Lateral Attic Wall Research Articles

Novel Method of Cartilage Harvest in Otology with Micro Dermatome: A Descriptive Study.

Cartilage is used in middle ear surgery for reconstruction of tympanic membrane, ossicular chain, posterior canal wall and lateral attic wall. When used in tympanic membrane reconstruction, thickness of the cartilage is thought to interfere with the sound conduction. In our otology practice for tympanic membrane reconstruction, we prefer the sliced cartilage graft to achieve acoustic benefit. We have used a microdermatome for precise reduction of the thickness of the cartilage. This also allows us to select exact thickness of cartilage slice and also permits slicing from donor site directly. To describe the use of novel method of cartilage slicing using a micro dermatome and to report our preliminary experience. This is a descriptive study, with a total number of 350 cartilage grafts used in tympanoplasty and mastoidectomies have been prepared with micro dermatome from 2019 to 2021. Our study reports the technique of slicing the Conchal cartilage and how its uniform measurement can be obtained. Our modified technique using the micro dermatome is easy to master, provides precise cartilage thickness as per needs within a short span of time. Harvesting from the donor site is as per the graft requirement and rest of the cartilage is left in place for the future revision surgery if needed. The cartilage obtained were structurally integral without any undue breakage and functionally stable. The thickness of the cartilages obtained makes it pliable for easy handling and placement in ear surgeries.

Clinical analysis of 21 cases of cholesteatoma recidivism after canal-wall-up mastoidectomy with tympanoplasty

Objective:To discuss the possible reasons for cholesteatoma recidivism after canal-wall-up mastoidectomy with tympanoplasty by analyzing clinical characteristics of patients. Methods:Data of 21 cases who suffered from cholesteatoma recidivism after canal-wall-up surgery were retrospectively reviewed, including preoperative examination, high resolution temporal bone CT, and intraoperative findings. Results:90.5%（19/21） cases had recurrent cholesteatoma with retraction pockets. Among 12 cases with previous operative notes, 66.7%（8/12） had extensive cholesteatoma which was not limited to attic in the original surgery. The intraoperative features of revision surgery in 21 patients including the destruction of reconstructive lateral attic wall and scutumwere found in 19.0%（4/21） cases, the head of malleus left in 19.0%（4/21） cases, the cholesteatoma found in hidden part in 14.3%（3/21） cases, the hadeustachian tube dysfunction in 38.1%（8/21）cases. the sclerotic mastoid in 42.9%（9/21） cases. hadanatomic variations of the temporal bone in 14.3%（3/21） cases and atresia of external auditory canal in 4.8%（1/21） cases. Conclusion:In this group of recidivism cases, most patients had extensive cholesteatoma, which may lead to excessive mucosa loss during lesion clearance, poor ventilation of tympanic isthmus after surgery, and promote the formation of retraction pocket. In addition, some cases had eustachian tube dysfunction, unstable reconstruction of attic lateral wall, and improper selection of the indications, which may also increase the risk of recurrence. Therefore, in order to reduce cholesteatoma recidivism after canal-wall-up surgery, attention should be paid to the striction of surgical indications, comprehensive preoperative evaluation, thorough clearance of lesions and firm reconstruction.

Mrmc Neo Surgical Ventilating Port and Neo Attic Malleo-Incudal Complex in Endoscopic Management of Limited Attico-Antral Cholesteatoma.

