Cholesteatoma Surgery Research Articles

Introducing the “ChOLE” Classification and Its Comparison to the EAONO/JOS Consensus Classification for Cholesteatoma Staging

: Many previous attempts have been made to classify or categorize cholesteatomas. Recently, the European Academy of Otology and Neurotology and the Japanese Otological Society proposed a classification system based primarily on extension and complications. The European Academy of Otology and Neurotology/Japanese Otological Society consensus statement makes an effort to standardize reporting of surgical techniques. Internet-based multicenter studies are facilitated by increasing connectivity, but a mutually-agreed framework for reporting is necessary for results to be comparable across sites. New technologies compete with established standardized surgical approaches and need to be validated. It is definitively the right time to find a consensus on how to record and report surgical findings in cholesteatoma surgery. To stimulate this interesting discussion, we propose a ChOLE-classification system, which is based on the differentiation into extension (Ch), status of the ossicular chain at the end of surgery (O), complications (L), and degree of pneumatization and ventilation (E). A numeric rule is used to stage these cholesteatomas from I-III.

Successful Posterior Canal Wall Reconstruction with Tissue-Engineered Cartilage.

Difficulties are associated with reconstruction of middle ear bony structures in surgery for destructive lesions, including cholesteatoma. Although autologous cartilage appears to be the optimal choice because of its resistance to infection, the harvesting of sufficient volumes may be challenging. Therefore, regenerative medicine techniques to obtain sufficient material for reconstruction are awaited. We herein present a case of middle ear surgery for cholesteatoma with a sufficient volume of stick-shaped tissue-engineered cartilage produced from a piece of autologous auricular cartilage and autologous serum, with sufficient firmness to reconstruct bony structures. During surgery, sections of tissue-engineered cartilage were placed side by side to reconstruct the posterior canal wall. The postoperative course was uneventful. This is the first-in-human report of reconstructing middle ear bony structures with tissue-engineered cartilage. The results suggest a promising future for the satisfactory reconstruction of middle ear structures with minimal morbidity at the donor site.

Cholesteatoma Presenting with Post Auricular Abscess, is Drainage and Mastoidectomy at the Same Time or with Time Interval? (Case Report with Clinical Challenge)

Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. The authors report a case of a 31-year-old man with chronic otitis media of his left ear for many years with a positive history of partial mastoidectomy in 10 years ago. His presentation was as follows: otorrhea as a funky pus from the left ear for 10 days, tenderness, Erythema, and fluctuation in the left posturicular ear and general appearance was ill and feverish. In The laboratory evaluation C-reactive protein (CRP) was 2+ and Erythrocyte sedimentation rate (ESR) was 55(mm/h).after that the Computed tomography scan (CT) was taken and incision and drainage of abases was done. Two weeks later mastoidectomy for cholesteatoma was done. We raised the case for discussing the time of cholesteatoma surgery and its time interval with cholesteatoma complication. And with the case, we can propose that if there is a definite time interval between the two surgeries due to the better field of surgery and reduce inflammation. So Second surgery was easier and less risky and with better results. We prepared the operating room for incision and derange.

Canal wall up surgery with mastoid and epitympanic obliteration in acquired cholesteatoma.

The objective of this study was to evaluate surgical outcome and residual and recurrence rates of canal wall up (CWU) surgery with obliteration of the mastoid and epitympanum. Retrospective cohort study in a tertiary referral center. Patients with (sequelae of) acquired cholesteatoma treated with primary or revision CWU surgery with obliteration of the epitympanum and mastoid were identified retrospectively from 2010 to 2014. Obliteration was performed with cartilage chips or a periosteal midtemporal flap in combination with bone pâté and/or hydroxyapatite. Patients were followed up with micro-otoscopy and magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI). Ninety-nine ears in 96 patients were managed with obliteration of the epitympanum and mastoid following CWU surgery. Mean postoperative follow-up was 39.6 (standard deviation [SD] = 16.3). Mean follow-up until the last MRI-DWI was 29.7 months (SD = 16.0). In total, 74 ears in 72 adult patients (mean age = 46.8 years) were operated and 25 ears in 24 pediatric patients (mean age = 12.8 years). The overall recurrence rate was 7.1%, and the residual rate was 7.1%. In comparison, before the introduction of obliteration, the residual rate in our clinic was 24.4% and the recurrence rate 39.7%. After CWU surgery with obliteration, recurrence in pediatric patients (16.0%) was more frequent than in adults (4.1%). Although this difference was not statistically significant, a trend was observed (P = .066). Obliteration of the epitympanum and mastoid is a reliable and safe technique following CWU surgery for cholesteatoma, resulting in low residual and recurrence rates. 4 Laryngoscope, 129:981-985, 2019.

