Objective: To determine the frequency of different contributing factors leading to discharging mastoidcavity in patients undergoing canal wall down mastoidectomy.Material and Methods: The study was Cross-sectional which was conducted in the Department of ENT, Unit-II, Services Hospital, Lahore. Retrospective study of 6 months from 01/01/2024 to 30/06/2024 respectively.This study involved 25 patients having discharging ear for more than 3 months, presenting within 1 year afterundergoing canal wall down surgery. A written informed consent was taken from each patient.Results: The age of the patients ranged from 12 years to 65 years with a mean of 31.45±11.83 years. Therewere 13 (57.9%) male and 12 (42.1%) female patients in the study group. The time since operation atpresentation ranged from 12 weeks to 48 weeks with a mean of 27.96±10.28 weeks. Among the contributingfactors highest frequency was noted for narrow meatoplasty (82.1%), followed by residual cholesteatoma(70.5%), high facial ridge (65.3%), persistent air cells (50.5%) and remaining malleus head (25.3%). Whencross tabulated, there was no statistically significant difference in the frequency of narrow meatoplasty(p=.627), high facial ridge (p=.939), persistent air cells (p=.869) and remaining malleus head (p=.850) acrossvarious age groups. However, the frequency of residual cholesteatoma was significantly higher in youngerpatients; 12-29 years vs. 30-47 years vs. 48-65 years (84.2% vs. 53.3% vs. 37.5%; p=.001). There was also nostatistically significant difference in the frequency of narrow meatoplasty (p=.242), residual cholesteatoma(p=.581), high facial ridge (p=.206), persistent air cells (p=.743) and remaining malleus head (p=.689) acrossvarious genders. Similarly, there was also no statistically significant difference in the frequency of narrowmeatoplasty (p=.616), residual cholesteatoma (p=.381), high facial ridge (p=.671), persistent air cells (p=.468)and remaining malleus head (p=.391) across various groups according to time since operation at presentation.Conclusion: Among the contributing factors highest frequency was noted for narrow meatoplasty (82.1%),followed by residual cholesteatoma (70.5%), high facial ridge (65.3%), persistent air cells (50.5%) andremaining malleus head (25.3%). The frequency of residual cholesteatoma was significantly (p=.001) higherin younger patients.Keywords: Chronic Suppurative Otitis Media, Canal Wall Down Procedures, Discharging mastoid cavity,Contributing FactorHow to cite: Syed SH, Awan AA, Nadeem S, Rafiq F, Iftikhar M, Ahmad J. Assessment of Different ContributingFactors Leading to Discharging Mastoid Cavity after Canal Wall Down Procedures. Esculapio - JSIMS 2025;22(01):DOI: 10.51273/esculap.v22i01.1420

Background: Mastoid obliteration following canal wall down mastoidectomy reduces cavity-related morbidity. Conventional obliteration materials act primarily as passive fillers, whereas tissue engineering (TE) strategies aim to achieve biologically active bone regeneration. Methods: This systematic review was conducted in accordance with PRISMA 2020 guidelines. PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library were searched from January 2010 to December 2025. Studies evaluating tissue engineering-assisted mastoid obliteration involving growth factors, mesenchymal stem cells, polymer scaffolds, or 3D-printed constructs were included. Results: Fifteen studies met inclusion criteria (12 preclinical and three clinical). Polymer-supported MSC constructs demonstrated the most consistent osteogenic enhancement in animal models. Clinical evidence remains limited to small PRP-based case series. Conclusions: Preliminary evidence suggests that tissue engineering-assisted mastoid obliteration has regenerative potential, although the evidence is limited by predominantly preclinical data and a moderate-to-high risk of bias. Standardized outcome measures and well-designed prospective clinical studies are required to confirm long-term safety and efficacy.

