Extensive Cholesteatoma Research Articles

Radiological study of the temporal bone in chronic otitis media: Prospective study of 50 cases

Aim: To assess radiological findings in Chronic otitis media (COM), its involvement in middle ear and adjacent structure and to compare with similar published data. The ability of the radiological investigations to detect the various pathological and anatomical variations were evaluated and compared with intraoperative findings. COM is a long standing inflammation of the middle ear cleft without reference to etiology or pathogenesis. Due to the strategic location of the tympanomastoid compartment, separated from the middle and posterior cranial fossa by the thinnest of bony partitions, otitis media has the potential for intracranial extension. Hence, it becomes very important to know the location and extent of the disease before proceeding to surgical treatment. Radiological examination of the temporal bone helps us to achieve this objective. The present work has been undertaken to study the role of radiological imaging of the temporal bone as a diagnostic modality in COM and its use in determining the lines of management as in the type of surgical intervention required. Materials and Methods: This is a prospective study in which total of 50 cases with COM were studied. Results: HRCT is reliable for all the parameters like scutum erosion, ossicular erosion, mastoid pneumatisation, low lying dura, anterior lying sigmoid, Korner's septum, cholesteatoma extension in the middle ear and mastoid, and presence of complications such as mastoiditis and mastoid abscess, mastoid cortex dehiscence, sigmoid sinus plate erosion, facial canal dehiscence, tegmen mastoideum erosion and labyrinthine fistula and intracranial complications with a P < 0.05 but not reliable for tegmen tympani erosion and posterior fossa dural plate erosion. Conclusion: HRCT is highly reliable and findings are in par with intraoperative findings in this study.

Congenital cholesteatoma in siblings

The exact aetiology of congenital cholesteatoma, the less common form of this destructive disease, is still under debate. A two-year-old boy was referred to paediatric otolaryngology with persistent, bloody, left-sided otorrhoea refractory to oral and ototopical antibiotics. Prior to its onset at age 16 months, all ear examinations on the affected side were normal. Physical examination, imaging with computed tomography and eventual tympanomastoidectomy revealed extensive cholesteatoma. The extent of the disease, age at onset of symptoms and absence of otological disease before initial presentation suggested the diagnosis of congenital cholesteatoma. Review of the family history revealed that the patient's older brother had undergone tympanomastoidectomy for a small, well-encapsulated, mesotympanic congenital cholesteatoma at two years of age. This case joins a single, previous report describing congenital cholesteatoma in multiple family members, suggesting that in some cases, hereditary factors may play a role in the formation of the disease.

The Correlation between Presenting Features and Surgical Outcomes in Pediatric Cholesteatoma

Objectives: Determine how presenting features of cholesteatoma in children influence surgical outcome. Methods: A prospective database of 319 consecutive children with cholesteatoma was analyzed to compare features of cholesteatoma at presentation with patient-focused outcome measures. Features of disease included the presence of otorrhea, hearing loss (mean 4 tone air conduction audiogram more than 30dB HL), the type and extent of cholesteatoma, and ossicular status. Outcomes included hearing threshold, number of surgeries, and canal wall preservation. Cases with cholesteatoma surgery or tympanoplasty prior to referral were excluded. Results: Of 200 children with cholesteatomas, 32 ears presented with congenital lesions and 178 ears presented with acquired lesions. The mean age at diagnosis was 6.6 years for congenital and 11.5 years for acquired cholesteatoma. A history of continuous otorrhea had a sensitivity of 0% for diagnosis of congenital cholesteatoma and 37% for acquired. Hearing loss had a sensitivity of 57% for congenital and 72% for acquired cholesteatoma. The canal wall was preserved in 181 (86%) ears at first surgery. Mean hearing level was unchanged after surgery at 36dB HL. More extensive cholesteatoma correlated with more ossicular erosion, more canal wall down surgery, worse postoperative hearing, and more repeated surgeries ( P &lt; 0.05; multiple regression analysis). Conclusions: Better outcomes for children with cholesteatoma can be achieved by early identification and surgery when lesions are smaller. As cholesteatoma can be relatively silent in children, without otorrhea or hearing loss. Physicians must be trained to identify otoscopic features of congenital and acquired cholesteatoma and initiate prompt referral.