To study functional outcome of the endoscopic management of limited attico-antral cholesteatoma in terms of visualization of sac, cholesteatoma disease clearance, ABG closure improvement, preservation of residual anatomy and recurrence of disease. It is a prospective study done during Feb 2016 to March 2017 done on 20 pts with limited attico-antral cholesteatoma with CT confirmation. Endoscopic management of limited attico-antral cholesteatoma with complete removal of sac, infected discharge and granulations along with creation of MRMC Neo surgical ventilating port (joining Anterior & posterior isthmuses) done in cases where residual attic anatomy was present to establish physiological attic ventilation and drainage. Whereas in cases of attic and ossicular erosion, ossiculoplasty along with neo attic malleo-incudal complex (with composite tragal cartilage with perichondrium graft) for lateral attic wall reconstruction was done to prevent attic retraction. Patients had mean pre op ABG of 36.29±6.29 and mean post op ABG closure of 16.33±6.50 with no recurrence of cholesteatoma at 6months of follow up. Patient showed significant (55%) improvement in hearing with all having graft uptake in which four cases having mild pars tensa retraction which recovered later without any intervention. Thus creation of new MRMC Neo surgical ventilating port or neo attic malleo-incudal complex with endoscopic approach allows better visual access to clear the limited attico-antral disease with sparing of normal residual attic anatomy along with physiological ventilation and drainage having better hearing results and outcome.

Reconstruction of lateral attic wall in acquired cholesteatoma

Background/Aim. Attic cholesteatoma is an epithelial cystic pseudotumor which arises in the top compartment of the middle ear. Surgery is the only therapeutic treatment for attic cholesteatoma. The aim of this study was to analyze the surgical and audiological results in tympanoplasties that use a logical application of several techniques for the management of attic cholesteatoma. Our hypothesis was that the tympanoplasty technique with cartilage/bone reconstruction of the achieve better outcome than the tympanoplasty technique with only temporal fascia reconstruction of the lateral attic wall. Methods. This retrospective clinical study included 80 patients, aged 16?65 years, with attic cholesteatoma undergoing canal ?wall up? tympanoplasty with lateral attic wall reconstruction, under general anesthesia in the Eear, Nose and Throat Clinic, Military Medical Academy in Belgrade between 2006 and 2010. The patients were divided into two groups according to the type of lateral attic wall reconstruction: the group I of 60 patients with cartilage/bone plus temporalis fascia lateral attic wall reconstruction and the group II of 20 patients with only temporal fascia lateral attic wall reconstruction. Postoperative follow-up examinations were done at least 5 years after the surgery. The ?2 test was used to compare postoperative sequelae for two groups of operated patients with lateral attic wall reconstruction. The independent and paired samples t-test of air conduction and air-bone gap were used to compare the results of preoperative and postoperative hearing tests. Results. The differences between hearing measurements of the two groups according to preoperative and postoperative auditory thresholds of the air conduction and the air-bone gap were considered no statistically significant. The difference between the two groups recarding to recurrent attic retraction pocket appearance and recurrence of cholesteatoma was considered statistically significant and the results were much better in the group I of the operated patients with cartilage/ bone lateral attic wall reconstruction. Conclusion. ?Wall up? tympanoplasty for attic cholesteatoma with lateral attic wall reconstruction leads to good anatomical and audiological results. A significant hearing improvement was obtained in both the types of lateral attic wall reconstructions in this study. Reconstruction with cartilage or mastoid cortex bone showed favorably long-term functional and anatomical results compared to primary tympanoplasty using only temporal fascia for lateral attic wall reconstruction in cases of attic cholesteatoma.

Lateral Attic Wall Reconstruction with Glass Ionomer Bone Cement in the Management of Primary Acquired Attic Cholesteatoma in Children: A Preliminary Experience.

To assess the effectiveness of glass ionomer bone cement (GIBC) in lateral attic wall reconstruction after primary acquired attic cholesteatoma surgery. This prospective study was conducted on twenty children collected from the ENT outpatient clinics of a secondary and tertiary hospital. All patients presented with chronic suppurative otitis media with cholesteatoma of the primary acquired attic type. All patients underwent intact canal wall mastoidectomy (ICWM) with a transcanal atticotomy to address primary cholesteatoma involving the attic and the supratubal recess. Removal of the incus with or without decapitation of the malleus depended on the extension of the pathology. GIBC was used to build up the lateral attic wall in all cases. Ossiculoplasty and tympanoplasty were performed according to the extent of disease. All patients had integrated skin covering the reconstructed attic wall with no signs of granulation tissue formation, canal wall edema, glass ionomer extrusion, or foreign body reaction on the 6th month, 1st year and 2nd year follow-up visits. Also, no persistent otorrhea was noted. The postoperative air-bone gap was significantly improved (p=0.007). GIBC could be considered as a reliable artificial material for reconstruction of the lateral attic wall after transmeatal atticotomy in ICWM, making it feasible to avoid cavity problems of canal wall down mastoidectomy, especially in children.