To report medical outcomes and time-related recidivism after extensive cholesteatoma treated with canal wall-down (CWD) mastoidectomy, external ear canal (EEC) reconstruction, tympanoplasty, and S53P4 bioactive-glass mastoid obliteration. Retrospective study of 127 ears with extensive cholesteatoma treated at a tertiary center. Patients were scheduled for annual otoscopic and non-echo-planar DW MRI follow-up for up to 4 years. For each postoperative year, only ears attending that visit and all previous yearly visits were analyzed. Main outcomes were: completely epithelialized, dry ear; tympanic membrane and/or posterior–superior EEC retraction; retraction pocket (RP) cholesteatoma; and residual cholesteatoma on MRI. Follow-up attendance declined from 100% (127/127) in year 1 to 67.2% (41/61) in year 4. A dry, epithelialized ear was achieved in 96.9% (123/127). Retraction developed in 33.9% (43/127), with probabilities of 13.4%, 26.4%, 28.9%, and 34.1% at 1, 2, 3, and 4 years, respectively. RP cholesteatoma occurred in 11.8% (15/127) and residual cholesteatoma on MRI in 7.0% (9/127); 23% of retracted ears progressed to RP cholesteatoma. Children ≤ 11 years had higher rates of retraction and RP cholesteatoma. Despite counseling on the importance of follow-up, attendance declined over time. CWD mastoidectomy with EEC reconstruction, tympanoplasty, and S53P4 obliteration yielded high long-term dry ear rates in extensive and recurrent cholesteatoma, but complete eradication was not achieved. Younger and re-operated patients were at higher risk of retraction and RP cholesteatoma. Recidivism appeared years after the first surgery, supporting prolonged follow-up. Reporting annual outcome incidence in future studies would enhance understanding of extensive cholesteatoma.

In our previous report, we described a surgical technique for cochlear implantation in canal wall down (CWD) ears. Specifically, this involved extending the endaural incision superiorly, harvesting a large temporal fascia flap, completely removing the tympanic epithelium, inserting the electrode array, obliterating the middle ear cavity with the temporal fascia flap, and sealing the external auditory canal with a tragal cartilage plug. This report details the safe application of this technique in a patient with severe ear malformation and suspected CHARGE syndrome, supplemented with a brief literature review. The patient was a 28-year-old woman with malformations of the auricle, middle ear, and inner ear, as well as patent ductus arteriosus, amblyopia, and mild intellectual disability.Temporal bone CT revealed significant inferior displacement of the emissary vein, precluding standard electrode insertion via the posterior tympanotomy approach to the round window. We therefore applied our previously reported technique to this malformed ear without prior surgical history. Sequential bilateral implantation was performed. Surgical duration was 96 minutes (right) and 167 minutes (left). Wide bony exposure via CWD facilitated uneventful electrode insertion bilaterally, with minimal bleeding. Postoperative sound-field aided thresholds were favorable at 35dB (right) and 38.3dB (left). Speech discrimination scores were 90% at 60dB (right) and 0% (left). The cochlear implantation technique for CWD ears was safely adapted to this patient with congenital malformation. This approach represents a viable surgical option for cases with severe malformations such as CHARGE syndrome.

Abstract Background The surgical management of cholesteatoma presents a classic dilemma between canal wall down (CWD) mastoidectomy, which offers low recurrence at the cost of anatomical and functional integrity, and canal wall up (CWU) mastoidectomy, which preserves hearing but has a historically higher recurrence rate. The introduction of the endoscope may mitigate the risks of CWU surgery by improving visualization of hidden recesses. This investigation aims to compare the recurrence rates and hearing outcomes of endoscopic-assisted canal wall up (EACWU) versus CWD tympanomastoidectomy. Methods This prospective, randomized clinical trial included 50 adult cases with cholesteatoma. Cases were randomly allocated to 2 groups: Group A (25 cases) underwent EACWU tympanomastoidectomy, and Group B (25 cases) underwent CWD tympanomastoidectomy. Preoperative assessment for all cases included otoscopic/endoscopic examination, CT of the petrous region, and pure-tone audiometry (PTA). The primary outcomes were disease recurrence, assessed via clinical and endoscopic follow-up, and hearing outcome, measured by changes in the air-bone gap (ABG) and air conduction (AC) thresholds at the 8th week postoperatively. Results Recurrence occurred in 8% of cases in the EACWU group compared with 4% in the CWD group, a difference that was not statistically significant ( p = 0.55). The EACWU group demonstrated a substantial postoperative hearing improvement, with the mean ABG decreasing from 34.80 dB to 18.08 dB (a mean closure of 16.72 dB, p < 0.0001). Conversely, the CWD group experienced a significant hearing decline, with the mean ABG increasing from 32.40 dB to 42.00 dB ( p < 0.0001). Postoperative ABG and AC thresholds were markedly better in the EACWU group relative to the CWD group ( p < 0.0001 for both). Conclusion Endoscopic-assisted CWU tympanomastoidectomy offers a superior hearing outcome compared to CWD mastoidectomy, with a comparably low rate of disease recurrence. This evidence supports the use of EACWU as a primary surgical option for suitable cases with cholesteatoma to achieve both disease eradication and functional preservation.