Endoscopic Transcanal Autologous Cartilage Ossiculoplasty.

This was a randomized clinical trial, of thirty-two patients undergoing endoscopic ossiculoplasty, as a second look surgery, at 6months after primary endoscopic cholesteatoma surgery, in a duration of 9years. All patients underwent trans-canal endoscopic ossiculoplasty under local anesthesia. Prosthesis used were (1) Titanium partial ossicular replacement prosthesis (PORP) in fourteen, (2) Titanium total ossicular replacement prosthesis (TORP) in six and (3) Autologous cartilage in twelve cases. Puretone audiometry (PTA) were done preoperatively and postoperatively at 2months and 3years. Out of twenty-four cases, which presented only with stapes superstructure; fourteen underwent PORP ossiculoplasty and twelve had cartilage short columella ossiculoplasty (SCC). Out of eight cases, which had only mobile stapes footplate, six underwent TORP ossiculoplasty and only two underwent long columella cartilage ossiculoplasty (LCC). Pre-operative average air conduction threshold (AC) of pure tone audiometry were 45.47dB (PORP), 66.10dB (TORP), 49.15dB (SCC) and 59.15dB (LCC) groups. The post-operative AC at 2months were respectively 27.37dB (PORP), 45.83dB (TORP), 29.99dB (SCC) and 39.15dB (LCC) groups. The gap of air and bone conduction (ABG) at 2months post-operative stage were 19.05dB (PORP), 20dB (TORP), 20.32dB (SCC) and 39.15dB (LCC) groups and not much changed after 3years. Extrusion occurred in three PORPs and four TORPs at 4-8years after surgery. Four cases were lost to follow up. No extrusion occurred in cartilage ossiculoplasty. Trans-canal endoscopic autologous cartilage ossiculoplasty shows encouraging results comparable to titanium prosthesis in repairing ossicles in cholesteatoma disease.

Surgical outcome in chronic otitis media with cholesteatoma

<p class="abstract"><strong>Background:</strong> Cholesteatoma is synonymous with active squamous type of disease where there is retraction of pars flaccida or tensa that has retained squamous epithelial debris and is associated with inflammation and the production of pus. This pathology can only be eradicated by meticulous surgery. Our study compares the surgical outcome of intact canal wall vs. canal wall down surgeries done for cholesteatoma.</p><p class="abstract"><strong>Methods:</strong> Prospective study on 42 patients who underwent surgery for cholesteatoma between December 2010 and March 2013 at VIMS, Bellary. </p><p class="abstract"><strong>Results:</strong> The net improvement in ABG in ICW mastoidectomy was 16.03 (±7.5) dB and that in CWD mastoidectomy was 11.39(±7.4) dB with a significant p value of 0.04 as determined by the independent ‘t’ test. The residual disease rate for ICW mastoidectomy was determined as 12% whereas recurrence rate was nil. CWD mastoidectomy had no residual or recurrent disease in the 6-month follow-up period. Postoperative complications were noted in 15% of the study population.</p><p class="ETDBodyText"><strong>Conclusions:</strong> The ICW and CWD surgeries have their own advantages and disadvantages and when performed meticulously both serve the purpose of rendering the patient a safe ear. The ICW procedure leaves behind an anatomically near normal ear and when quality of life concerns needs to be addressed this should be the procedure of choice, with advancement in technology and availability of angled endoscopes which have marched well into otology. The CWD procedure should be reserved to cases presenting with complications and in patients who are more likely to be lost to follow-up.</p>

Clinical and cost utility of an intraoperative endoscopic second look in cholesteatoma surgery.