Extensive Tympanic Membrane Cholesteatoma with Marginal Perforation: An Unusual Case

The migration of squamous epithelium of external ear through a tympanic membrane perforation into the middle ear forms a cholesteatoma. But it is extremely a rare condition to observe extensive cholesteatoma on the medial surface of tympanic membrane with perforation. This condition is termed tympanic membrane cholesteatoma (TMC). We herein present an exceptional case of extensive TMC with marginal perforation.

Rozległy perlak piramidy kości skroniowej – opis przypadku

A case of 47-year-old woman with extensive cholesteatoma of the petrous temporal bone extending to the atlas vertebra was described. She was treated by lateral petrosectomy. Diagnostic and therapeutic problems connected to skull base pathology management were discussed.

Middle Ear Cholesteatoma and Its Complications

Objective: Cholesteatoma is still one of the most challenging ear diseases, its evolution leading sometimes to serious complications (facial palsy, vestibular disorders, meningitis, intracranial abscesses, sigmoid sinus thrombosis, etc). Surgical treatment is always required to heal the disease. Method: We reviewed the surgical reports of 534 patients treated in the ENT Clinic from Cluj between 2003 to 2010. Patients’ ages ranged from 3 to 81 years, with a mean age of 30 years. The surgical procedure was to follow the cholesteatoma extension from the tympanic cavity to the mastoid cavity. Results: Most of the cases were operated in closed technique. We have used for ossicular reconstruction incus body without osteitis, the head of the malleus, and cortical of temporal bone. For tympanic membrane and canal wall reconstruction we have used perichondrium cartilage with or without perichondrium. Patients with complications underwent open technique. Recurrence of suppuration was noticed in 28% of cases, requiring a second intervention. Hearing improvement was obtained in 58% of patients, satisfactory results were obtained in 19% of patients, and 23% of patients showed no improvement of hearing. Conclusion: Autologous materials remain a useful alternative for middle ear reconstruction, improving the hearing in most of the cases. The treatment in cholesteatoma is always surgical, requiring a careful removal of the infection. The surgical technique should be individualized from case to case.

Posterior cranial fossa extension of congenital cholesteatoma in children : report of two cases

Posterior cranial fossa extension of congenital cholesteatoma in children : report of two cases

Exclusive Endoscopic Ear Surgery for Acquired Cholesteatoma

To present preliminary results in transmeatal exclusive endoscopic ear surgery. Retrospective. Rigid endoscopes were used for all procedures. A wide posterior tympanomeatal flap was elevated transmeatally, and the scutum was removed with a bone curette or was drilled until visualization of cholesteatoma extension and the mastoid antrum. The malleus and incus were removed when they were involved in the cholesteatoma or restricted access to it. When present, the stapes was left intact. Endoscopic accessibility was defined by no extension of the cholesteatoma beyond the level of the lateral semicircular canal. Scutumplasty was by with tragal cartilage, and tympanic membrane defects were reconstructed with the palisade technique and perichondrium. Thirty patients, aged 9 to 75 years, underwent the exclusive endoscopic transmeatal cholesteatoma eradication between July 2008 and May 2010. There were no incidents of iatrogenic injuries to the facial nerve or ossicles. Closure of the tympanic membrane and good hygienic status (water tolerance and absence of inflammation) were achieved in all operated ears. Two patients had significant postoperative worsening of their sensorineural hearing loss: the cholesteatoma of one of them involved all 3 ossicles and oval window and the other patient experienced postoperative labyrinthitis. There was no residual disease in 18 patients who were followed for more than 1 year, and the non-echo-planar base diffusion-weighted sequence magnetic resonance imaging was negative in 3 patients. Our preliminary results indicate that the minimally invasive endoscopic ear surgery allowed complete eradication of cholesteatoma from the middle ear and its extensions, with minimal morbidity and good functional results.

Transmastoid approach to otogenic brain abscess: 14 years experience

Objectives: Objectives of this study were to review our experience in on otogenic brain abscess and its management by transmastoid drainage and compare the results. Materials and Methods: All patients with brain abscess secondary to CSOM presenting to our department from January 1997 to December 2010 were included in this study. All patients subjected to clinical, neurological, opthalmological examination and CT scan was done as an imaging modality. All patients managed by radical mastoidectomy or modified radical mastoidectomy and transmastoid drainage of brain abscess as neurosurgical facility not available. Results: Seventy-two patients in whom brain abscess secondary to chronic suppurative otitis media was diagnosed and has been treated since 1997 are presented. 85% of patients were below 20 years of age. More than 50% patients presented with more than one complication of chronic suppurative otitis media. 85% of patients were having extensive cholesteatoma and 15% patients were having extensive granulations in middle ear and mastoid air cells. 83% patients were having cerebellar abscess while 17% patients were having temporal lobe abscess. 80% of the pus culture was sterile while in 20% patients various microorganisms such as Proteus spp., Escherichia coli, Pseudomonas aeruginosa, Staphylococcus spp., and Streptococcus spp were cultured. Overall mortality in this series was 4.4%. Conclusion: In diagnosis of otogenic brain abscess CT scan with constrast is of immense help. Transmastoid drainage of brain abscess is a safe and effective method that can be performed by otologists in cases of otogenic brain abscess.

