Cholesteatoma Surgery Research Articles

Inside out technique for cholesteatoma surgery: Functional and anatomical outcomes

Inside out technique for cholesteatoma surgery: Functional and anatomical outcomes

Surgical treatment of chronic otitis media in children using three-dimensional imaging

The introduction of three-dimensional exoscopy has opened a new stage in microsurgery in recent years. Researchers from various specialties give mostly positive reviews. There are very few works on the use of three-dimensional imaging in otorhinolaryngology, and there are practically no such works on otosurgery. This article presents a short review of publications and our own clinical examples, which are the first detailed description of VITOM 3D KARL STORZ exoscope use for cholesteatoma surgery in children, published in the available world literature. The first experience allowed us to draw preliminary conclusions about the comparability of this method of intraoperative imaging with a microscope. In addition, we have identified additional benefits of the exoscope. Further research will make it possible to better adapt the technique to the peculiarities of otosurgery, and it should take its place in the arsenal of ENT surgeons, along with microscopy.

The evaluation of canal wall up cholesteatoma surgery with the Glasgow Benefit Inventory

PurposeThe aim of the study was to investigate the change in health-related quality of life (HRQoL) after canal wall up cholesteatoma surgery, using the Glasgow Benefit Inventory (GBI).MethodsData from a consecutive group of 47 adults scheduled for primary cholesteatoma surgery using canal wall up (CWU) with obliteration, from January 2005 to December 2009, were analysed. Information was extracted from a medical database, and complementary data from patient files and audiograms were collected and recorded retrospectively. The GBI questionnaire was used for the assessment of HRQoL after surgery.ResultsThere was no finding of residual or recurrent cholesteatomas in the study group. Hearing was improved at 1 and 3 years postoperatively. No patient suffered a total hearing loss. The overall GBI scores showed an improved HRQoL after surgery. Twenty-nine (85%) patients benefitted from surgery, 1 (3%) had no change, and 4 (12%) expressed deterioration.ConclusionsCholesteatoma surgery using CWU with obliteration gives an improved HRQoL for the majority of patients. The GBI questionnaire provides complementary information to hearing and healing results after cholesteatoma surgery.

The endoscopic anatomy of the cochlear hook region and fustis: surgical implications.

SUMMARYThe cochlear hook region can be considered as the interface between the middle and inner ear. The identification of surgically-relevant endoscopic landmarks of this anatomical entity and assessment of their clinical value is still lacking in the literature. Procedures like cholesteatoma surgery and minimal invasive endoscopic approaches to the lateral skull base may particularly benefit from these considerations. We hypothesize that the spatial orientation of anatomical landmarks in the cochlear hook can be expressed in angles and are reproducibly identifiable by transcanal otoendoscopy. Therefore, endoscopic dissection of the cochlear hook region was performed in 32 temporal bone specimens. Topographic anatomy was documented and analysed. We performed computed tomography of 28 specimens to assess the region in three-dimensional reconstructions. The mean angle between the round window and the basal scala tympani was assessed 25.9° in endoscopic and 28.2° in three-dimensionally reconstructed models. The fustis was recognised as a reliable landmark for the basal turn. A mean angle of 155.4° to the basal scala tympani was assessed. A slight bulging without obstruction of the basal turn was observed in 5 cases. The utility of the revealed anatomical details was assessed in minimal invasive endoscopic lateral skull base approaches. In conclusion, we described the angles between anatomical landmarks of the cochlear hook region. Moreover, the angle as recorded through an endoscope was found to be reliable compared to three-dimensional reconstructions from computed tomography.

Book Review: Atlas of Cavityless Cholesteatoma Surgery Vol I by K.P. Morwani, Madhuri Mehta

Kaiser Permanente Fremont, California [email protected] The author discloses no conflicts of interest.

Efficacy of an Exclusive Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Efficacy of an Exclusive Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Endaural Laser-Assisted Single-Stage Inside-Out Cholesteatoma Surgery (LASIC) to Treat Advanced Congenital Cholesteatoma.