This study aimed to determine the clinical and cost-effectiveness of endoscopes during cholesteatoma surgery. More specifically, this study hypothesized that endoscope use would reduce cholesteatoma recurrence rates and cost. Case series involving the prospective enrollment of 110 consecutive cholesteatoma patients over a 2-year period. Patients underwent cholesteatoma surgery with microscopy. During dissection, the location of the cholesteatoma was assessed. At the end of dissection and before reconstruction, the same subunits were visualized with straight and angled endoscopes for residual cholesteatoma. Hearing was analyzed before surgery and at the last possible examination. Costs were analyzed using Medicare reimbursement rates from the Centers for Medicare and Medicaid Services. Intraoperative endoscopic surveillance was able to detect residual cholesteatoma in 18 patients. With a 0° endoscope, residual cholesteatoma was noted in the epitympanum (two patients), sinus tympani (one patient), and the supratubal air cells (one patient). With a 45° endoscope, residual cholesteatoma was noted in the epitympanum (three patients), sinus tympani (nine patients), the supratubal air cells (two patients), and the mesotympanum (two patients). From a cost analysis, endoscopic surveillance ($6110.36 per patient) are less expensive than second look surgeries ($11,829.83 per patient), observation ($7097.20 per patient), and observation with annual magnetic resonance imaging studies ($9891.95 per patient). The patients hearing improved after surgery, consistent with previous studies. No complications were noted from the use of endoscopes. Intraoperative endoscopic surveillance reduced recurrence in our series of 110 patients. Endoscopes are particularly useful in evaluating the epitympanum, mesotympanum, sinus tympani, and supratubal air cells. Moreover, endoscopic surveillance is cost-effective. 4 Laryngoscope, 128:2867-2871, 2018.

Middle ear cholesteatoma: a study of correlation between HRCT temporal bone and intraoperative surgical findings

<p class="abstract"><strong>Background:</strong> Cholesteatoma is a long-standing infection of the middle ear cleft having erosive properties. Chronic ear discharge and decreased hearing are most common clinical presentation. Multi-directional tomography of high quality can provide a detailed understanding of the interpretation of anatomical structures visualized by HRCT. Knowledge of the anatomical variations and changes induced by pathology in the temporal bone are the guiding marbles for surgery.</p><p class="abstract"><strong>Methods:</strong> This is a Prospective study consisted of 100 cases of chronic suppurative otitis media of unsafe type requiring ear surgery admitted in the E.N.T. department of P.D.U. Civil Hospital Rajkot in 2 years from December 2015 to December 2017. A total no. of 100 patients of both gender between 5 to 80 years has been included in the study. </p><p class="abstract"><strong>Results:</strong> In this study, 58% patients were females while males were 42%. Left ear (46%) was involved more as compared to right ear (40%). Most of the patients belonged to 11-20 (25%) years of age group. mean age is 24.5 years. Most common symptoms were ear discharge (98%) and decreased hearing (83%).</p><p class="abstract"><strong>Conclusions:</strong> HRCT guides the surgeon on the possible surgical hazards before the surgery and helps in earlier management and operative complications. The use of CT in the case of chronic suppurative otitis media does provide valuable information. HRCT scanning is a unique method of detection of early cholesteatoma as well as detection of cho­lesteatoma in hidden areas. In addition, HRCT scanning serves as a road map to assist the surgeon during cholesteatoma surgery.</p>

Chronic otitis media with cholesteatoma: clinical presentation and surgical management

