was to compare postoperative results after CWDTwR by using either bone allografts or 45S5 bioactive glass as a filling tissue with an 18-month follow-up. This was a single-center observational trial including all patients undergoing CWDTwR. Patients were divided into two groups according to the filling material used: allograft bone (AB group) or 45S5 bioactive glass (BG group). Clinical monitoring was performed regularly, with control imaging performed at 18 months (CT scan and DW MRI). The two groups were compared with the t test for quantitative variables and the chi square test for qualitative variables (no revision surgery, audiometric results, complications, mastoid obliteration volume). Thirty-two patients underwent CWDTwR between October 2015 and 2018. The mean age was 48 years, and 71.9% (23/32) were men. A total of 46.9% (15/32) of the patients had undergone at least 3 middle-ear surgeries prior to CWDTwR. The most frequent preoperative symptom was otorrhea (100.0%, 32/32), and only 12.5% (4/32) experienced dizziness. Fifteen and 17 patients underwent surgery with bone allografts and 45S5 bioactive glass, respectively. At 18 months post-operation, 53.3% of the patients (8/15) in the AB group presented with recurrent otorrhea versus 5.9% (1/17) of patients in the BG group (p = 0.005). Seventy-eight percent (7/9) of symptomatic patients had undergone revision surgery at 18 months postoperation: 40.0% (6/15) in the AB group and 5.9% (1/17) in the BG group (p = 0.033). One patient’s surgery was cancelled due to the COVID-19 pandemic, and one patient refused surgery. The effects of CWDTwR with bone allografts are disappointing in early follow-up, with significant resorption leading to a 40.0% revision surgery rate. 45S5 BG is a simple solution, with preliminary results that are superior to those of AB. However, prospective controlled studies with longer follow-up times are needed to evaluate the value of BG versus other synthetic materials (such as hydroxyapatite) in surgical management of CWDTwR.Trial registration: retrospectively registered.

Canal wall up versus canal wall down mastoidectomy techniques in the pediatric population with cholesteatoma: A systematic review and meta-analysis of comparative studies.

The optimal surgical management of cholesteatoma remains controversial. Within pediatric otolaryngology, one of the most vital points of contention is the selection of canal wall-up (CWU) versus canal wall-down (CWD) procedures. Pediatric cholesteatoma has high rates of recurrence (16%-54%). In adults, there is evidence that the selection of surgical techniques affects recurrence rates. This has not been shown in children. 1. To systematically review the literature on recurrent and residual cholesteatoma after CWU and CWD in children and perform a meta-analysis of the data. 2. To assess the rates of recurrent and residual cholesteatoma between CWU and CWD techniques in pediatric patients. 3. To assess hearing outcomes by evaluating postoperative differences in the air-bone gap (ABG) between CWU and CWD techniques. A systematic search of PubMed, Embase, Scopus, and Cochrane Collaboration was performed from inception to May 1st, 2020, to identify studies that compared CWU and CWD procedures for acquired cholesteatoma in children. Search records were screened in duplicate by four reviewers. Inclusion criteria consisted of comparative randomized clinical trials and observational studies assessing outcomes of CWU and CWD techniques in the pediatric population. Studies involving patients with congenital cholesteatoma were excluded. Four reviewers working independently and in duplicate systematically reviewed and extracted study data. Dichotomous variables were analyzed as risk ratios (RR), while continuous variables were compared using weighted mean differences (MD). The risk of bias was assessed using the CLARITY Scale. The outcomes were recurrence, residual disease, air-bone gap (ABG), and air conductive (AC) thresholds. After screening 1036 publications, 17 retrospective cohort studies were selected. 1333 children were included; the overall mean age was ten years (SD 7.9), and the overall mean follow-up time was 5.9 years (SD 6.6). CWU and CWD techniques were performed in 60% (796) and 40% (537) cases. We did not find differences in cholesteatoma recurrence (RR: 1.50, 95% CI 0.94; 2.40; n=544; I2 0%; Tau [2]: 0.00), or rates of residual cholesteatoma (RR 1.51, 95% CI 0.96; 2.38, n=506; I2: 0%; Tau [2]: 0.00) in patients who underwent CWU and CWD mastoidectomy. The mean air-bone gap was lower with CWU than CWD (mean difference: 7.60, 95% CI -10.65; -4.54; n=242; I2: 71%; Tau [2]: 5.98). and relevance: We show similar rates of recurrence and residual disease after either CWU or CWD tympanoplasty. Our results challenge the fundamental principle of CWD surgery as a standard technique, as there is no difference in rates of recurrence and residual disease in CWU and CWD. Moreover, audiometric results support CWU with improved hearing outcomes. PROSPERO identifier: CRD42020184029.