To determine whether transcanal surgery without mastoidectomy, canal wall up (CWU), canal wall down (CWD), or CWU mastoid obliteration (MO) surgery for pediatric cholesteatoma has a more favorable effect on middle ear pressure (MEP) homeostasis. Data from children having mastoid surgery for acquired cholesteatoma were collected prospectively. Tympanometric values of MEP were compared after transcanal, CWU, CWD, and MO surgery analyzing (i) a single measure per ear from last clinic visit, and (ii) linear mixed-effects modeling (LMEM) to control for multiple measures, surgeries, age, and cholesteatoma severity (EAONO-JOS stage). 742 surgeries on 471 ears and 2382 tympanograms were completed. At last visit, (average age 15.6 years [6.0-19.3]), Type a tympanograms were present in 80/173 (46%) of transcanal surgeries, 64/132 (48%) CWU, 15/32 (47%) CWD, and 11/25 (44%) MO (Chi-square, p = 0.19), but 185/209 (89%) contralateral ears without cholesteatoma (Chi-square: p = 1.08 × 10-7). Median MEP was -47 daPa (IQR: 133) after transcanal, -65 daPa (IQR: 156) after CWU, -90 daPa (IQR: 151) after CWD, and -31 daPa (IQR: 151) after MO surgery and (Kruskal-Wallis: p = 0.4) but 5 daPa (IQR: 45) in normal contralateral ears (Wilcoxon: p = 7.92 × 10-13). LMEM showed MEP was dependent on age (p = 6.3 × 10-7) but not type of mastoid surgery (p = 0.70) or EAONO-JOS stage (p = 0.51). MEP after surgery for pediatric cholesteatoma is similar after transcanal, CWU, CWD, or MO surgery and remains lower than normal. Hypotheses that propose beneficial effects of these different surgical approaches on MEP homeostasis are not supported, so should not be used to influence choice of surgical approach.

IntroductionCholesteatoma is an abnormal skin growth within the middle ear that can destroy the ossicular chain and cause hearing loss. This study aimed to evaluate the cost effectiveness of canal-wall-down (CWD) mastoidectomy for cholesteatoma removal with or without hearing reconstruction using an active transcutaneous bone conduction implant (BCI) in patients with advanced cholesteatoma to support the design of a future clinical study.MethodsA Markov model was developed to evaluate the cost effectiveness of the following strategies: CWD without hearing reconstruction (CWD only); CWD with simultaneous BCI implantation (CWD+BCI0); CWD with implantation of BCI after one year (CWD+BCI1), two years (CWD+BCI2), three years (CWD+BCI3), or five years (CWD+BCI5). The outcomes evaluated over a lifetime were quality-adjusted life years (QALYs), costs (from the perspective of the National Health Fund, Poland), and net monetary benefit (NMB), assuming a willingness-to-pay threshold of one gross domestic product (GDP) per capita in Poland (PLN92,955 [USD53,422]). One-way deterministic sensitivity analyses (DSA) were performed to evaluate the robustness of the results. Cost and NMB results were presented in 2024 PLN and USD (conversion using purchasing power parities for GDP).ResultsThe simulation indicated that CWD+BCI0 was expected to be the most effective strategy, yielding 18.35 QALYs, followed by CWD+BCI1, CWD+BCI2, CWD+BCI3, CWD+BCI5, and CWD only. The lifetime costs of performing CWD+BCI0 were expected to be lower than the costs of CWD+BCI1, CWD+BCI2, and CWD+BCI3. Moving from CWD only to CWD+BCI0 would incur an additional cost of PLN67,754 (USD38,939) over a lifetime to gain 3.13 QALYs. CWD+BCI0 resulted in the higher NMB (PLN1,595,530 [USD916,971]), followed by CWD+BCI1 (PLN1,578,976 [USD907,457]), CWD+BCI2 (PLN1,569,383 [USD901,944]), CWD+BCI3 (PLN1,560,090 [USD896,603]), CWD+BCI5 (PLN1,542,377 [USD886,424]), and CWD only (PLN1,372,572 [USD788,834]), respectively. DSA showed that the results were robust.ConclusionsCWD with simultaneous hearing reconstruction using a BCI (CWD+BCI0) is expected to be the most cost effective strategy for patients with cholesteatoma in the Polish context. This result will support the design of a clinical study evaluating the surgical and audiological outcomes of the simultaneous approach.