<p class="abstract"><strong>Background:</strong> Cholesteatoma has long been a formidable adversary to the otologic surgeon. There is no single surgical treatment of choice for aural cholesteatoma. The extent of cholesteatoma, the amount of preoperative destruction, and mastoid pneumatization, guides the surgeon in choosing the type of operation for a particular ear. Intra-operative findings guide the surgeon to perform the required surgery despite thorough pre-operative work-up.</p><p class="abstract"><strong>Methods:</strong> Prospective study on 42 patients who underwent surgery for cholesteatoma. </p><p class="abstract"><strong>Results:</strong> Cholesteatoma most commonly affected males aged between 10-20 years. Also, the disease was noted to be more aggressive in the paediatric age group. Foul smelling ear discharge was the most common presenting symptom followed by hearing loss. 21% of patients presented with complications. Canal wall down mastoidectomy was done in patients with complications and in cases where adequate disease clearance could not be accomplished with the posterior canal wall intact. All patients in the study underwent ossicular reconstruction. This was owing to either the destruction of ossicles by the disease process or to achieve adequate disease clearance.</p><p class="abstract"><strong>Conclusions:</strong> Disease eradication is still the main aim of the surgery, but, when it can be achieved keeping the posterior canal wall intact, the canal wall should always be left intact. With advances in technology and availability of angled endoscopes this should be given more consideration. However, in a patient with complications and patients who are not available for regular follow-up the canal wall down surgery is preferred.</p>

The Bony Obliteration Tympanoplasty in Pediatric Cholesteatoma: Long-term Hearing Results.

To present the hearing results of a 5-year longitudinal study in a pediatric population undergoing surgery for extensive cholesteatoma using a canal wall up (CWU) approach with bony obliteration of the mastoid and epitympanic space, with a standard residual rate of 5.8%, a recurrence rate of 2.9%, and all ears waterproof, free of otorrhea and all external ear canals patent and self-cleaning. Retrospective consecutive study. Thirty-three children (≤18 yr) undergoing surgery for cholesteatoma (34 ears) between 1997 and 2009. Therapeutic. Tertiary referral center. Hearing and gain in hearing at 1- and 5-year postsurgery: (1) pure-tone average (PTA), (2) pure-tone average high frequency, (3) pure-tone average including 3 kHz, (4) bone conduction at corresponding frequency averages, (5) gain at corresponding air conduction and bone conduction (gain at corresponding air conduction) frequency averages. (6) The Amsterdam Hearing Evaluation Plots were used to study the individual cases. The Amsterdam Hearing Evaluation Plots at 5-year showed in 58.8% of patients a positive gain air conduction. In 23.5% a successful functional result was achieved, defined as an air-bone gap closure to 20 dBHL or less. In 6 patients (17.6%) a limited bone conduction deterioration was shown all limited to maximum 20 dBHL. The CWU bony obliteration tympanoplasty in a consecutive series of pediatric extensive cholesteatoma shows a similar to slightly improved hearing outcome as compared with CWU surgery without BOT. Although the series shows a clearly reduced reoperation rate and a significantly improved safety and hygienic outcome as compared with CWU without BOT, better hearing outcomes remain desirable in this group of children.

Hearing loss and ossicular status in cholesteatoma

<p class="abstract"><strong>Background:</strong> Chronic otitis media with cholesteatoma is associated with hearing loss. Cholesteatoma causes bone erosion leading to ossicular chain defects. These ossicular lesions are only detected intraoperatively. If the ossicular status could be detected preoperatively by audiometric parameters, it would aid in better information to the patient, surgeon and preparation for the surgery. The aim of this study is to describe the intraoperative ossicular status, preoperative hearing status and to correlate them in patients with cholesteatoma.</p><p class="abstract"><strong>Methods:</strong> This is a retrospective case series study conducted in a tertiary care centre. Data was collected from inpatient files of 47 patients who underwent surgery for cholesteatoma from January 2016 to December 2017. Air and bone conduction thresholds, air- bone gaps from pure tone audiometry (PTA) reports were collected. The status of the ossicles was collected from the operative notes. </p><p class="abstract"><strong>Results:</strong> PTA revealed hearing loss in all the patients, predominantly conductive loss (83%). Ossicular defects were noted in 87% with incus most frequently involved (78.7%). Ossicular lesions were significantly associated with worse air conduction, bone conduction thresholds and air bone gap.</p><p><strong>Conclusions:</strong> Cholesteatoma is frequently associated with ossicular defects. PTA shows worse parameters in ossicular defects. But, it doesn’t reflect the status of ossicle involved or the number of ossicles involved.</p>

The Transplantation of hBM-MSCs Increases Bone Neo-Formation and Preserves Hearing Function in the Treatment of Temporal Bone Defects - on the Experience of Two Month Follow Up.