A comparative study of hearing outcome in cholesteatoma surgery canal wall up versus canal wall downmastoidectomy in 100 patients

Cholesteatoma is a well-demarcated sac of keratinizing squamous epithelium in the temporal bone, which is commonly characterized as “skin in the wrong place. The major goal of surgery for cholesteatoma is to make the ear safe and dry with increasing concern of the hearing outcome of patients. Two main surgical techniques employed are Canal Wall down (CWD) and Canal Wall up Mastoidectomy (CWU). In the current study, an attempt would be made to evaluate which technique would be better for achieving disease clearance with favorable hearing outcome and dry ear.1. To evaluate the hearing results following CWU and CWD surgery in patient with cholesteatoma.2. To decide surgical approach according to extension of disease.Materials and Methods:This is a prospective study involving 100 patients with cholesteatoma who had undergone CWD and CWU surgery over the period of 3 years.The choice of mastoidectomy, CWD or CWU, was the decision of the surgeon, after completely evaluating the patient, preoperatively and intraoperatively. All cases were followed up &amp; assessed by autoscopic examination &amp; PTA for minimum of 3 months. In the CWD group, mean hearing gain, in 3 months was 12±1.73dB. In the CWU group, hearing gain in 3 month postoperative period was 18±2.06 dB. Also the hearing gain between the two groups was compared and it was found to be statistically significant for the 3 months (p=0.0002) postoperatively; signifying that there was a comparable difference for CWU over CWD mastoidectomy in the matter of Hearing Gain. SNHL was also seen post operatively in both group. Total 3 (6%) patient in CWU had SNHL post operatively in comparison to 7(14%) patients in CWD. From our study results, we think that CWU is superior to the CWD surgery in cases of cholesteatoma because of good post-operative hearing outcome as well as less complication and law morbidity. CWD surgery should be used in cases of extensive cholesteatoma, mental retardation, not sure about follow up and inadequate middle ear space cases.

Revision surgery for chronically discharging mastoid cavities: mastoid obliteration with canal wall reconstruction versus non-obliteration surgery

PurposeTo evaluate the surgical results of revision canal wall down (CWD) surgery for chronically discharging mastoid cavities and to compare the non-obliteration approach to mastoid obliteration with canal wall reconstruction.MethodsThis is a retrospective cohort study. All adult patients (≥ 18 years) who underwent revision surgery for chronically draining mastoid cavities between January 2013 and January 2020 were included. Primary outcome measures included the dry ear rate, complications and postoperative hearing.Results79 ears were included; 56 ears received revision CWD with mastoid obliteration and posterior canal wall reconstruction and 23 ears received CWD without mastoid obliteration. The dry ear rate at the most recent outpatient clinic visit (median 28.0 months postoperative) was significantly higher in the obliteration group with 96.4% compared to 73.9% for the non-obliteration group (p = .002). There were no differences in audiological outcome and incidence of complications between the two techniques.ConclusionWe show that in our study population revision CWD surgery with mastoid obliteration and posterior canal wall reconstruction is superior to revision CWD surgery without mastoid obliteration in the management of chronically discharging mastoid cavities. In the obliteration group, a dry ear was achieved in 96.4% as this was 73.9% in the non-obliteration group. We found no differences in audiological outcome and in incidence of complications between the two techniques.

Trends and Healthcare Use Following Different Cholesteatoma Surgery Types in a National Cohort, 2003-2019.

To describe national trends in cholesteatoma management. Retrospective analysis Optum Clinformatics® Database from 2003 to 2019. 16,179 unique adult and pediatric patients who received cholesteatoma surgery. Patients were categorized into three groups by initial surgical modality: canal wall down (CWD), canal wall up (CWU), and tympanoplasty without mastoidectomy (TnoM). Three major comparisons between groups were performed: 1) temporal trends, 2) clinical and sociodemographic determinants, and 3) healthcare use in terms of total costs and incidence of postoperative imaging and subsequent surgery. Overall, 23.2% received initial CWD surgery, 44.3% CWU, and 32.5% TnoM. 1) The incidence of initial CWD surgery decreased (odds ratios [OR] = 0.98, 95% confidence intervals [CI] [0.97,0.99]), while CWU increased (OR = 1.02, 95% CI [1.01,1.03]), and TnoM remained stable over the study period (OR = 0.99, 95% CI [0.98,1.00]). 2) Relative to CWU, TnoM surgery was less likely in adults, patients with prior complications, and non-White patients, while being more likely in patients with higher household income. CWD was more likely than CWU in adults, patients with prior complications, and non-White patients, while income had no effect. 3) Postoperative costs for CWU and CWD were similar. In 2 years following initial surgery, postoperative imaging and/or subsequent surgery was performed in 45.48% of CWD, 57.42% of CWU, and 41.62% of TnoM patients. Incidence of initial CWD surgery decreased and social disparities in cholesteatoma management were observed. Postoperative imaging or second-look surgery were performed in less than 60% of patients with initial CWU surgery and over 40% of patients with initial CWD.

