Canal Wall-up Tympanoplasty Research Articles

Konjenital Kolesteatomun Otoendoskopik Cerrahi ile Tedavisi

The author aims to describe the features of congenital cholesteatoma in adults and the value of the exclusive otoendoscopy in the surgical management. The congenital cholesteatoma is well known in children. This disease is uncommon in adults and is described here through a case-report in a 25-year-old patient. The forms localized to the upper posterior part of the tympanic cavity are the least common and can take the features of an acquired cholesteatoma. The surgical treatment is usually performed with otomicroscopy, with a canal wall-up tympanoplasty. In this case, the management was performed with a transmeatal approach with the exclusive otoendoscopic surgery. This procedure allows an access to anatomical areas hidden for the microscope. It belongs to a new surgical era in otology and is one of the minimal invasive surgical procedures of the future.

S204 – Postoperative Residual Cholesteatoma: Value of MR Imaging

Objectives This study was carried out to evaluate the utility of diffusion-weighted imaging (DWI) and contrast-enhanced MR imaging (CE-MRI) for the detection of postoperative residual cholesteatoma in cases where computed tomographic (CT) findings were not conclusive. Methods 14 ears from 13 patients, who had undergone canal wall-up tympanoplasty for cholesteatoma and nonspecific opacity images on postoperative follow-up CT, underwent MR imaging before revision surgery. T1WI, T2WI DWI (using b-factors of 0 and 800 sec/mm2) and CE-MRI were performed using a 1.5-T MR unit. MR imaging examination was generally completed within 30 min. In all cases, imaging findings were compared with second- or third-look operative findings. Results MR imaging depicted 9 out of 10 residual cholesteatomas (sensitivity, 90.0%). In a remaining (false-negative) case, a 3-mm cholesteatoma pearl that was encircled by granulation tissue was not depicted. There were no false-positive cases (specificity, 100%). The positive predictive value and negative predicitive value were 100% and 75%, respectively. DWI showed cholesteatoma high signal intensity in peculiarity. However, the spatial resolution was low and artifacts appeared at the base of skull in DWI. In the case with a small cholesteatoma in the dura mater, CE-MRI was effective. The minimum size of the cholesteatomas detected by the MR imaging including DWI was 4 mm. Conclusions When postoperative CT is not conclusive, DWI combined with CE-MRI is a valuable technique for the detection of residual cholesteatoma.

A New Role of Staged Tympanoplasty for Cholesteatoma

Objective 1) Investigate a correlation between pathological findings at the 2nd stage operation and long-term outcomes in a staged canal wall-up tympanoplasty (SCUT) for middle ear cholesteatoma. 2) Advocate a new role of the staged manner based on the study. Methods SCUT was performed on 90 ears with cholesteatoma involving both the ossicles and the mastoid cavity. The 1st stage operation included scutum plasty and mastoid cortex plasty with bone pate following removal of cholesteatoma and ossicles involved. The 2nd stage operation records were reviewed regarding the pathological findings associated with retraction pocket (RP) and residual cholesteatoma (RC) formation. The scutum defect was revised with auricular cartilage, and the mastoid cortex plasty was again performed after removal of RC. Postoperative follow-up with endoscopic observation and CT was performed for all patients. Results At the 2nd stage, RP was seen in 15 ears (16.7%) which all showed partial or total absorption of the scutum reconstructed. Aeration grade of the mastoid cavity reconstructed did not correlate with RP or RC formation. RC was found in 28 ears (31.1%) regardless of RP formation. The long-term follow up study revealed that the statistically higher incidence of RP re-formation (26.7%) and RC (3.2%) was seen in ears which had been identified at the 2nd stage, respectively. Conclusions The present study showed that the long-term outcomes after SCUT were correlated with RP and RC formation at the 2nd stage. This indicates the 2nd stage operation has a role of the long-term prognosis in addition to exploration of RC.

The Value of Magnetic Resonance Imaging in the Diagnosis of Residual or Recurrent Acquired Cholesteatoma After Canal Wall-Up Tympanoplasty

The value of magnetic resonance imaging (MRI) in the diagnosis of recurrent or residual cholesteatoma after canal wall-up tympanoplasty is studied in a retrospective cohort study at a tertiary referral center. A total of 31 patients, who underwent 32 canal wall-up tympanoplasty procedures with MRI before revision surgery, were included in the study. MRI examination, using both the conventional and echo-planar diffusion-weighted sequences, was performed, with additional spin echo diffusion-weighted MRI sequences in 4 patients. All patients were treated with a canal wall-up tympanoplasty. The presence of residual or recurrent cholesteatoma at revision surgery is matched with preoperative findings on MRI. MRI could correctly detect the residual disease in 54.5% of the surgically matched residual or recurrent cholesteatomas. MRI yielded a false-negative result in 45.5%. There was 1 false-positive result (10%). Sensitivity, specificity, and positive and negative predictive values of MRI were 54.4%, 90%, 92.3%, and 47.4%, respectively. Preoperative MRI could correctly detect residual or recurrent cholesteatoma in somewhat over half the cases. A high number of false-negative results were obtained. At thismoment, MRI cannot yet replace revision surgery.