Temporal bone reconstruction is a persisting problem following middle ear cholesteatoma surgery. Seeking to advance the clinical transfer of stem cell therapy we attempted the reconstruction of temporal bone using a composite bioartificial graft based on a hydroxyapatite bone scaffold combined with human bone marrow-derived mesenchymal stromal cells (hBM-MSCs). The aim of this study was to evaluate the effect of the combined biomaterial on the healing of postoperative temporal bone defects and the preservation of physiological hearing functions in a guinea pig model. The treatment's effect could be observed at 1 and 2months after implantation of the biomaterial, as opposed to the control group. The clinical evaluation of our results included animal survival, clinical signs of an inflammatory response, and exploration of the tympanic bulla. Osteogenesis, angiogenesis, and inflammation were evaluated by histopathological analyses, whereas hBM-MSCs survival was evaluated by immunofluorescence assays. Hearing capacity was evaluated by objective audiometric methods, i.e. auditory brainstem responses and otoacoustic emission. Our study shows that hBM-MSCs, in combination with hydroxyapatite scaffolds, improves the repair of bone defects providing a safe and effective alternative in their treatment following middle ear surgery due to cholesteatoma.

Bilateral Congenital Cholesteatoma.

To report the first large case series of extremely rare bilateral congenital cholesteatoma (CC). A retrospective cohort study. University hospital otology referral clinic. Six hundred four children with surgically confirmed CC. The bilateral CCs were compared with the unilateral CCs. The incidence of bilateral CC was 3.6% (22/615) per case or 1.8% (11/604) per child. Bilateral CC did not differ from unilateral CC regarding its demographics, and invasiveness by the proportion of advanced CC as 31.8% (7/22) versus 28.2% (167/594). But the invasiveness or location randomly differed between the ears, that advanced CC per child was higher as 45.4% (5/11). Bilateral exploration was attempted with a concern for hearing loss, which featured a combination of laser myringotomy to treat early CC and endaural laser-assisted single-stage inside-out cholesteatoma surgery to treat advanced CC. Bilateral exploration was difficult in three children with initially negative otoendoscopy. Among the seven advanced CC, proportion of anterior type was 71.4% (5/7), who all exhibited more than 20 dB HL, but two posterior type retained normal hearing. Therefore, bilateral advanced CCs of anterior origin showed poorest hearing outcome as bilateral more than 20 dB HL, which were in two children. Six second-look operations and one third-look operation were required to treat six residual CCs (30%) in four children (40%), including bilateral residual CC in two (20%); such reoperations were significantly more frequent than in unilateral CC. The diagnosis of bilateral CC required high index of suspicion from TBCT, and early bilateral exploration.

Minimal Invasive Endoscopic Ear Surgery: A Two Handed Technique.

To evaluate the surgical outcome of two handed technique of endoscopic ear surgery with endoscope holder. Retrospective Non Randomized Clinical Study. A total of 547 endoscope holder (Justtach) assisted ear surgeries (331 cartilage tympanoplasties and 216 cholesteatoma surgeries) were operated with Justtach from July 2013 to April 2016 with a follow up period ranging from 12 to 45months to evaluate its feasibility and results with the technique. The design of the endoscope holder, Justtach is described along with its functioning and maneuvering techniques. In the endoscopic tympanoplasty group, at 1year follow up, the graft uptake was seen in 323 ears with three residual perforation and 5 recurrent perforations giving a success rate of 97.58%. At the 2years follow up, the graft uptake was in 322 ears with 6 recurrent perforations and 3 residual perforations with a success rate of 97.28%. Whereas in case of endoscopic cholesteatoma surgery, there was residual cholesteatoma in 5 and recurrent in 6 out of 216 cases. The study reports the successful application and use of endoscope holder in two handed technique of endoscopic ear surgery. Level of Evidence Level 4.