Revision canal-wall down surgery: comparison of surgical outcomes with three different techniques.

This study aimed to analyze the role of the endoscope in revision canal-wall down (CWD) tympanomastoid surgery and compare its use to the more traditional microscopic approach. Moreover, we aim to investigate functional outcomes of revision surgeries in a cohort of two tertiary reference centers. A total of 103 patients undergoing revision surgery after previous CWD tympanomastoidectomy were included in the present study and divided in three groups according to the surgical technique used: endoscope exclusive (n = 22), combined (n = 35) and microscope exclusive (n = 46). Data regarding surgical indications, pre-operative clinical and audiological assessments, intraoperative findings and surgical considerations were extracted. During follow-up, data regarding anatomic and audiologic outcomes were collected and persistence or recurrence of the disease assessed. The most frequent sites of cholesteatoma recurrence or persistence was the anterior epitympanum. There was a statistically significant ABG improvement of -6.02dB HL (95% CI -8.87 to -3.16, p < 0.001) between pre-operative and postoperative ABG, without significant effect of surgical technique. During follow-up, no significant differences regarding disease or otorrhea control were observed. Duration of surgery and hospitalization was shorter in the endoscopic cohort without statistical significance. Intra- and postoperative complications were lower in the endoscopic group. Revision CWD surgery can take advantage of the endoscope as a minimally invasive exclusive or adjunct tool to traditional microscopic procedures. Outcome measures of endoscopic revision CWD surgery showed anatomic and functional results comparable to those of the microscopic group. The complication rate, the duration of surgery and hospitalization were favorable in the endoscopic group.

Comparison of mastoid obliteration with middle temporal artery flap versus open cavity: a comparative study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The objective was to study the outcomes of the canal wall down (CWD) mastoidectomy patients in those with soft canal wall reconstruction by using middle temporal artery (MTA) flap in comparison to those with cavity left open.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective study of 20 patients undergoing CWD surgery was done with 10 in each group of mastoid obliteration and open cavity. The outcomes were studied at 1, 3, 6 and 12 months post-surgery. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; At the final assessment of 12 months post op, the obliteration group had only 10% patients with grade 1 infection while open cavity group had 40% with grade 2 infection. Obliteration of mastoid cavity and reconstruction of canal wall with soft tissue MTA flap gave excellent control of infection.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The MTA flap is highly flexible and versatile for otologic reconstruction with an excellent arc of rotation and robust blood supply. It does not have the issues of resorption, dehiscence or fistula formation faced in other obliteration techniques.&lt;/p&gt;

Middle-ear cholesteatoma co-existing with labyrinthine fistula and vestibular schwannoma

BackgroundMany conditions, among them vestibular schwannoma and middle ear cholesteatoma with lateral semicircular canal destruction, may be associated with asymmetrical sensorineural hearing loss (SNHL) and vertigo. However, the probability that these two distinct disease entities causing the same symptoms occur in a single patient is very low, approximately 1 per 28 billion per 1 year.MethodsWe present the case of a 40-year-old male admitted to our clinic because of chronic middle ear inflammation with concomitant tinnitus vertigo, and deafness in the right ear. The patient was diagnosed with lateral semicircular canal fistula caused by middle-ear cholesteatoma and concomitant vestibular schwannoma. Canal wall-down surgery was carried out to remove the cholesteatoma, followed by gamma knife radiosurgery for the vestibular schwannoma.ResultsVertigo and tinnitus resolved within 3 days after the ear surgery, and gamma knife treatment resulted in the complete involution of the vestibular schwannoma. The patient presented with completely dry middle-ear cavity and no recurrence of the cholesteatoma was observed during a 3-year follow-up.ConclusionAs the hereby reported condition is very rare, the results cannot be compared with any similar report published previously. Nevertheless, based on the outcome, the treatment strategy seems to be both reasonable and effective.