Recurrence of cholesteatoma mimicking dural herniation.

A 25 year old man was admitted to otorhinolaryngology department with a mass in the ear canal. The patient had a history of tympanoplasty with mastoidectomy in another centre (for chronic otorrhea) 2 years earlier. Details of the surgery were not available. He had no discharge during this time and he came to our hospital for routine follow-up visits. On otomicroscopy a white mass was noticed in the superior part of the canal, the origin of which could not exactly be localized. On palpation with a blunt instrument it proved to be soft. No otorrhea was noted in the canal and the tympanic membrane seemed to be intact in the visible area. The most likely diagnosis was cholesteatoma recurrence but the chief differential diagnosis to be ruled out in such cases is meningocele and dural herniation. An HRCT was ordered and the mass origin from attic was obvious. The intact tegmen tympani rules out intracranial involvement. The patient was operated and a rather extensive cholesteatoma was found and cleaned. It seems that he has had an attic cholesteatoma which went unnoticed and consequently unmanaged in the previous surgery and tympanoplasty had been done on the epidermal remnants in the attic.

Posterior cranial fossa extension of congenital cholesteatoma in children: Report of two cases

Abstract Objectives : To present the results of surgical treatment and long term follow-up of two cases of congenital cholesteatoma in young children extending into the posterior cranial fossa. Method : A retrospective review of 264 children, surgically treated for cholesteatoma of the temporal bone between 1999 and 2008 was performed. The presenting symptoms, tympanic membrane findings, surgical findings, methods, and results were investigated retrospectively. Results : 30 cases satisfied the criteria of congenital cholesteatoma. Two patients presented radiological and surgical evidence of extension of the cholesteatoma in the posterior cranial fossa. Post-operative air-bone gap changes were not significant. No recurrence is observed to date. Conclusion : Congenital cholesteatoma is a different disease entity from acquired cholesteatomas, no previous otorrhea episodes are described and the tympanic membrane appears to be intact; the first symptom is usually hearing loss, but in very young children, one side hearing loss may be misdiagnosed, therefore CC may have severe intracranial complications as onset symptomatology. Pre-operative CT imaging is useful for the evaluation of the extension of the disease and planning the appropriate surgical technique.

Acute mastoiditis in Greenland between 1994-2007

The indigenous populations of the Arctic are prone to middle ear infections starting with an early age first episode, followed by frequent episodes of acute otitis media (AOM) during childhood. A high proportion develop chronic otitis media. Acute mastoiditis is a serious complication of AOM in childhood with postauricular swelling, erythema, and tenderness, protrusion of the auricle, high fever and general malaise. The disease may protrude intracranially. The incidence rates for acute mastoiditis in the Western world range from 1.2 to 4.2 cases/100 000 per year. There exists no epidemiological data on acute mastoiditis in the Arctic region. A retrospective search was made for the WHO ICD-10 code DH70.0 (denoting acute mastoiditis) using the National Greenland Inpatient Register for the period 1994-2007, inclusive. Fifteen patients were registered and their medical records were retrieved. Four patients were obviously misclassified, leaving 11 patients for evaluation. The medical records were available for 10 patients. The diagnostic inclusion criterion was written clinical signs of acute mastoiditis. Based on the case series the incidence rate was calculated to be 1.4 for the total Greenlandic population and 7.4 for children 0 and 10 years of age. Median age was 14 months (5-105 months) and eight were female (72%). Seven of the 10 were exclusively treated with antibiotics and three underwent additional ear surgery. Bacteriological examination was performed in five of 10. One 8 month-old girl presented with a contemporary facial nerve paralysis and was treated with intravenous antibiotics; one 8 year-old girl was evacuated to Copenhagen for urgent surgery due to signs of meningitis. Acute CT scan showed a cerebellar abscess and a thrombosis in the lateral sigmoid sinus vein. An extensive cholesteatoma was found and eradicated during surgery. Six weeks later the patient returned home with a maximal conductive hearing loss as the only complication. All patients recovered from the disease. The incidence of acute mastoiditis in Greenland is comparable to the incidence elsewhere, although AOM occurs more frequently among small children in the Greenlandic population. The disease is serious and must be treated immediately with intravenous antibiotics, followed by urgent surgery if there is no improvement.