Life table analysis of results of staged intact canal cholesteatoma surgery using bone pate to reconstruct the lateral attic wall

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Hearing results of tympanoplasty with attic reconstruction vs. obliteration in attic cholesteatoma

INTRODUCTION: The aim of the study was to compare hearing results between tympanoplasty with attic wall reconstruction and attic obliteration. MATERIAL AND METHODS: A prospective study included 88 patients who were operated for chronic suppurative otitis media (CSOM) and cholesteatoma in the ENT Department University Clinic Center Banja Luka from 2006 to 2011. Analysis of variance (ANOVA) was conducted to assess the impact of two different techniques of tympanoplasty: attic wall reconstruction and attic wall obliteration on patients` hearing. Hearing outcome was measured comparing preoperative to postoperative pure-tone average (PTA) and postoperative air-bone gap (ABG). RESULTS: Cholesteatoma was found in 54 (61.4%) patients: 31 (35.2%) sinus cholesteatoma, 20 (22.7%) attic cholesteatoma, 3 (3.4%) tensa tympanic cholesteatoma, and 34 cases (38.6%) of CSOM. Lateral attic wall and ossicular chain reconstruction was performed in 33 cases with subsequent attic reconstruction if the long process of the incus and the incudo-stapedial joint were missing. A mixed between-within-subjects analysis of variance showed significant improvement of PTA postoperatively in comparison to preoperative levels: Wilk`s Lambda=0.33, F(1,86)=172.1, p<0.001. ANOVA showed significant improvement of ABG postoperatively in comparison to preoperative levels: Wilk`s Lambda=0.23, F(1,86)=286.3, p<0.001. Hearing improvement was measured in both cases, the ABG closure and mean PTA improvement was larger in the attic reconstruction compared to attic obliteration technique. CONCLUSION: Attic wall reconstruction with cartilage provides better postoperative hearing compared to attic obliteration. Attic reconstruction in revision cases for cholesteatoma recurrence is not recommended.

Magnetically driven middle ear ossicles with laser vibrometry as a new diagnostic tool to quantify ossicular fixation

Conclusion: Information on the degree of incus fixation can be gathered by measuring the ratio of incus to umbo long process velocity through the ear canal. Objectives: To test a new method of quantifying partial ossicular fixation in an ear with an elevated tympanic membrane. Methods: Measurements were made on four fresh-frozen human temporal bones. After elevating the tympanic membrane a small magnet was attached to the manubrium and an electromagnetic excitation coil was used to vibrate the ossicles. The vibration response of the tip of the incus long process and the umbo were measured before and after artificially fixating the incus to the lateral attic wall. Results: Partial incus fixation resulted in a decrease in both the incus and umbo velocities, with the incus velocity being more severely reduced. The decreased ratio of their vibrations is a clear indicator of the degree of incus fixation.

Imaging Findings in Auto-Atticotomy

An acquired attic cholesteatoma may spontaneously drain externally into the external auditory canal, leaving a cavity in the attic with the shape of the original cholesteatoma but now filled with air, a phenomenon referred to as "nature's atticotomy" or auto-atticotomy. We describe and quantify the CT appearance of the auto-atticotomy cavity as it pertains to the appearance of the scutum and the lateral attic wall. Twenty-one patients with erosion of the scutum and loss of the lower attic wall on MDCT were identified during a 5-year span. Images were assessed for measureable widening of the space between the ossicles and the lower lateral attic wall in the axial and coronal planes. Three measurements of the lateral attic were made on the axial images. Findings were compared with the same measurements in 20 control subjects. The 21 patients had a characteristic blunting of the scutum with loss of the lower lateral attic wall and widening of the lateral attic, consistent with an auto-atticotomy. There was a statistically significant (P < .001) widening of the lateral attic dimensions in the axial plane in the patients with auto-atticotomy. Spontaneously evacuated cholesteatoma may mimic a surgical atticotomy on MDCT. Scutal erosion and attic enlargement with a smoothly contoured bony remodeling of the lower lateral attic wall in a patient with no history of surgery suggest that a cholesteatoma was previously present and spontaneously drained.