Dried amniotic membrane grafting as an adjuvant to canal wall-down procedure in pediatric cholesteatoma

Purpose To evaluate the effect of dried amniotic membrane grafting on healing of radical cavity after canal wall-down procedure. Patients and methods A total of 24 cases were included. All had canal wall-down surgery done with the use of dried amniotic membrane at the end of procedure to line the radical cavity. According to the course of healing, cases were divided into four groups regarding wideness and dryness of cavity. Results were statistically analyzed. Results Among the 24 patients in the postoperative follow-up period of 6 months, only three (12.5%) patients needed revision meatoplasty for having narrow and wet cavities. Sixteen (66.7%) patients achieved the optimum goal of wide and dry cavity. Two (8.3%) patients had dry but narrow cavities. Three (12.5%) patients had wide but wet cavity, with recurrence of cholesteatoma. Conclusion Dried amniotic membrane graft can be used safely to line the radical cavity. Further comparative studies are needed to evaluate efficacy among other materials used to achieve safe and dry cavities.

Outcomes Following Modified Tympanomastoidectomy With Soft-wall Reconstruction.

To report outcomes following modified tympanomastoidectomy with soft-wall reconstruction (MTMSWR). Retrospective cohort. Tertiary referral center. Forty-seven patients (48 ears) with aggressive cholesteatoma undergoing MTMSWR. Canal wall down (CWD) tympanomastoidectomy with temporalis fascia reconstruction of the posterior external auditory canal (EAC). Cholesteatoma recidivism; hearing outcomes; degree of soft-wall retraction; time to epithelialization; otorrhea. All ears had some form of ossicular compromise. There were 41 ears with completed surveillance of which 39% demonstrated recidivism for cholesteatoma. Of these, 68.8% had a small cholesteatoma foci averaging 3.7 mm. Air pure-tone average remained stable or improved for 60.0% and declined ≤ 20 dB for 85.7%. Excluding ears unable to undergo ossicular chain reconstruction, final air-bone gap was ≤ 30 dB for 66.7%. Retraction of the reconstructed wall was absent-to-mild in 34.7% and moderate-to-full in 52.1%. Thirteen percent had soft-wall breakdown. Average time to full epithelialization of the wall was 58.5 days. MTMSWR is an option for restoring the posterior EAC wall following CWD surgery. Recidivism is comparable to canal wall up surgery, and hearing outcomes are generally better than CWD. Other advantages include rapid epithelialization, low rates of otorrhea, and restoration of a self-cleaning EAC regardless of retraction into the mastoid cavity.

Long-term Results of Troublesome CWD Cavity Reconstruction by Mastoid and Epitympanic Bony Obliteration (CWR-BOT) in Adults.

To present the long-term surgical outcome of the bony mastoid and epitympanic obliteration technique with canal wall reconstruction (CWR-BOT) in adults with an unstable cavity after previous canal wall-down surgery for extensive cholesteatoma. Retrospective study. Therapeutic. Tertiary referral center. Fifty consecutive adult patients undergoing a CWR-BOT between 1998 and 2009. (A) Recurrence and residual rates of cholesteatoma, (B) postoperative hygienic status of the ear, including postoperative aspect of the tympanic membrane and external ear canal integrity (EAC), (C) functional outcome, and (D) long-term safety issues. (A) The percentage of ears remaining safe without recurrent or residual disease after CWR-BOT was 96% after a mean follow-up time of 101.8 months. Recurrent cholesteatoma occurred in 2% (n = 1) and a residual cholesteatoma was detected in 2% (n = 1) of the patients. (B) A safe dry, and trouble-free graft and selfcleaning EAC was achieved in 94%. (C) The postoperative hearing results showed a gain of 1.7 dB on pure-tone average air-conduction. (D) Nonecho planar diffusion-weighted imaging (non-EP DW magnetic resonance imaging) documented the residual (n = 1) and recurrent cholesteatoma (n = 1). The 1- and 5-year imaging follow-up revealed no other recurrent or residual disease. The CWR-BOT is a safe and very effective option for treatment of problematic unstable canal wall-down mastoid cavities, resulting in dry trouble-free ears.