Cholesteatoma Invasion into the Internal Auditory Canal

Introduction: Temporal bone cholesteatoma usually originates in the mastoid and middle ear cavity. The process of enzymatic bone lysis may result in erosion of the tympanic cavity and mastoid borders and finally extend into the bony labyrinth and internal auditory canal (IAC). The involvement of the membranous labyrinth and IAC poses a serious threat to the facial nerve and vestibulocochlear functions. The origin of cholesteatomas that invade the IAC continues to be a matter of controversy. Such invasion is rare and originates from either acquired giant cholesteatomas, which aggressively erode the labyrinth, or from congenital cholesteatomas that develop in the vicinity of the IAC. Cholesteatoma invasion into the IAC usually results in irreversible, complete hearing loss and facial paralysis on the affected side. The current study, which aims to investigate the clinical characteristics of patients with cholesteatoma invading the IAC, analyzes possible routes of cholesteatoma extension and describes the surgical approaches used and patient outcomes.

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

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

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

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

Cholesteatoma invasion into the internal auditory canal

Cholesteatoma invasion into the internal auditory canal (IAC) is rare and usually results in irreversible, complete hearing loss and facial paralysis on the affected side. This retrospective study examines the clinical characteristics of seven patients with cholesteatoma invading the IAC, analyzes possible routes of the cholesteatoma's extension and describes the surgical approaches used and patient outcome. Extension to the IAC was via the supralabyrinthine route in most patients. A subtotal petrosectomy, a translabyrinthine approach or a middle cranial fossa approach combined with radical mastoidectomy were required for the complete removal of the cholesteatoma. All seven patients presented with some preoperative facial nerve palsy. The facial nerve was decompressed in four patients and facial nerve repair was performed in three others, two by hypoglossal-facial anastomosis and one by a greater auricular nerve interposition grafting. All patients ended up with total deafness in the operate ear. At 1 year following surgery, the facial nerve function was House-Brackmann grade III in six cases and grade II in one. In conclusion, cholesteatoma invading the IAC is a separate entity with characteristic clinical presentations, require a unique surgical approach, and result in significant morbidity, such as total deafness in the operated ear and impaired facial movement.

Residual Cholesteatoma

To compare the incidence and localization of residual cholesteatomas in canal wall down tympanoplasty with soft-wall reconstruction with results with the canal wall down and open tympanoplasty or canal wall up tympanoplasty. Retrospective case-series study. Tertiary care university hospital. Eighty-five patients (85 ears) with fresh extensive cholesteatomas who underwent canal wall down tympanoplasty with soft-wall reconstruction as first-stage surgery and a second operation after 1 year to confirm residual cholesteatomas and perform ossiculoplasty. The incidence and localization of residual cholesteatomas in the middle ear were compared between surgery using the canal wall down and open tympanoplasty and canal wall up tympanoplasty. Possible technical causes of the residua were reviewed in a retrospective videotape analysis of the first-stage operations. Of the 85 ears operated on, 18 had residual cholesteatomas, for an overall incidence of 21%, with 1 residuum per ear. Six cholesteatomas were located in the epitympanum (33%), 3 in the sinus tympani (17%), 3 in the antrum (17%), 2 on the stapes (11%), 2 on the tympanic membrane (11%), 1 on the tympanic portion of the facial canal (6%), and 1 just under the skin of the external auditory canal (6%). The retrospective videotape analysis revealed that the main cause of residual cholesteatomas in the epitympanum and sinus tympani was incomplete removal of the matrix under an indirect surgical view because of insufficient drilling. Residual matrix in a bony defect in the middle cranial fossa or facial canal was the cause of residual cholesteatomas in the antrum or facial canal. Inappropriate keratinizing epithelium rolling during tympanic membrane or external auditory canal reconstruction was the cause of residual cholesteatomas in the tympanic membrane or external auditory canal. The incidence of residual cholesteatomas in patients who underwent canal wall down tympanoplasty with soft-wall reconstruction was similar to that in patients who underwent surgery involving the canal wall down and open tympanoplasty or canal wall up tympanoplasty. In terms of localization, with canal wall down tympanoplasty with soft-wall reconstruction, there is the possibility of residua not only in the tympanic cavity but also in the antrum or mastoid cavity, as with the canal wall up method. Results of this study suggest that in patients with extensive cholesteatoma, canal wall down tympanoplasty with soft-wall reconstruction should be followed by a second procedure to detect any residual cholesteatomas in the tympanic cavity, antrum, or mastoid cavity.