Usefulness of Delayed Postcontrast Magnetic Resonance Imaging in the Detection of Residual Cholesteatoma after Canal Wall-Up Tympanoplasty

Imaging takes an increasing place in the follow-up of patients who have undergone surgery for cholesteatoma, with computed tomography (CT) as the first line imaging technique. However, in case of complete opacity of the tympanomastoid cavities, CT is not able to differentiate residual cholesteatoma from postoperative scar tissue. The aim of this study was to assess the usefulness of magnetic resonance imaging (MRI) using delayed postcontrast T1-weighted images for the detection of residual cholesteatoma after canal wall-up tympanoplasty (CWU) in cases where CT was not conclusive. Prospective study. MRI, with delayed postcontrast T1-weighted images (30-45 minutes after contrast injection), was performed before revision surgery in 41 consecutive patients who had undergone CWU for cholesteatoma and presenting with a nonspecific complete opacity of the mastoid bowl on CT. In all the cases, imaging results were compared with operative findings at surgical revision. A residual cholesteatoma was found in 19 of 41 patients at revision surgery and was correctly detected on MRI in 17 patients. In the two remaining cases, cholesteatoma pearls smaller than 3 mm were not seen. There was no false-positive case. Statistics were as follows: sensitivity 90%; specificity 100%; positive predictive value 100%; negative predictive value 92%. When postoperative CT is not conclusive because of complete opacity of the tympanomastoid cavities, MRI with delayed postcontrast T1-weighted images is a reliable additional technique for the detection of a residual cholesteatoma when its diameter is at least 3 mm.

Etiopathogenetic aspects of recurrent cholesteatoma development

The causes of cholesteatoma development have been interpreted in different ways. The object of our study was to present the most frequent causes of recurring cholesteatomas on the basis of our investigations. The prospective study carried out at the Institute for Otorhinolaryngology and Maxillofacial Surgery included 120 patients treated surgically for cholesteatomas. Seventy-five patients were cured after the first operation, while 45 were reoperated after recurrent cholesteatoma.The modified student t test was used to establish the difference between statistically significant groups (small independent sample proportion). The cholesteatoma was often localized in attic (25.3%) and was spreading into antrum (28%). Another group of cholesteatoma was more frequently present in mesotympanum. The small marginal perforations in back quadrants were noted more frequently in the second group (26.7%). Likewise, 40% of the patients from this group had intact chain of auditory ossicles. Destruction of all three auditory ossicles was more often in the first group. Polypoid mucosa was less detected in the first group (18.7%) in relation to the second group (46.7%). Canal wall-up tympanoplasty was used more commonly in the second group of patients.In patients treated surgically for cholesteatoma, the recurrence of the condition may be caused by different factors such as development of cholesteatoma in posterior parts of cavum, polypoid mucosa, localization of cholesteatoma in meso- and retrotympanum and obscured cavity recesses, intact chain of auditory ossicles and the application of close tympanoplasty.

The canal wall-up technique versus the canal wall-down in tympanoplasty with mastoidectomy

Canal wall-up (CWU) tympanoplasty with mastoidectomy gave increasing percentages of failures and recurrences. Eustachian tube malfunction has been proved in all cases of chronic suppurative otitis media (CSOM). This presentation is a mathematical comparison between CWU and canal wall-down (CWD) techniques in favor of CWD.

Detection of postoperative residual cholesteatoma with delayed contrast-enhanced MR imaging: initial findings.

Our objective was to assess the value of delayed contrast-enhanced T1-weighted spin-echo MR imaging in the detection of residual cholesteatoma in patients who have undergone canal wall-up tympanoplasty procedure. The MR imaging was obtained prior to revision surgery in 18 patients with opacity of the post-operative cavity at CT examination 12-18 months after canal wall-up tympanoplasty. In each patient the following was performed: precontrast T1- and T2-weighted images; and early and delayed contrast-enhanced axial and coronal T1-weighted imaging. Early and delayed MR imaging results were separately compared with surgical second-look findings. Sensitivity, specificity, and predictive values were evaluated for early and delayed post-contrast MR imaging, compared with second-look surgery findings. A residual cholesteatoma was correctly identified in 8 of 9 cases with delayed contrast-enhanced T1-weighted MR imaging. Mean sensitivity, specificity, positive predictive value, and interobserver agreement (evaluated by kappa statistics) were, respectively, 85.2, 92.6, 92.6%, and kappa=0.78 for the delayed contrast-enhanced MR imaging technique. The same parameters were, respectively, 96.3, 33.3, 60.6, and 0.30 for the early contrast-enhanced T1-weighted MR images. We conclude that delayed contrast-enhanced T1-weighted MR imaging is reliable for the detection of residual cholesteatomas of the middle ear in patients who have undergone canal wall-up tympanoplasty.