Background and Objectives: To evaluate the surgical management and outcomes of lateral semicircular canal fistulas (LSCFs) in patients with middle ear cholesteatoma, focusing on hearing preservation and vestibular function. Materials and Methods: A retrospective study was conducted on nine adult patients diagnosed with LSCFs secondary to cholesteatoma who underwent surgery at a tertiary referral center between 2018 and 2024. The preoperative evaluation included otoscopy, audiometry, vestibular testing (HINTS), and high-resolution CT (HRCT) of the temporal bone. Surgical techniques included canal wall up (CWU) or canal wall down (CWD) mastoidectomy, depending on the disease extent. Cholesteatoma matrix removal from the fistula was performed carefully. Fistula closure involved layered grafts of temporalis fascia, temporalis muscle, and/or gelfoam. The postoperative follow-up included audiometry and vestibular assessments. Results: Nine patients with LSCFs were identified (one Type III, three Type IIb, and four Type I/IIa). Five patients were found to have additional disease complications intraoperatively, including facial nerve involvement and middle fossa dehiscence. Postoperatively, hearing outcomes varied, with some patients experiencing improvement, others demonstrating stable hearing, and some exhibiting further decline, particularly in cases with extensive disease. Vestibular symptoms, including vertigo, generally resolved postoperatively, although some patients required prolonged vestibular rehabilitation. Conclusions: LSCF management in cholesteatoma surgery requires a careful preoperative assessment, meticulous surgical technique, and individualized fistula closure based on the size and type. While hearing preservation remains a challenge, particularly in extensive cases, the “underwater technique” and layered grafting may contribute to minimizing further damage and promoting fistula closure. Vestibular rehabilitation plays a crucial role in managing postoperative balance issues. A long-term follow-up is essential to monitor for recurrence and assess both auditory and vestibular function.

According to the joint consensus of the European Academy of Otology and Neurotology and the Japan Otological Society on middle ear cholesteatoma, stage II encompasses a broad range of disease extensions, leading to variability in treatment outcomes among individuals with this disease stage. Herein, we aimed to investigate the risk factors for recidivism in stage II pars flaccida (PF) cholesteatoma. Retrospective cohort study. University hospital. In total, 228 consecutive ears with stage II PF cholesteatoma were treated surgically and followed up for >12 months. Patients underwent transcanal atticotomy, canal wall up tympanoplasty, or canal wall down (CWD) tympanoplasty with or without mastoid obliteration (MO). Recidivism rates, assessed using the Kaplan-Meier method, correlated with potential risk factors, including age, number of sites involved, difficult access sites (S1: supratubal recess, S2: tympanic sinus), and surgical procedures. The recidivism rate was significantly higher in pediatric patients (42.8%) than in adults (6.1%). Furthermore, recidivism rates were greater in patients with 3 or more involved sites (16.5%), S1 involvement (27.9%), and procedures other than CWD+MO (24.5%) than those with 2 involved sites (3.0%), no S1 involvement (5.1%), and underwent CWD+MO (5.4%), respectively. Multivariate analysis identified the involvement of 3 or more sites (hazard ratio: 5.12) and procedures other than CWD+MO (hazard ratio: 6.49) as independent risk factors for recidivism. In stage II PF cholesteatoma, involvement of 3 or more sites was identified as a risk factor for recidivism. CWD+MO intervention may reduce the recidivism rate.