MRI as an Alternative to Second Look Mastoid Surgery

The main goal of surgery of cholesteatoma is eradication of the disease and revision surgery is indicated when a dry and safe ear has not been achieved. Residual cholesteatoma usually occurs at the sites that are difficult to reach with an operating microscope, such as posterior tympanum and anterior epitympanic recess. Computed tomography can be performed to delineate the extent of disease. High-resolution computed tomography scanning is important for planning for surgery and is indicated for all revision mastoid operations. Magnetic resonance imaging is superior to computed tomography in tissue characterization for diagnosis of recurrent cholesteatoma. To evaluate the cases of recurrent cholesteatoma comparing the intraoperative surgical findings with the preoperative MRI radiological findings and if the preoperative MRI can replace the second look surgery for cholesteatoma. This study was applied on 60 patients that have a recurrent cholesteatoma after previous mastoid surgery. A preoperative radiological evaluation was done by Magnetic resonance, surgical management was done by canal wall up or canal wall down mastoidectomy to exclude residual disease. Then, radiological, and surgical findings correlation was done. Diffusion-weighted MRI successfully detected 42 cases out of the 45 cases of surgically proved cholesteatoma, it has accuracy 95%, sensitivity 93.33%, specificity 100%, PPV 100% and NPV 83.33%. MRI is better than CT in tissue characterization for diagnosis of recurrent cholesteatoma, and can replace the unnecessary second look surgery of cholesteatoma.

Functional and Anatomical Outcome of Inside Out Technique For Cholesteatoma Surgery

BackgroundTo study the efficacy of inside-out technique in completely eradicating the cholesteatoma from middle ear and mastoid, preservation of hearing & and quality of life post mastoidectomy with regards to recurrent discharge, wax, granulations. Material and methodsNon-randomized, prospective, observational study performed at the Department of ENT in our hospital. In the study we included 100 patients presenting with chronic suppurative otitis media with cholesteatoma, they underwent inside out mastoidectomy and were followed up till the end of the study to evaluate the efficacy of inside out mastoidectomy in eradicating the disease from the middle ear cleft. To assess preservation of hearing and to assess cavity problems. ResultsOf the 100 patients, 98 patients had a total clearance of disease by the inside out approach, and 2 patients, had doubtful clearance. All patients came for regular follow up and none of them had residual disease at the end of the study period. Thus, the overall success rate was 100% in our study. A significant improvement in the mean air conduction (p < 0.01) and the mean air bone gap (p < 0.01) was seen in all postoperatively at 3rd month PTA. Only one patient had conductive hearing loss one and a half years postoperatively after initial improvement. A dry self-cleansing cavity was achieved in 95% of the patients and only 5% required regular cleaning of wax the cavities. ConclusionInside out mastoidectomy is a better alternative in canal wall down procedures as it not only clears the disease from the middle ear cleft, but also leaves behind a small postoperative cavity, which will preserve the hearing, decrease the cavity problems and increase the quality of life of such patients.

Association between facial nerve second genu angle and facial canal dehiscence in patients with cholesteatoma: evaluation with temporal multidetector computed tomography and surgical findings

IntroductionOtitis media, mastoiditis or the pressure effect of tumorous lesions such as cholesteatoma can be the cause of facial canal dehiscence and facial nerve paralysis. The most common segment involved in dehiscence is the tympanic segment and the second most common is the lateral aspect of the facial canal in the oval window area. ObjectiveTo determine the prevalence of the facial canal dehiscence and the relationship between the angle at the second genu of the facial nerve and facial canal dehiscence. MethodsWe evaluated the surgical findings in 113 patients who underwent surgery for cholesteatoma. Facial canal dehiscence was detected in 62 of the 113 patients. Patients were divided into two groups: Group 1, with dehiscence of the facial canal and Group 2, without dehiscence of the facial canal. ResultsThe mean angles at the second genu of the facial nerve in Groups 1 and 2 were 117.8°±9.63° and 114°±9.9°, respectively. There was a statistically significant difference between the mean angles at the second genu for the two groups (p=0.04). ConclusionIn patients with dehiscence of the facial canal, the angle at the second genu was found to be wider than those without dehiscence.