Evaluation of Temporal Bone Cholesteatoma and the Correlation between High Resolution Computed Tomography and Surgical Finding

BackgroundAcquired cholesteatomas are commonly seen in patients less than 30 years. There is a typical history of recurrent middle ear infections with tympanic membrane perforation. The diagnosis of cholesteatoma is usually made on otologic examination.ObjectiveThe aim of the work was to study the role of high resolution computed tomography (HRCT) in detecting, evaluating, and diagnosing middle ear cholesteatoma.Patients and methodsThis was a prospective study that included 56 consecutive patients with chronic suppurative otitis media, unsafe type cholesteatomas. Each patient was subjected to full clinical evaluation, and HRCT examination. Intravenous contrast media was used in some patients with suspected intracranial complication. Preoperative radiological data were correlated with data related to surgical findings.ResultsThe study showed that a high incidence of cholesteatoma in the third decade of life. The scutum and lateral attic wall were the most common bony erosions in the middle ear bony wall (64.3%), and the incus was the most eroded ossicle in the middle ear (88.2%). Sclerosing of mastoid air cells were encountered in 60.7% of patients and the lateral semicircular canal was affected in 9%, while facial canal erosion was found in 21.4%. Temporal bone complications are more common than intracranial complications.HRCT findings were compared with operative features; the comparative study included the accuracy and sensitivity of HRCT in detecting cholesteatoma (92.8%), its location and extension (96.4%), ossicular chain erosion (98%), labyrinthine fistula and intracranial complications (100%).ConclusionThe important role of HRCT scannig lies on the early detection of cholesteatoma, and more conservative surgical procedures can be used to eradicate the disease.

Temporalis Fascia Graft Perforation and Retraction After Tympanoplasty for Chronic Tubotympanic Otitis and Attic Retraction Pockets

To correlate the recurrence of temporalis fascia graft perforation and retraction in adults and children after tympanoplasty for chronic tubotympanic otitis and deep attic retraction pockets with age, pathologic process, mucosal lesions, mucociliary transport time, chronic sinusitis, and lateral attic wall reconstruction. Retrospective study. Tertiary referral center. Two hundred seventy-four adult ears and 41 child ears were operated on for chronic tubotympanic otitis, 50 adult ears were operated on for traumatic tympanic membrane rupture, and 56 adult ears were operated on for attic retraction pockets. Underlay tympanoplasty with or without mastoidectomy and lateral attic wall reconstruction for attic retraction pockets. Mucociliary transport time was investigated using saccharin testing. Recurrent perforation, recurrent attic retraction, and temporalis fascia graft retraction were evaluated. Higher incidences of recurrent perforation were found in adults operated on for tubotympanic otitis vs traumatic tympanic membrane rupture (P = .02) and in children (P = .004), especially those 9 years and younger (P = .02). A risk factor in adults was chronic sinusitis (risk ratio, 35.0; 95% confidence interval, 32.1-38.2; P = .004). Temporalis fascia graft retraction correlated with slower mucociliary transport time in adults (P < .001). A lower incidence of recurrent attic retraction was associated with lateral attic wall reconstruction (P < .001). Recurrent temporalis fascia graft perforation after tympanoplasty for tubotympanic otitis may be related to age and coexisting chronic sinusitis. Temporalis fascia graft retraction correlates with slower mucociliary transport time in the eustachian tube. Lateral attic wall reconstruction minimizes recurrent attic retraction in adults.