Objective: To describe a practical surgical approach for mastoid cavity obliteration and canal wall reconstruction using autologous bone dust and conchal cartilage applied either during primary canal wall up (CWU) surgery or in revision of prior canal wall down (CWD) mastoid cavities, with the aim of restoring a self-cleaning, waterproof ear that retained its natural acoustic resonance. Methods: The indications, surgical technique, and follow up and imaging surveillance were described, detailing patient selection, harvesting and application of autologous materials, and the key technical steps for cavity obliteration and posterior canal wall reconstruction. The importance of preserving the ear canal’s standing wave resonance (~2000–2500 Hz) for optimal hearing was emphasized. Postoperative monitoring with non-echo planar diffusion-weighted imaging (DWI) MRI was recommended at least 1.5 years after surgery to detect residual or recurrent cholesteatoma. Results: This technique was performed successfully in 88 patients (32 males and 56 females, aged 6–80 years) across four hospitals in Metro Manila from January 2020 to July 2025. All patients had unremarkable postoperative courses and healed within three months. Among the 67 who underwent DWI MRI after 18 months, two required revision mastoidectomies with mastoid obliteration for cholesteatoma recidivism—one with residual and one with recurrent disease. Conclusion: Mastoid obliteration and reconstruction using autologous bone dust and cartilage has proven to be a safe, effective and cost-efficient technique. It converts problematic open cavities into dry, self-cleaning ears suitable for swimming while preserving the acoustic benefits of a near-normal ear canal. Long-term follow-up with diffusion-weighted imaging (DWI) MRI is essential to ensure durable disease control.

Background: Chronic otitis media with cholesteatoma often requires surgical intervention to eradicate disease and restore hearing. Canal wall up (CWU) and canal wall down (CWD) mastoidectomies are commonly performed techniques, each with distinct advantages and limitations regarding disease eradication, hearing preservation, and recurrence rates. Objectives: To compare postoperative hearing outcomes in patients undergoing CWU versus CWD mastoidectomy in our tertiary care center. Methods: This prospective, comparative study was conducted from June 2024 to May 2025 and included a total of 50 patients diagnosed with chronic otitis media, with or without cholesteatoma, who were scheduled for mastoidectomy. The patients were divided into two equal groups according to the type of surgical procedure performed: 25 patients underwent canal wall up (CWU) mastoidectomy, while the remaining 25 patients underwent canal wall down (CWD) mastoidectomy. Results: A total of 50 patients were included, with 25 undergoing canal walls up (CWU) and 25 canal wall down (CWD) mastoidectomy. Both groups were comparable in age, gender, and laterality. Preoperative hearing thresholds were similar (mean PTA: CWU 49.5 ± 10.5 dB, CWD 52 ± 10.5 dB; P = 0.38). Postoperatively, significant improvement was observed in both groups, with mean PTA of 29.5 ± 10.5 dB (CWU) and 33.25 ± 11.75 dB (CWD), and mean hearing gains of 20 ± 8.5 dB and 18.25 ± 10 dB, respectively, with no significant intergroup difference. Frequency-wise improvement was greatest at lower frequencies (500–2000 Hz). ABG closure of <10 dB was achieved in 40% of CWU and 28% of CWD patients (P = 0.35), with most patients achieving 11–20 dB closure. Postoperative complications were low and comparable, including infection, residual disease, dizziness/vertigo, and granulation tissue formation. Age showed a weak, non-significant negative correlation with hearing gain in both groups. Overall, both CWU and CWD techniques provided similar postoperative hearing outcomes with low complication rates. Conclusion: In conclusion, both canal wall up (CWU) and canal wall down (CWD) mastoidectomy provide significant and comparable hearing improvement in chronic otitis media. CWU showed slightly better gains and more patients with ABG <10 dB, but differences were not statistically significant. Complication rates were low and similar, and age did not affect outcomes. The choice of technique should depend on disease extent, intraoperative findings, and surgical judgment.