Investigation of endaural laser-assisted single-stage inside-out cholesteatoma surgery (LASIC) to treat advanced congenital cholesteatoma (ACC) by a modified staging system based on ossicle status. A retrospective case review. A university hospital otology referral clinic. Two hundred consecutive pediatric patients with ACC were enrolled. Endaural LASIC and postoperative temporal bone computed tomography (CT). Residual or recurrent CC and audiological outcomes. LASIC was feasible in 98.0% of patients. Single-stage ossiculoplasty was performed in 95.5% of patients. Hearing preservation to less than 20 dB was 59.2% and to the preoperative hearing level was 84.5%. Mastoid invasion did not result in worse recidivism or hearing loss (HL) but further invasion of the stapes superstructure (stage IV) significantly elevated both the recidivism (16.7%) and the risk for HL (to 84.8%) (p = 0.001). Ossicle preservation LASIC was frequently possible in stage III posterior type (75.6%), whereas it was rarely possibly (15.4%) in the anterior type. Incudostapedial joint (ISJ) invasion in the absence of cochleariform process (CP) invasion (III-posterior) did not increase the incidence of HL (6.1%) or recidivism (2.4%). However, simultaneous invasion of the CP and ISJ (III-anterior) elevated the risk of HL by 46.2% by ossicle removal, although recidivism was not increased (3.8%). Endaural LASIC for ACC achieved satisfactory recidivism (overall 7.5%, 16.7% in stage IV) comparable to early CC (17.2%). An ossicle status-based staging system was more efficient for correlation with audiologic and surgical outcomes of CC than that of mastoid invasion.

A study of surgical management of cholesteatoma and its outcome

Background: Cholesteatoma has long been a formidable adversary to the otologic surgeon. There is no single surgical treatment of choice for aural cholesteatoma. Hence it was important to determine the surgical outcomes of cholesteatoma in a country where the prevalence of the disease still remains high.Objectives1.To determine the incidence of residual & recurrent cholesteatoma with various surgical procedures.2.Evaluation of hearing status at post-operative stage with various surgical procedures.3.To determine the incidence of post-operative complications such as perichondritis, external auditory canal stenosis, wound dehiscence, facial nerve palsy, and sensorineural hearing loss.Methods: Prospective study on 50 patients who underwent surgery for cholesteatoma.Results: Cholesteatoma occurs more commonly in children with otorrhea as the most common presenting symptom. 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, but to note is that 5 of the 6 patients who underwent revision surgery for recurrent cholesteatoma had previous CWD mastoidectomy. 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. Conclusion: The literature supports the use of both ICW and CWD techniques. Eradication of cholesteatoma has always been the priority, but with advance in the surgical techniques hearing improvement and quality of life issues need to be addressed. With this in the background, ICW mastoidectomy is the preferred choice in our study. However owing to the high incidence of residual disease it is important for the surgeon to counsel the patients regarding the probable need for multiple surgeries. Further studies with long-term follow-up is recommended.

Symptom: Dizziness with Ear Pressure

Symptom: Dizziness with Ear Pressure

Cautionary Findings for the Presence of Facial Canal Dehiscence During Cholesteatoma Surgery

Our aim was to investigate the relationship between facial canal dehiscence (FCD) and surgical findings and procedures in patients with cholesteatoma. A total of 186 patients (118 males, 39.2 ± 15 years) who underwent surgery for advanced cholesteatoma between 2013 and 2018 were included in the study. The relationship between FCD and surgical findings was investigated via the surgical registries. The prevalence of FCD was 36.6% (68/186). The prevalence of FCD was 44%, and 13.2% for the patients who underwent canal wall down mastoidectomy (62/141) and canal wall up mastoidectomy (6/45), respectively (P < .001). Facial canal dehiscence was detected in 73.9% of the 23 patients who had a lateral semicircular canal (LSCC) defect (P < .001), in 61.9% of 21 patients who had a tegmen tympani defect, and in 58.1% of the 31 patients who had erosion on the posterior wall of the external auditory canal (EAC; P < .05). The prevalence of FCD was 3.1% in patients with isolated incus erosion, 59.1% in patients with erosion of malleus and incus, 60.7% in patients with erosion of stapes suprastructure and incus, and 43.2% in patients with whole ossicular chain deformation (P < .001). The defects on LSCC, EAC, tegmen tympani, and malleus and incus might be cautionary findings for the presence of FCD during cholesteatoma surgery.