Condition of the anterior part of the middle ear cleft in acquired cholesteatoma

Conclusion: The high rate of flogistic suffering of the controlateral ear seems to suggest a correlation between tubal dysfunction and acquired cholesteatoma but the low rate of pathological reports regarding the anterior mesotympanic region exclude a eustachian tube dysfunction (EDT) at the time of surgery. These observations support the hypothesis that ETD is not a factor that may influence the evolution of the cholesteatoma. Objectives: To evaluate the role of eustachian tube function in the middle ear secondary acquired cholesteatoma. Patients and methods: This was a case series study. The study group consisted of 72 patients submitted to tympanoplasty for middle ear secondary acquired cholesteatoma. Results: The contralateral ear was normal in 37 subjects (51%) and affected by chronic otitis media in 35 (49%); the anterior part of middle ear cleft was normal in 53 patients (74%). There was no significant relationship between the contralateral ear condition and the status of the anterior region of middle ear (p>0.05). The site of retraction or the presence of tympanic perforation with skin migration was not related to the condition of the protympanum. Otorrhea, cholesteatoma extension, and ossicular chain lesions were not significantly related to the status of the anterior part of the middle ear cleft (p>0.05).

Congenital cholesteatoma of the middle ear – a report of 10 cases

ObjectivesTo study clinical, imaging features and treatment outcomes of congenital cholesteatoma of middle ear (CCME). MethodsThis is a retrospective review of 10 CCME cases selected from 952 cholesteatoma cases treated between January 1995 and December 2005 at the Department of Otolaryngology-Head and Neck Surgery, Chinese PLA General Hospital. The main outcome measures were the site of origin, clinical features, surgical findings, imaging characteristics and hearing results. ResultsThe mean age of the 10 patients was 16 years(ranged from 10 to 24 years), with 6 being older than 18 years. There were 7 males and 3 females. The average delay to diagnosis was longer than 2 years. The mean preoperative PTA was 55 dB HL, with a mean ABG of 45 dB. Typical cholesteatomas were seen behind the tympanic membrane in the superoposterior quadrant on otoscopy only in 2 patients. High resolution CT was completed in all patients. Most of the patients(8/10) were diagnosed with otosclerosis or ossicular abnormality before operation. All patients underwent a one-stage tympanoplasty following transmeatal explorative tympanotomy and complete cholesteatoma removal, except one, who underwent a CWU mastoidectomy due to extensive cholesteatoma involvement. The choleasteatoma lesion was confined to the superoposterior mesotympanum in all patients. The mean postoperative PTA was 20 dB HL. All patients were followed-up for at least 1.5 years postoperatively. Revision procedures were performed in 2 patients for hearing deterioration. No residual or recurrence of cholesteatoma was found. ConclusionCCME is a rare disease that often gets delayed diagnosis. Residual lesions and the prognosis mainly depend on the extent of the lesion.

Improvements to staged canal wall up tympanoplasty for middle ear cholesteatoma

To describe our improvements to staged canal wall up tympanoplasty with mastoidectomy (SCUT) for middle ear cholesteatoma, and to show more successful outcomes of the surgery compared with our data previously reported. Retrospective study in a tertiary referral hospital. 78 ears of 76 patients with extensive cholesteatoma were operated on using the improved SCUT between July 1998 and December 2006. Improved SCUT included new techniques such as scutum plasty and mastoid cortex plasty performed in a staged manner. Only 2 ears showed retraction pocket formation (7.7%) without recurrence in 26 ears followed for more than 5 years. In 48 followed for more than 3 years, frequency of postoperative retraction pocket formation (5/48; 10.4%) was significantly lower compared to our previous results (41/134; 30.6%, P < 0.01). Our improvements to SCUT contributed to the decreasing of frequency of postoperative retraction pocket that may lead to cholesteatoma recurrence, although a longer follow-up study is required.