Background/Objectives: Mastoid obliteration (MO) after canal wall down (CWD) tympanoplasty for chronic otitis media with cholesteatoma (COMC) enables simultaneous surgical management of the pathology and shaping of a new external ear canal (EEC) that is similar to the natural one. The aim of the present work is to describe the results of a new MO technique that involves using homologous bone (HB) material and a Palva flap (“Cupeta technique”). Methods: A retrospective study was conducted on 12 patients undergoing MO for COMC, either during the same operation or in a second-time surgery after CWD. The surgical technique, patient demographics, audiometric data, the EEC volume, and clinical outcomes were analyzed. Results: The MO technique resulted in good outcomes in terms of healing at three months after surgery. Fewer clinical complications were observed compared with similar MO methods described in the literature. HB reabsorption was observed in two patients and was defined as only partial. Measurements of the EEC volume were normal in all patients. The preoperative and postoperative hearing thresholds were similar. Conclusions: Performing MO with the Cupeta technique after CWD is a suitable surgical management method for COMC and demonstrates good clinical postoperative results. We plan to conduct further studies with a longer follow-up and a larger group of patients in order to confirm our findings.

Objective: The objective of the study was to compare pre- and postoperative hearing results after cartilage augmentation over the stapes head in canal wall down mastoidectomy, and also to observe if there are any other considerations. Materials and Methods: Patients more than 10 years of age with squamous chronic otitis media with conductive or mixed hearing loss, with mobile stapes footplate and intact stapes suprastructure, operated for canal wall down mastoidectomy were included in our study. Patients with sensorineural hearing loss and revision surgeries were excluded from our study. Postoperative hearing was assessed in terms of air-bone gap closure on pure tone audiometry for both the groups, with and without cartilage augmentation, at the 6-month postoperative period. Otoendoscopy findings in terms of graft uptake and condition of the mastoidectomy cavity were also noted for both the groups. Results: Mean hearing gain in group with cartilage augmentation was 12.58 dB while in the group without augmentation, the gain was found to be 7.08 dB. The difference was found to be statistically significant on application of Student’s t-test. No significant difference was found in terms of healing and the condition of the mastoidectomy cavity in both the groups. Conclusion: Tragal cartilage is an easily available and economical graft material for augmentation in Type III tympanoplasty with canal wall down mastoidectomy. It also offers a significant advantage in hearing by increasing the effective vibrating area of the tympanic membrane graft.

Objectives: This study aimed to evaluate the clinical and hearing outcomes of patients with cholesteatomatous chronic otitis media using the ChOLE classification system and to assess its utility in predicting recurrence, guiding surgical approach, and anticipating hearing recovery. Materials and Methods: This retrospective study included 130 patients (141 ears) who underwent surgery for cholesteatoma between 2011 and 2020. Data were collected from surgical notes, imaging studies, and audiological evaluations. Patients were classified according to the ChOLE criteria, which incorporate cholesteatoma extension (Ch), ossicular chain status (O), and life-threatening complications (L). Surgical procedures and functional outcomes were compared across different stages and classification groups. Hearing outcomes were assessed in the early (3rd month) and late (2nd year) postoperative period. Results: Among the 130 patients (141 ears) evaluated, Stage II was the most common ChOLE stage (74.4%), followed by Stage I (17.7%) and Stage III (7.8%). The most frequently observed cholesteatoma extent was Ch3. A statistically significant association was found between surgical technique and ChOLE stage (p = 0.001): canal wall-down (CWD) tympanomastoidectomy was performed in 91% of Stage III cases and 84% of Stage II cases, whereas 76% of Stage I cases underwent canal wall-up (CWU) procedures. The overall recurrence rate was 29.5% in the CWU group and 16.4% in the CWD group, although this difference did not reach statistical significance (p = 0.792). However, ossicular chain status (O) showed a strong association with both early and late hearing outcomes. At 2 years, conductive hearing success was achieved in 90.9% of O0 patients, compared to 14% of O3b and 0% of O4 patients (p = 0.001). With regard to cholesteatoma extent (Ch), a statistically significant correlation was observed with early air–bone gap (ABG) closure success (p = 0.008) and late air conduction thresholds (p = 0.015). Similarly, ChOLE stage was significantly associated with early conductive hearing success (p = 0.012) and late ABG closure (p = 0.015). Overall, long-term hearing outcomes were superior to early results. Hearing success increased from 19.1% to 24.8% for air conduction thresholds and from 23% to 31.2% for hearing gain when comparing early and late follow-up periods. Conclusions: The ChOLE classification proved useful in guiding surgical strategy and predicting functional outcomes in cholesteatoma surgery. Advanced stage and greater cholesteatoma extension were associated with more extensive surgical procedures and poorer hearing results. Long-term audiological follow-up provided more accurate insights into surgical success. The standardized ChOLE system facilitates consistent reporting and meaningful comparison across institutions and studies.