Correlation between pre-operative CT findings and intra-operative features in pediatric cholesteatoma: a retrospective study on 26 patients.

To assess the predictive value of pre-operative CT imaging in pediatric patients affected by cholesteatoma of the middle ear, comparing pre-operative CT findings to intra-operative features. A retrospective study was performed on a population of 26 pediatric patients who underwent tympanoplasty for middle ear cholesteatoma at the Otorhinolaryngology Departments of Verona and Modena University Hospitals between December 2011 and June 2018. Comparison between pre-operative CT images and intra-operative findings (assessed from video recording) was made focusing on the involvement of specific structures: ossicular chain, tegmen tympani, labyrinthine fistula, facial nerve, and temporal bone involvement. CT sensitivity, specificity, positive and negative predictive values were calculated. Overall, 28 surgical procedures were evaluated. No statistically significant differences were encountered between CT images and intra-operatory findings regarding the selected parameters. Based on our study, pre-operative temporal bone CT scan is a valuable tool for the assessment of pediatric patient candidates for cholesteatoma surgery given the absence of statistically significant differences between radiologic and intra-operative findings. The present findings might support the indication to routinely perform temporal bone CT scan in children with cholesteatoma as part of pre-surgical plan. III.

Growth and Late Detection of Post-Operative Cholesteatoma on Long Term Follow-Up With Diffusion Weighted Magnetic Resonance Imaging (DWI MRI): A Retrospective Analysis From a Single UK Centre.

To evaluate the growth rate and late detection of residual cholesteatoma on long-term follow-up with diffusion weighted magnetic resonance imaging (DWI MRI) in clinically stable ears following definitive surgery, in order to define surveillance imaging protocols. Retrospective case review. Tertiary referral center. Patients who underwent DWI MRI at our institution between February 2007 and May 2013 for postoperative cholesteatoma follow-up. Non-echo planar imaging (non-EPI) Half-Fourier Acquisition Single-shot Turbo spin Echo (HASTE) DWI MRI. Intervals between the definitive surgery and the first and subsequent DWI MRI, the maximum coronal dimension of the lesion on DWI and length of follow-up. The study evaluated 152 postoperative DWI studies performed for 88 patients. In 12 cases, DWI was initially negative but became positive on repeat imaging after a mean interval of 3.8 years from the initial cholesteatoma surgery (median 3.7 years, range 1.6-7.9). Of these, 3/12 had more than one negative/indeterminate DWI before disease was eventually detected on imaging; in this subgroup, the mean interval between surgery and positive DWI was 3.2 years (median 2.6 years, range 2.3-4.2). 39 DWI positive foci with serial imaging demonstrated a mean growth rate of 4 mm/year (median 2 mm, range 0-18). After negative initial DWI, it is proposed that interval imaging should be considered for a minimum of 5 years in stable ears following definitive cholesteatoma surgery. In view of the marked variability in growth rate, an additional interval scan between 2 and 3 years postoperatively is indicated.

Tympanomastoidectomy for Cholesteatoma in Children: Audiometric Results.