Traumatic dislocation of the incudostapedial joint repaired with fibrin tissue adhesive

We present a case of traumatic dislocation of the incudostapedial joint (ISJ) and a simple method for controlled application of the glue using commercial fibrin tissue adhesive. A 26-year-old female presented to our ENT clinic for hearing impairment to her left ear 2 months after a head trauma due to a motorcycle accident. The audiogram revealed a 40- to 50-dB HL conductive hearing loss with a notch configuration in bone conduction curve on the left ear. Computed tomography of the left temporal bone revealed a longitudinal fracture line. An exploratory tympanotomy was performed under general anesthesia. The ISJ was found dislocated while the incus was trapped by the edges of the bony lateral attic wall fracture. A small bony edge that impeded incus movement was removed and a small amount of the glue was precisely applied to the lenticular process of the incus with an angled incision knife. The long process of the incus was firmly pressed over the stapes for 30 seconds with a 90° hook and 60 seconds after the application of the glue the ISJ was repaired. One year after our patient achieved full airbone gap (ABG) closure (ABG, ≤10 dB HL), while she demonstrated overclosure in frequencies 2 and 4 kHz. Fibrin tissue glue allowed safe, rapid, and accurate repair of the ISJ and resulted in an anatomically normal articulation as the mass and shape of the ossicles was preserved. Moreover, our patient achieved full ABG closure.

Reconstruction of lateral attic wall using autogenous mastoid cortical bone

Purpose To explore the outcomes of lateral attic wall (LAW) reconstruction using autogenous mastoid cortical bone in cases with poorly developed zygomatic root cells and/or a low tegmen or with significant anterior or lateral sigmoid sinus in tympanomastoid surgery. Material and methods Thirty-five ears with chronic suppurative otitis media, all of them either with poorly developed zygomatic root cells and/or a low tegmen (26/35 ears), or with significant anterior or lateral sigmoid sinus (9/35 ears), were included. LAWs were removed temporarily to offer exposure of the attic; after removal of the pathological conditions in the attic and the mastoid, LAW was reconstructed using autogenous mastoid cortical bone. The condition of the reconstructed LAW and tympanomastoid aeration was evaluated by computed tomographic scan or/and otoendoscopy. Results The pathological conditions in the attic, the antrum, and the mastoid could be removed with safety in all cases; no serious complications occurred, the new canal appeared to be of normal size and shape, and no dislocation or necrosis of the repaired part was noted. Most of the cases had no significant attic retraction and kept good tympanomastoid aeration postoperatively. Conclusion The reconstruction of LAW is especially suited to the cases in our study, and the reconstructed LAW can produce an almost normal anatomical external auditory canal, prevent the formation of attic retraction, and restore the mastoid cavity aeration in most of the cases.

Osteoplastic atticoantrotomy with autologous bone chips and a bony attic strut in cholesteatoma surgery

The objectives of this study were to determine whether autologous bone chips are suitable materials for canal wall reconstruction after cholesteatoma removal and to evaluate the effectiveness of a separate attic bone graft for the prevention or recurrent cholesteatomas using prospective study of two consecutive patient series (29/31 unselected patients with an average follow-up of 36.3 +/- 11.1/21.5 +/- 6.3 months) and retrograde resection of the posterior-superior canal wall followed by reconstruction of the canal defect using one or more temporal squama bone chips. In the second series, lateral attic wall reconstruction and pars flaccida reinforcement was established by a notched bony attic strut attached onto the neck and short process of the malleus for structural support. In the first series, the rate of recurrent cholesteatomas (17.3%), in particular of attic retraction pockets (31%), was significantly high. The average postoperative air-bone gap was 6.4 +/- 6.3 dB in type-I tympanoplasty (TP), 8.7 +/- 3.4 dB in type-III TP with intact stapes suprastructure, and 16.4 +/- 9.3 dB in type-III TP with TORP, respectively. In the second series, recurrent cholesteatoma and retraction pocket rate could be decreased to 9.7 and 6.5%, respectively. The postoperative air-bone gap was 7.5 +/- 5.1 dB HL in type-I tympanoplasty (TP), 11.6 +/- 4.9 dB HL in type-III (PORP) TP, and 17.9 +/- 12.2 dB HL in type-III (TORP) TP. Connecting the attic strut to the malleus neck did not affect the malleus mobility and hearing outcome. Osteoplastic atticoantrotomy with autologous bone chip reconstruction enables a tailor-made anatomical and physiological reconstitution of the auditory ear canal, thus enhancing the acoustic properties. Precise reconstruction of the lateral attic wall and reinforcement of the superior part of the tympanic membrane seems to be important for the prevention of retraction pockets and subsequent recurrent cholesteatoma development.