Chronic otitis media with cholesteatoma (COMC) is a serious, potentially life-threatening middle ear condition characterized by keratinizing squamous epithelium growth, chronic inflammation, and progressive bone erosion. Surgical intervention remains the mainstay of treatment, with canal wall up (CWU) and canal wall down (CWD) mastoidectomies being the primary approaches. Objectives: To evaluate the prevalence, clinical presentation, and surgical outcomes of COMC, comparing the efficacy and complications of CWU and CWD mastoidectomy. Methods: A prospective study was conducted across multiple healthcare centers in Karachi. The study included 136 COMC patients, divided by surgical technique (CWU vs. CWD). Demographics, symptoms, audiometry, recurrence, and complications were assessed over six months. Data were analyzed using SPSS. Results: The mean age of patients was 32.6 ± 12.5 years, with a slight male predominance (60%). Otorrhea (80%) and hearing loss (73%) were the most common presenting symptoms. Recurrence was significantly higher in the CWU group (71.4%) compared to none in the CWD group (p=0.003). However, CWU surgery yielded better hearing outcomes postoperatively (mean gain: 15 dB) compared to CWD (mean gain: 8.9 dB), with a significant difference in final hearing thresholds (p=0.04). Complications were more frequent in the CWD group but were not statistically significant (p=0.19). Conclusions: It was concluded that canal wall down (CWD) offers better disease control with low recurrence, while canal wall up (CWU) preserves hearing. Surgical choice should balance disease clearance and function, with regular follow-up.

To evaluate the hearing outcomes and complications of primary malleus head interposition ossiculoplasty during canal wall down (CWD) tympano-mastoidectomy surgery in patients with cholesteatoma. Most ossiculoplasty techniques depend on interposition or reposition ossiculoplasty. Therefore, in cases where the Incus is eroded, the malleus becomes the only remaining ossicle and can be used for interposition ossiculoplasty. This prospective study included 27 patients with cholesteatoma. All patients received primary malleus head interposition ossiculoplasty during CWD tympano-mastoidectomy. Follow-up of patients carried out in an outpatient clinic through routine follow-up visits at 1, 3, and 6 months using a pure tone audiometer. Postoperative air bone gab (ABG) closure had values of 11.03, 9.63, 8.96, and 10.7 dB at 500, 1000, 2000, and 4000 Hz, respectively. The mean postoperative ABG decreased from 33.81 ± 5.69 to 24.85 ± 3.08 dB with an improvement of 9 dB that was statistically significant (P < .001). The malleus head interposition technique is simple and effective for ossiculoplasty in CWD tympano-mastoidectomy. This technique was considered effective in enhancing the stability of the graft and the efficacy of the overall ossiculoplasty procedure. It is characterized by availability, low cost, and low complication rate.

Sociodemographic Factors Influencing Operative Time and Extent of Surgery in the Management of Cholesteatoma.