The aim of this study was to investigate the audiometric outcomes of tympanomastoidectomy in children with cholesteatoma and to evaluate factors that may affect outcomes. A retrospective cohort study was conducted. All pediatric patients diagnosed with cholesteatoma who underwent primary canal wall-up tympanomastoidectomy with or without ossicular reconstruction from 2009 to 2016 at a tertiary university-affiliated pediatric medical center were included. Pure tone average (PTA) and air-bone gap (ABG) at 0.5, 1, 2, and 4 kHz were compared before and after surgery. The cohort included 100 children (104 tympanomastoidectomies) of mean age 10.35 ± 3.6 years. The mean duration of follow-up was 35.4 ± 24.1 months. At surgery, 22 patients (21.2%) had intact ossicular chains, and 82 (78.8%) had ossicular discontinuity. Fifty-three patients (51%) underwent ossicular reconstruction, either partial (34 patients [64.1%]) or total (19 patients [35.8%]). In comparison with preoperative audiometry, there was a statistically significant improvement in PTA-ABG at the first postoperative examination (27.5 ± 12.7 vs 21.1 ± 11.1 dB, P = .001) and at the end of follow-up (20.2 ± 12.7 dB, P = .003) . Overall, values of less than 20 dB were measured in 34% of patients preoperatively and 73% postoperatively. On subgroup analysis, in patients who underwent any ossicular reconstruction, PTA-ABG was significantly improved relative to the preoperative value (28.1 ± 14.7 dB) at both the first (19.1 ± 11.9 dB, P = .006) and last (22.4 ± 15.1 dB, P = .011) audiometry examinations. Hearing outcomes after pediatric cholesteatoma surgery are diverse and related to several factors. The authors found that ossicular reconstruction improves audiometric outcomes, and the changes remain stable over time. IIB.

Management of Acquired Cholesteatoma Associated With Patulous Eustachian Tube and Habitual Sniffing.

ObjectivesTo investigate the effect of surgical treatment with eustachian tube (ET) catheter insertion in patients with acquired cholesteatoma associated with patulous eustachian tube (PET) and habitual sniffing.MethodsNine ears of nine patients (two men and seven women; age, 20 to 65 years; average, 37.9±12.0 years) of acquired cholesteatoma associated with PET and habitual sniffing who underwent cholesteatoma surgery with simultaneous additional ET catheter insertion were examined in this study. Successful treatment was defined as stoppage of sniffing, a relief of a PET handicap inventory-10 (PHI-10), an improvement of autophony grade and no cholesteatoma recurrence.ResultsET catheter insertion was performed in all ears. Follow-up duration ranged from 16 to 37 months (average, 25.4 months). Cases consisted of nine pars flaccida type (100%). All patients obtained relief from aural symptoms and stopped sniffing. Postoperative PHI-10 scores were significantly lower than preoperative scores (P<0.001). During an average follow-up of 25.4 months, no cholesteatoma recurrence has occurred to date. One patient developed otitis media with effusion (OME) post-catheterization; OME resolved spontaneously without treatment. Four patients had a consecutive ET catheter insertion on the other side to resolve PET-related aural symptoms.ConclusionIn case of acquired cholesteatoma with PET and habitual sniffing, ET catheter insertion performed simultaneously with cholesteatoma surgery could help reduce aural symptoms and stop sniffing. Moreover, the procedure might help in preventing cholesteatoma recurrence.

Evaluating the role of otoendoscope in cholesteatoma surgery

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Endoscope assisted ear surgery (EAES) reduces the chances of residual cholesteatomas as compared to the conventional microscopic technique, primarily because of the direct visualization of sites where residual cholesteatoma is common, which is often missed out during the traditional microscopic surgical procedure. The aim of the study was to evaluate the hidden areas of middle ear using endoscopes during the conventional microscopic cholesteatoma surgery.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The present prospective study was carried out in the Dept. of Otorhinolaryngology and Head &amp;amp; Neck Surgery, Shri Mata Vaishno Devi Narayana Superspeciality Hospital, Katra, Jammu for a period of one year during which a total of 20 patients of acquired cholesteatoma who underwent conventional microscopic surgery were followed by oto-endoscope assisted examination were enrolled. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Otoendoscope was used in all the surgeries to look for residual cholesteatoma in the hidden areas like protympanum, sinus tympani and anterior attic. An overall incidence of cholesteatoma observed and removed from hidden areas using otoendoscope was recorded to be 30% in the present study.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Microscopic ear surgery assisted with oto-endoscope allows a better visualization of the extent of cholesteatoma and thus improved eradication of residual/recurrent disease from the hidden areas of middle ear such as facial recess, sinus tympani, anterior epitympanic space, protympanum and hypotympanum.&lt;/p&gt;

Petrous Bone Cholesteatoma: Radical Excision with an Endeavour for Hearing Preservation.