Long-Term Outcome of Atticotomy for Cholesteatoma in Children

To evaluate the long-term outcome of atticotomy (AT) surgery for cholesteatoma in children. Case series, retrospective chart review. General otology practice in a teaching hospital. Fifty-three children aged 5 to 16 years old with cholesteatoma limited to the attic and middle ear who underwent AT between the years 1979 to 1994. AT consisting of removal of cholesteatoma confined mainly to the attic. The procedure consists of removal of the lateral attic wall (scutum) and involved ossicles with excision of the cholesteatoma and tympanic membrane grafting with temporalis fascia, leaving a small attical cavity. The mastoid antrum was left intact. Disease recurrence, middle ear status, hearing results, and the need for further surgery. Mean follow up was 5.1 (+/-3.6) years. Eleven (21%) children required completion canal wall down tympanomastoidectomy because of residual disease or recurrence. The mean preoperative speech recognition threshold was 39.4 +/- 13.4 dB. The mean postoperative speech recognition threshold was 34.5 +/- 15.4, an improvement of 6.1 dB compared with the preoperative level. Last follow-up examination revealed a dry ear in all cases but one. In selected cases, AT can be a less invasive option in children with cholesteatoma limited to the attic and middle ear.

A retrospective study on cholesteatoma otitis media coexisting with cholesterol granuloma.

To investigate the etiology and pathogenesis of cholesteatoma otitis media accompanied by cholesterol granuloma and the relationship between cholesteatoma and cholesterol granuloma, 63 cases of middle ear cholesterol granuloma treated in our hospital during the period from March 1988 to May 2000 were retrospectively reviewed. All cases were surgically and pathologically verified. 15 cases of cholesteatoma coexisting with cholesterol granuloma were found among the 63 patients. All 15 cases had a long-term history of otitis media, such as otorrhea (sanguine purulent otorrhea and bloody otorrhea in 8 cases) and perforation of the eardrum (perforation of pars flaccida in 8 cases). Temporal bone CT scans showed cholesteatoma in 11 cases. All patients were treated surgically, and cholesteatoma and cholesterol granuloma were found coexisting alternately, the latter lying mainly in the tympanic antrum, attic and mastoid air cells. Chocolate-colored mucus was accumulated in well-developed mastoid air cells, and glistening dotty cholesterol crystals were also found. In most cases, enlarged aditus, destruction of lateral attic wall, erosion of ossicular chain, exposure of horizontal segment of facial nerve and tegmen of attic were observed. Occlusion of Eustachian tube was noted in 6 cases, and occlusion of tympanic isthmus was revealed in all cases. A post-operative dry ear was achieved in all patients, and hearing improvement was achieved in all 12 cases following tympanoplasty. Cholesteatoma and cholesterol granuloma in middle ear may share a common pathophysiological etiology: occlusion of ventilation and disturbance of drainage. The diagnosis should be considered when patients presented with chronic otitis media with bloody otorrhea. CT and magnetic resonance imaging are useful for the diagnosis before operation. The surgical approach depends on the location, extension and severity of the lesion. The purpose of surgery is to remove the lesion and create an adequate drainage.

Saddle blanket graft tympanoplasty and lateral attic wall reconstruction for defects produced by primary acquired cholesteatoma.

Saddle blanket graft tympanoplasty and lateral attic wall reconstruction for defects produced by primary acquired cholesteatoma.

Transcanal atticoaditotomy and transcortical mastoidectomy for cholesteatoma: the Farrior-Olaizola technique revisited.