This retrospective study aimed at comparing the extent of epithelialization in mastoid obliteration after Canal Wall Down (CWD) mastoidectomy using Hydroxyapatite (HA) alone or using HA in combination with Concentrated Growth Factor (CGF) extracted from autologous blood. A total of 56 patients undergoing the CWD mastoidectomy were enrolled. One group was treated by HA, while the other group received HA and CGF for mastoid obliteration (CGF/HA). A review of the medical follow-up records of all patients was conducted, with a primary focus on the otoendoscopic imaging materials. Complete epithelialization was determined by the absence of granulation, discharge, and swelling. The requisite period for complete epithelialization of the mastoid cavity was thus calculated, scored, and analyzed between treatments. Ear discharge, graft swelling, and poor blood supply were more frequently observed in the HA group. The proportion of patients group that achieved complete epithelialization within 60 days post operation was significantly higher in the CGF/HA group than the HA group. According to the scoring system for complete epithelialization, the median score of the CGF/HA group was 2, significantly higher than that of the HA treatment group (median score = 1, p = 0.032). Altogether, our results indicated that duration needed for complete epithelialization in the CGF/HA group was shorter than the control group. The application of CGF to surgical cavity obliteration following a CWD mastoidectomy significantly promotes epithelialization, thereby achieving satisfactory results. Randomized controlled trials with a larger number of patients enrolled were worth launching in the future to better substantiate the value of CGF in obliteration of mastoid cavity. Level 2-Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence.

Objective The objective of this study was to evaluate the effect of postoperative medicated mastoid cavity packing on healing outcomes following canal wall down (CWD) mastoidectomy compared to no packing. Methods This prospective observational study included 125 patients undergoing CWD mastoidectomy, matched for age and sex, and assigned to two groups. Group A (n=62) received medicated mastoid cavity packing containing ofloxacin, ornidazole, clobetasone propionate, and itraconazole on postoperative days 0, 10, and 20. Group B (n=63) received no postoperative packing. Healing outcomes were evaluated and compared between the groups on postoperative days 45, 75, and 105. A p-value of <0.05 was considered statistically significant. Results The groups were comparable in age and sex distribution. The packed group demonstrated significantly higher rates of complete epithelialization on day 45 (48.4% vs. 15.9%, p < 0.0001) and day 75 (72.6% vs. 49.2%, p = 0.007), with no difference observed by day 105. Graft uptake duration was similar between groups (76.94 days in Group A and 76.19 days in Group B). Granulation tissue, mucosal folds, and otorrhea were more frequent in the non-packed group (25.4%, 6.3%, and 4.8% vs 12.9%, 3.2%, and 3.2%, respectively) during early follow-up, though not statistically significant. Mean epithelialization time was significantly shorter in the packed group (84.0 vs. 92.8 days, p = 0.001). Conclusion Medicated mastoid cavity packing promotes earlier epithelialization following CWD mastoidectomy and is associated with a lower incidence of granulation tissue without affecting graft uptake. It offers particular benefits in low-resource settings by enhancing healing and reducing follow-up needs. Larger studies are warranted to establish standardized postoperative care protocols.

Introduction Chronic active otitis media - squamous variety is a disease characterized by chronic inflammation of middle ear. Advantage of Canal Wall down Mastoidectomy are complete removal of the disease, easy visualization of the entire middle ear cleft. This study will focus on this advancement of gain in audiological function following canal wall down mastoidectomy with appropriate tympanoplasty and ossicular reconstruction. Materials and Methods It is an Institutional based descriptive study undertaken in a tertiary care hospital among patients with squamous variety of Otitis Media belonging to the age group 12- 65years, planned to undergo single stage reconstruction after Canal Wall Down Mastoidectomy. The results were analysed by SPSS (version 27.0) . Results The age distribution of patients of 17-29 years was 14 (35%), 30-42 years 21 (52.5%) and 43-59 years 5 (12.5%). The sex distribution were 18 (45%) Female and 22 (55%) male. In the pre-operative Air Bone Gap, number of ears in ≤25 dB, 26-40 dB and 41-60 dB were 5, 33, 2 respectively whereas in post-operative it was 25, 15, 0 respectively. There was a gain of 6.899 dB between pre-operative &amp; post-operative mean air bone gap. Conclusion Canal wall down mastoidectomy is a safe and effective surgical procedure commonly performed for Chronic Otitis Media squamosal type and currently is a preferred procedure. There was a gain in post-operative air bone gap.