To describe surgical outcomes following resection of giant petrous bone cholesteatoma. Retrospective cohort study was undertaken at a tertiary care centre on patients who had undergone surgery for petrous bone cholesteatoma (PBC) from August 2014 to September 2017. For patients with serviceable hearing preoperatively, labyrinth preserving techniques, namely, modified transmastoid translabyrinthine approach (massive PBC-1) and supralabyrinthine approach (supralabyrinthine PBC-1) were considered. In the former, bony labyrinth which had been destroyed due to the disease process, membranous labyrinth remained anatomically and functionally intact following meticulous dissection to remove cholesteatoma matrix. In the latter, supralabyrinthine cell tracts were exenterated without disturbing the cochlea and labyrinth with a canal wall down mastoidectomy. For the remaining patients, labyrinth ablative approach was undertaken (translabyrinthine/transotic). Facial nerve function was evaluated using House-Brackman grading system. Hearing was evaluated using pure tone audiometry. 7 patients were identified (massive-2, supralabyrinthine-3, supralabyrinthine apical-1, infralabyrinthine apical 1). None of the patients experienced deterioration of postoperative bone conduction or facial nerve function (preop-grade 5-4, grade 6-3; postop-grade 2-1, grade 3-2, grade 4-4). Facial nerve was decompressed and anatomically intact in 3 cases. In the remaining, facial hypoglossal anastomosis was done in 3 and facial masseteric anastomosis was done in 1 patient. With a median follow-up of 26months, recurrence in the form of keratin pearl was seen in 1 patient. Modified translabyrinthine approach preserving membranous labyrinth is a promising hearing preservation strategy.

Improvement of otoendoscopic surgery for epitympanic cholesteatoma invading the mastoid

Background: In recent years, the otoendoscopic surgery for epitympanic cholesteatoma has achieved great development, but it still has some disadvantages.Objective: This work aims to improve otoendoscopic surgery for epitympanic cholesteatoma invading the mastoid to retain the normal structure of the middle ear as much as possible.Methods: We classified the patients according to the lesion scope and applied different strategies of using the combination of otoendoscope and microscope. The surgery was improved and the recurrence and residual of middle ear cholesteatoma after operation were observed preliminarily.Results: Forty-six patients with middle ear cholesteatoma accepted surgical treatment, including 10 cases of independent otoendoscopic surgery, 29 cases of otoendoscope–microscope combined surgery, and seven cases of microscopic surgery assisted with an otoendoscope. All cases were treated with canal-up cholesteatoma surgery. The postoperative recurrent rate was 4/46.Conclusion: We improved existing otoendoscopic surgery to reduce or avoid bony defects of the acoustic meatus, and then decreased the proportion of canal-down surgery.

Management of 242 patients with middle ear cholesteatoma by otoendoscopic surgery and the postoperative effect analysis

Objective: To summarize and discuss the characteristics of endoscopic approach to manage the middle ear cholesteatoma, and to evaluate the operative safety and outcomes based on the data from the multicenter study. Methods: The data of 242 cases diagnosed with the middle ear cholesteatoma and received operation through endoscopic approach between June 2016 and June 2017 in six tertiary hospitals in China were analyzed in this work. There were 130 males and 112 females, with the age ranging from 3 to 72 years old. We evaluated the strategy about how to manage the cholesteatoma, discussed the detailed techniques about how to remove the cholesteatoma and to improve the efficiency under endoscopic visualization. Meanwhile, the recurrence rate and residual rate of cholesteatoma as well as the complications in endoscopic approach were summarized. Results: A total of 158 cases were operated in exclusively endoscopic transcanal approach, 72 cases operated in combined approach, and 12 cases operated majorly under microscope and minorly under endoscope. 219 cases were operated in one stage surgery, 23 cases received second look. In the second look, 3 cases were detected with residual cholesteatomas. Among them, 2 cases were found by MRI-DWI examination after the first-stage operation. With endoscopic examination after operation, 17 cases showed retracted pocket recurrence (7%,17/242). With introduction of endoscope in cholesteatoma, 153 cases were achieved canal wall-up operation (63%, 153/242). The complications in endoscopic approach included chord tympani never injury in 27 cases, skin injury of ear canal in 11 cases, tinnitus in 13 cases, vertigo in 7 cases, external ear canal stenosis in 1 case. Conclusions: Using otoendoscope in cholesteatoma surgery would help keeping the normal structures of middle ear as much as possible, benefit to remove the hiding pathologies, help reducing residual cholesteatoma and lowering the rate of canal wall-down operation as well. This study showed good safety of otoendoscopic cholesteatoma surgery, however, strict evaluation of indication and quite good surgical techniques and skills are necessary for avoiding unexpected complication.