Conservative mastoid surgery in the management of middle ear cholesteatoma has been a subject of controversy for decades. Proponents of the combined-approach tympanoplasty for cholesteatoma do not entirely support the conservative approach in children, especially in the hands of an inexperienced surgeon. We describe here our experience with a modified technique of conservative mastoid surgery involving an atticoaditotomy and a separate simple mastoidectomy with lateral attic wall reconstruction (modified Farrior technique) that can be relatively safely used in the majority of cases of chronic squamous otitis media, even in children. This was a prospective analysis of the therapeutic effects and benefits of the technique used in 103 cases of cholesteatoma at Staffordshire General Hospital from 1991 to 1997. The follow-up was between 3 and 9 years. The study group consisted of 55 male patients and 48 female patients, including 28 children less than 16 years of age. The age ranges were 9 to 61 years in male patients and 10 to 48 years in female patients. After an audiological assessment, all patients underwent the described mastoid procedure, and some of them required revision surgery, mostly for a second look or for ossiculoplasty. The chief outcome measures used were complete eradication of disease, incidence of disease recurrence, and restoration of hearing. The steps of the procedure, its pros and cons, and the results of the series are presented. Also discussed is an overview of the literature pertaining to intact-canal wall mastoid surgery. Of the 103 patients, only 3 had a recurrence of disease, and 9 patients showed no hearing improvement. We conclude that this modified technique has several advantages over the previously described mastoidectomy procedures. It is a relatively simple and effective technique that can be performed even in children.

Cholesteatoma--pathology and treatment.

(1) The prerequisite for development of cholesteatoma is a cholesteatoma bed, that is a loose subepithelial connective tissue layer which acts as a nutrient bed and makes papillary growth of squamous epithelium possible. (2) The formation of cholesteatoma is facilitated by disturbed tubal function with reduced ventilation of the middle ear. (3) The progression of cholesteatoma, especially the bone destruction, is due to enzyme-activated cell groups. The epidermal layer in the postero-superior area of the tympanic membrane has a higher papillary content and during an inflammatory process there is a marked vascular reaction. This particular area has a special nutritional zone and the epidermis is especially well nourished [Lange, 1925]. The main artery to the tympanic membrane travels along the handle of the malleus and gives off branches. In our animal experiments epithelial cones grew into this well-nourished subepithelial zone and formed cholesteatoma. The importance of tubal function as regards cholesteatoma formation can be seen in everyday clinical practice. In stapedectomy patients, the lateral attic wall is usually removed to allow full visualisation of the stapes, but retraction pockets in this area are never seen at subsequent follow-up. However, if the lateral attic wall is removed during surgery for chronic otitis media, reconstruction with cartilage or ceramic is necessary to prevent retraction. This adds weight to the hypothesis that tubal dysfunction is an important aetiological factor in cholesteatoma. This is further supported by the 30 times greater incidence of retraction pockets in patients with cleft palate.

Tomographic Diagnosis of Gholesteatoma of the Middle Ear

Tomographic study coupled with information obtained from otoscopic observation of the ear drum, middle ear and audiometry provide otologists with a complete picture of cholesteatomatous involvement of the temporal bone. Tomographic studies were performed in our clinic preoperatively using a Hitachi Polytome. The ear was sectioned at consecutive levels 2.5mm apart with 4 cuts for lateral projection and 5 for frontal. Diagnosis of cholesteatoma was made when there were tomographic findings of widening over 3mm of spur interval (distance between the lateral aspect of the head of malleus and the lateral attic wall), destruction of the anterior tympanic spine and an excessively blurred attic.In the retrospective review of tomograms of the surgically treated patients, we found changes compatible with cholesteatoma in 89% of 46 patients with surgically confirmed cholesteatoma. Tomographically we were able to determine the size and extent of cholesteatoma as well as the involvement of the ossicles, dural plate, facial canal, lateral sinus and lateral semicircular canal. Forty-six cases of cholesteatoma were classified according to the site and the extent of cholesteatoma into three types: the attic type (13 ears), the tympanic type (15) and the advanced type (18).Thus the usefullness and accuracy of preoperative tomographic examinations in cholesteatoma cases have been well demonstrated.