Curved adjustable fibre-optic diode laser in microscopic cholesteatoma surgery: description of use and review of the relevant literature.

The use of lasers in cholesteatoma surgery is common and well accepted. The most commonly used laser fibres are straight and non-adjustable; these have several limitations. This paper describes the use of an alternative laser fibre. This 'How I Do It' paper describes and illustrates the use of an alternative curved adjustable fibre-optic diode laser in microscopic cholesteatoma surgery. The curved, adjustable laser fibre allows accurate and atraumatic disease removal when the use of a straight laser fibre may be less effective or accurate. It reduces potential damage to delicate structures without the need for extra drilling or bone removal. It is suggested that the curved adjustable laser fibre is superior to the traditional straight fibre for cholesteatoma surgery.

Facial sinus endoscopic evaluation, radiologic assessment, and classification.

To describe facial sinus anatomy from an endoscopic perspective and present a radiologic classification. Facial sinus was studied by endoscopy and high-resolution computed tomography (HRCT) scan in 39 temporal bones that underwent exclusive transcanal endoscopic approach. A radiomorphologic classification based on the relationship between the facial sinus and the mastoid portion of the facial nerve is created as follows. In type A facial sinus, the pneumatization of the facial sinus did not extend medially or posteriorly to the mastoid portion of the facial nerve. In type B facial sinus, the pneumatization extended posteriorly to the mastoid portion of the facial nerve. In type C facial sinus, the pneumatization extended posteriorly and medially to the mastoid portion of the facial nerve. In all the specimens that underwent HRCT (n = 31), facial sinus could be identified, and its depth classified, in relation to the facial nerve. In this group, 58% type A, 29% type B, and 13% type C facial sinuses were identified. In all the specimens (n = 39), the facial sinus could be assessed by means of an exclusive endoscopic transcanal approach, and anatomical variants of the chordiculus, previously known as chordal ridge, could be described: ridge (39%), bridge (18%), incomplete (15%), and absent (28%). Endoscopic exploration of the retrotympanum guarantees a very good exposure of the facial sinus, allowing detailed anatomic descriptions of its conformation and relationships with other structures. Improvement in our knowledge of its anatomy might decrease the possibility of residual disease during cholesteatoma surgery. Angled endoscopes (e.g. 45 °, 70 °) can guarantee a better view of the facial sinus. NA. Laryngoscope, 128:2397-2402, 2018.

Functional and anatomical results of inside out approach for cholesteatoma surgery

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The objective of the study was t&lt;span lang="EN-IN"&gt;o study the efficacy of inside-out approach in completely eradicating the cholesteatoma from middle ear and mastoid, preservation of hearing and quality of life post mastoidectomy with regards to recurrent discharge, wax, granulations. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Non-randomizedprospective observational study performed at the Department of ENT in Bombay hospital Mumbai. The study involved 40 patients presenting with chronic suppurative otitis media with cholesteatoma. All of them underwent inside out mastoidectomy and were followed up till the end of the study to evaluate the efficacy of inside out mastoidectomy in eradicating the disease from the middle ear cleft, to assess preservation of hearing and to assess cavity problems. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Of the 40 patients, 39 patients had a total clearance of disease by the inside out approach, and in 1 patient, we were doubtful of the clearance. All patients came for regular follow up and none of them had residual disease at the end of the study period. Thus, the overall success rate was 100% in this study. A significant improvement in the mean air conduction (p&amp;lt;0.01) and the mean air bone gap (p&amp;lt;0.01) postoperatively was seen in all in the postoperative 3&lt;sup&gt;rd&lt;/sup&gt; month PTA. Only one patient had increased conductive hearing loss one and a half years postoperatively after initial improvement. A dry self-cleansing cavity was achieved in 95% of the patients and only 5% required regular cleaning of waxes the cavities. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Inside out mastoidectomy is a better alternative in canal wall down procedures as it not only clears the disease from the middle ear cleft, but also leaves behind a small postoperative cavity, which will preserve the hearing, decrease the cavity problems and increase the quality of life of such patients.&lt;/span&gt;&lt;/p&gt;