Facial canal dehiscence in patients with cholesteatoma: concordance between intraoperative inspection, computed tomography and neurophysiological findings.

To assess the diagnostic capacity of intraoperative neurophysiological monitoring with respect to "gold standard" microscopic findings of facial canal dehiscence in middle ear cholesteatoma surgery. We carried out a retrospective cohort study of 57 surgical interventions for cholesteatoma between 2008 and 2013 at Hospital Universitario de Canarias, Spain. Each patient underwent preoperative computed tomography (CT), intraoperative neurophysiological monitoring and intraoperative inspection of the facial nerve during microsurgery. Diagnostic concordance on the presence/absence of facial canal dehiscence was assessed in 54 surgical interventions. Presence of facial canal dehiscence. Of 57 interventions, 39 were primary surgeries; 11 (28.2%) showed facial canal dehiscence. and 18 were revision surgeries; 6 (33.3%) showed facial canal dehiscence. The facial nerve was not damaged in any patient. Facial canal dehiscence was observed in 17 (29.82%) interventions. We used intraoperative microscopic findings as the gold standard. Neurophysiological study showed a sensitivity of 94.1, specificity 97.3, positive predictive value (PPV) 57.8 and negative predictive value of 97.2. CT showed a sensitivity of 64.7, specificity 78.4, PPV 57.8 and negative predictive value of 82. Our neurophysiological study showed greater sensitivity and higher PPV than CT for the detection of facial canal dehiscence. We found no relationship between disease progression time and the presence of facial canal dehiscence.

The benefit of trans-attic endoscopic control of ossicular prosthesis after cholesteatoma surgery.

To show the efficiency of using transmastoid atticotomy (TMA) endoscopy on the outcome of ossiculoplasty in patients with cholesteatoma. TMA is often performed as part of the surgical management of patients with middle ear cholesteatoma extending to the epitympanum. TMA can also be used as an access for endoscopic view to confirm the right alignment and stability of the ossicular prosthesis because the reconstruction of the tympanic membrane will obscure the visualization of the prosthesis. A retrospective study was done at a tertiary referral institute, including 133 ears with cholesteatoma that underwent canal wall-up tympanomastoidectomy (CWU) with ossicular reconstruction using titanium prosthesis between August 2013 and August 2015. Post packing of the ear canal and position, stability, and axis of the prosthesis were checked using endoscope positioned in the attic through TMA. A postoperative pure-tone average air-bone gap (ABG) of 20 dB or less was considered as a successful hearing result. Results are compared with historical control groups. Of the 133 ears, 88 patients underwent reconstruction with partial ossicular replacement prosthesis (PORP), whereas the rest (45 patients) had total ossicular replacement prosthesis (TORP). A postoperative ABG ≤ 20 dB was obtained in 77.4% of all the patients (79.5% for PORP; 73.3% for TORP). Endoscopic assessment of the ossicular prosthesis via the attic, after repositioning of the tympanomeatal flap and packing the ear canal, decreases the risk of immediate ossiculoplasty failure and improves the functional outcome after ossicular chain reconstruction in cholesteatoma surgery. 4 Laryngoscope, 129:2754-2759, 2019.