Impact of Staging the Procedure on Audiological Results in Canalwalldown Surgery for Cholesteatoma

Cholesteatoma is a progressive destructive ear disease. Can affect any age group. But more severe in children and young adults. It erodes the bone of middle ear, mastoid and ossicles. It causes partial to total deafness, unpleasant smelling discharge, pain, tinnitus, vertigo and facial paralysis. It can even cause meningitis, brain abscess and death. Canal wall down surgery is 95% effective in removing the disease and prevents recurrence of cholesteatoma. When the disease can be completely cleared to the satisfaction of the surgeon, reconstruction can be undertaken in the same sitting. When this cannot be done, reconstruction should be postponed to a later date. Staging of tympanoplasty gives a chance to relook and clear residual disease. There is lack of data on audiological outcome caused by such staging of reconstruction. So we would like to undertake the study to know the specific role of staging in improving audiological outcome.

Clinical Indications for Canal Wall‐down Mastoidectomy in a Pediatric Population

To establish clinically derived indications for performing canal wall-up or canal wall-down surgery when treating children with cholesteatoma. Case series with chart review. Tertiary care academic pediatric otolaryngology practice. Retrospective review of 420 children who underwent 700 procedures for cholesteatoma between 1996 and 2010. The canal wall was preserved in 89.5% of cases. Common reasons for removing the canal wall were to provide access to the disease, extensive erosion of key structures, and the desire to avoid further surgery. The mean pure-tone average (PTA) for the canal wall-up group was 30 dB, whereas the canal wall-down group had a mean PTA of 45 dB. A matched-pairs analysis demonstrated that the better performance of the canal wall-up group was independent of preoperative hearing levels. Furthermore, although the presence of the stapes did influence hearing results, the canal wall-up procedure yielded better results even when the condition of the stapes was taken into account. The number needed to treat with canal wall-up to prevent 1 case of hearing loss (ie, mean threshold >30 dB) would be around 6. The need for revision surgery was higher in the canal wall-up group (51%) compared with the canal wall-down group (21%). In the setting of adequate follow-up and open access to surgical resources, most children with cholesteatoma can be managed with an intact canal wall technique. The authors believe that the better audiometric outcomes and easier postoperative care outweigh the need for revision surgery in this group.

Type III Tympanoplasty With Titanium Total Ossicular Replacement Prosthesis

To evaluate anatomical and functional results using titanium prostheses in cartilage palisade tympanoplasties. Retrospective clinical study. Data were collected from patients' charts and clinical review. Tertiary referral center. Cartilage tympanoplasty with titanium total ossicular replacement prosthesis after tympanoplasty or tympanomastoidectomy in patients operated on between July 1998 and February 2006. Anatomical results (closure of the perforation, rate of retraction pockets, recurrent cholesteatoma, and extrusion and re-perforation rates) were clinically evaluated. Pure-tone averages of air and bone conduction were analyzed. A postoperative air-bone gap (ABG) of 20 dB or less was taken to represent successful hearing.The hearing outcomes of canal wall up (CWU), canal wall down (CWD), primary and revision surgeries, and 2 groups of a short-term (<12 mo) or long-term (>24 mo) follow-up (f-u) were assessed and compared. Ninety-four cases were observed during the visiting period: 43 (45.7%) underwent primary procedures and 51 (54.3%) underwent revision surgeries. Closure of the tympanic membrane was achieved in 98.9%.Postoperative ABG was 20 dB or lower in 62 (66%) of 93 cases, between 11 and 20 dB in 33 cases (35%), and 10 dB or lower in 29 cases (31%).All cases undergoing CWU had a mean +/- SD postoperative ABG of 14.59 +/- 11.28 dB. There were no statistically significant differences (independent-samples t test, p = 0.5) between these patients and those receiving CWD surgery (15.95 +/- 10 dB).Thirty-eight (68%) of 56 CWD and 24 (64%) of 37 CWU cases achieved a postoperative ABG between 0 and 20 dB (chi = 0.08, p = 0.7, correlation = 0.031).Thirty-three (64.7%) of 51 who underwent revision surgeries and 29 (69%) of 42 who underwent primary procedures had a postoperative ABG between 0 and 20 dB. The difference between the groups was not significant (chi = 0.3, correlation = 0.058, p = 0.5).The mean ABG in the short f-u group was 12.38 +/- 7.34. There was no significant difference regarding long-term f-u after 24 months (11.76 +/- 8.9; Wilcoxon signed-rank test, p = 0.7).We compared the mean postoperative ABG in low hearing frequencies (500 and 1,000 Hz) and high hearing frequencies (2,000 and 4,000 Hz). A better sound transmission was achieved in high frequencies (10.32 +/- 10.6 versus 20.61 +/- 13.73 dB, respectively); the difference was statistically significant (p < 0.001, paired-samples t test). Our results suggest that tympanoplasty with titanium total ossicular replacement prosthesis reconstruction offers a stable improvement of the ABG less than 20 dB in 66% of cases, in both short-term and long-term f-u. There were no differences in the results between CWU and CWD or between primary and revision surgery. The titanium prosthesis achieves the best acoustical results for sound transmission at high frequencies (2,000 and 4,000 Hz).

The functional and anatomical results of the canal wall down tympanoplasty in extensive cholesteatoma

Conclusion: Although we have shown that malleus handle and mucosal factors were important prognostic factors for hearing, we were unable to show the positive effect of the stapes superstructure on hearing results. The positive effect of the presence of the stapes superstructure on hearing results is closely related to the quality of the mucosa. Objective: The aim of this study was to investigate the impact of ossicular and mucosal factors on hearing in primary canal wall down (CWD) surgery with ossicular chain reconstruction (OCR) performed for extensive acquired cholesteatoma. Patients and methods: A total of 134 adults who had CWD surgery with OCR for extensive acquired cholesteatoma between January 1996 and May 2007 were retrospectively analyzed. Results: The graft insufficiency was 13%, chronic infection without cholesteatoma was 6% and cholesteatoma recurrence was 8% after the first operations. The rate of anatomic failure was 10% after a follow-up period of 46.3 months. In this study, we present the anatomic results for 136 ears and functional results for 135 ears. The hearing gain was significantly higher in the cholesteatoma-only group when compared with the mucosal–cholesteatoma disease group. Forty-three ears (54%) in the cholesteatoma-only group and 23 ears (42%) in the mucosal–cholesteatoma disease group had postoperative ABG within 20 dB. The best hearing results were obtained in Austin group B, while the worst hearing results were evident in Austin group C (p=0.017). Postoperative ABG was within 20 dB in 44% (n=31) of the patients with an intact stapes superstructure, while this ratio was 54% (n=35) when the stapes superstructure was absent.

A multivariate analysis of the factors predicting hearing outcome after surgery for cholesteatoma in children

To explore factors influencing hearing outcomes in children treated by canal wall up (CWU) and canal wall down (CWD) mastoid surgery. Retrospective cohort study including three units in Bristol and Bath, UK. Ninety consecutive children underwent cholesteatoma mastoid surgery, with the first procedure between 1998 and 2001; minimum follow up was three disease-free years. The CWU and CWD cohorts significantly differed in pre-operative stage and hearing. After disease eradication, air conduction (AC) thresholds changed by +4.0 dB (95 per cent confidence intervals (95% CI) -2.0, 10.1) in the CWD group and -5.3 dB (95% CI -9.3, 1.3) in the CWU group (p=0.029). Using multiple linear regression to account for cohort differences, AC thresholds were increased by: pre-operative AC threshold (p<0.0001), initial ossicular stage (p=0.013), and CWD-surgery (p=0.005). Disease-free hearing was better with CWU-surgery, less initial ossicular damage, and better pre-operative hearing. Worse initial disease increased the likelihood of CWD surgery. Wider use of ossiculoplasty in the CWU cohort (51 per cent vs 5 per cent) may partially explain the superior results.

Efficacy of tympanomastoid surgery for control of infection in active chronic otitis media.

The efficacy of surgery in controlling infection in 272 tympanomastoidectomy procedures for chronic otitis media (COM) was assessed by means of a four-point rating scale that incorporated both symptoms and signs, such as the presence or absence of otorrhea and granulation tissue. Of the 272 procedures, 170 were performed for COM with cholesteatoma and 102 were for active COM with granulation tissue but no cholesteatoma. Forty-seven percent were primary procedures, and 53% were revisions. Minimum follow-up was 12 months for all cases, with a mean of 30 months. Adequate control of infection occurred in 248 (91%) of the 272 cases. Of the 24 cases (9%) that developed persistent infection, 10 were controlled with a combination of oral and topical antibiotics and/or delayed skin grafting in the office. Thus overall satisfactory control of infection was achieved in 258 of 272 cases (95%). The outcome was influenced by the diagnostic category of COM: COM with cholesteatoma did significantly better than COM with granulation tissue (P = 0.02). The outcome was not influenced by the following variables: primary versus revision surgery, canal wall-up versus canal wall-down surgery, and extent of disease. The results suggest that active COM with granulation tissue may be more difficult to control than COM with cholesteatoma.