Postoperative Retraction Pocket Research Articles

Attic Reconstruction in Pediatric Canal Wall‐up Mastoidectomy

Objective: 1) To evaluate 3 methods: conchal cartilage, tragal cartilage, and bone pate, for primary attic reconstruction (scutumplasty) in pediatric canal wall-up mastoidectomies in terms of recurrence rates and formation of retraction pockets. Method: All patients undergoing attic reconstruction following a canal wall up mastoidectomy were evaluated from a single surgeon prospective pediatric otological database maintained over a 10-year period. The reconstruction of the scutum defects was done using bone pate, conchal and tragal cartilage. The outcome measures were postoperative retraction pocket formation and recurrence of cholesteatoma. Results: A total of 120 patients underwent primary attic reconstruction following canal wall-up mastoidectomy over a 10-year period. The overall recurrence rate was 9.83% (n = 12). Fifty-one patients underwent attic reconstruction with tragal cartilage, while 33 were reconstructed using conchal cartilage and 36 with bone pate. The recurrence rate with various reconstruction methods was 5.8% (n = 2), 15.1% (n = 5), and 13.8% (n = 5) for tragal, conchal, and bone pate, respectively. Cholesteatoma recurrence rates with the use of tragal cartilage for reconstruction of the scutum were significantly lower as compared to that of conchal cartilage ( P = .034, chi square = 3.308) and bone pate ( P = .046, chi square = 2.834). Conclusion: The use of the tragal cartilage for scutum reconstruction is associated with the least recurrence rate for pediatric cholesteatoma. The easy accessibility, stability, and good long-term results with the use of the tragal cartilage makes it an ideal material for outer attic wall reconstruction in pediatric canal wall up mastoidectomies.

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.

Surgical Treatment of Retraction Pocket With Bone Pate: Scutum Plasty for Cholesteatoma

Postoperative attic retraction pocket is a critical issue and may be indicative of disease recurrence after canal-up tympanoplasty for middle ear cholesteatoma. Although scutum plasty is an acceptable procedure that can be used to prevent the pocket formation, how the scutum is reconstructed has remained controversial. The aim of this study was to clarify the value of scutum plasty using bone pate. Retrospective study. Bone pate scutum plasty was performed in 69 ears during first-stage operations. We attempted to reconstruct a smooth attic bony wall. At the time of the second-stage operations, the results of the scutum plasty were examined. The incidence of retraction pocket was statistically reduced from 20.2% to 5.8%. Although the reconstructed scutum showed atrophy to some extent, bone pate scutum plasty is effective in preventing postoperative retraction pocket if a smoothly shaped attic wall can be reconstructed.

Surgical treatment of retraction pocket with bone pate: Scutum plasty for cholesteatoma

Objectives: Postoperative attic retraction pocket is a critical issue in canal up tympanoplasty for the treatment of middle ear cholesteatoma because it is the most frequent cause of the recurrence. Although scutum plasty is accepted as one of the procedures to prevent the pocket formation, the most effective method of the plasty has remained controversial. This study aims to clarify the value of scutum plasty using bone pate as a preventive measure of postoperative retraction pocket. Methods: Between 1997 and 2002, scutum plasty using bone pate was carried out in 69 ears with cholesteatoma at the first stage operation. We attempted to reconstruct a smooth attic bony wall that facilitates epithelial migration from the eardrum to the external ear canal. At the second stage operation, the results of the scutum plasty were examined. The incidence of retraction pocket, grade of the aeration and inflammation in the middle ear were assessed. Then the results were compared with those in the previous 84 ears without bone pate scutum plasty surgery. Results: The incidence of retraction pocket in the recent group was 5.8% while in the previous group 20.2%. The difference was statistically significant. There was no significant difference in the middle ear aeration and inflammation between the 2 groups. Conclusions: Although the reconstructed scutum showed some extent of atrophy, the scutum plasty is effective to prevent postoperative retraction pocket if a smoothly shaped attic wall is reconstructed. Therefore the scutum plasty using bone pate will help reduce recurrence of cholesteatoma in canal up operation.

Canal wall up tympanoplasty: prevention of cholesteatoma recurrence following postoperative retraction pocket

The ideal surgical treatment for middle ear cholesteatoma is to create a re-pneumatized middle ear cavity from the Eustachian tube to the mastoidectomy cavity. The canal wall up technique is advantageous in this regard although its reliability for the prevention of cholesteatoma recurrences has always been subject to controversy. This paper describes the surgical concepts to create a communication route from the protympanum to the attic by widening the tympanic isthmus with anterior tympanotomy. Removal of the incus and the head of the malleus helps to maintain its patency in ears with a poorly developed supratubal recess. Erosion of the scutum should be repaired using autologous cartilage. We apply staging operation with placement of silicon sheeting in the middle ear space in ears with irreversibly diseased or absent middle ear mucosa.

Tympanoplasty with Soft Posterior Meatal Wall Reconstruction for Prevention of Retraction Cholesteatoma Recurrence

It is reasonable to reconstruct the new middle ear in which the retraction pocket is difficult to bring about even when negative pressure is generated in the post-operative middle ear cavity, considering the prevention of cholesteatoma recurrence. It is also better to attain dry ears in a short post-operative period and to prevent cavity problems. We began to perform tympanoplasty with reconstruction of the soft posterior meatal wall for the prevention of post-operative retraction pocket formation in 1989. This report presents the surgical procedure and the theory of our method, discusses the advantages of this surgery by comparing two cases with different post-operative middle ear conditions and presenting a third case with retraction cholesteatoma recurrence.

Facial nerve tumors.

To evaluate the surgical results in primary facial nerve (FN) tumors. Retrospective case review. Private neuro-otological and skull-base tertiary referral center. Twenty eight consecutive patients affected by primary FN tumors that underwent surgery between December 1990 and February 2001. The lesions were removed through a variety of surgical approaches, depending on tumor location and extension, as well as preoperative hearing. In one case, partial removal was performed. Preoperative and postoperative FN function; preoperative and postoperative hearing level; and postoperative complications. Based on histologic examination, tumors were distributed as follows: 18 schwannomas, six hemangiomas, two meningiomas, and two neurofibromas. Tumor location varied, with lesions distributed along the entire length of the nerve. Facial dysfunction was the most frequently recorded symptom, followed by hearing loss. Only five patients presented a preoperative grade 1 facial function. In the remaining patients of the group, the facial deficit lasted from 2 to 120 months, with a mean of 31.2 months. Anatomic integrity of the nerve was preserved in 4 cases; all others required a nerve interruption followed by reconstruction using a sural nerve graft. The complications recorded were: one cerebrospinal fluid leak, one postoperative retraction pocket, and one external auditory canal wall resorption requiring a surgical revision. Preoperative hearing remained unchanged in 8 out of the 15 patients in whom a hearing preservation procedure was attempted. In 25 cases, a follow-up of equal to or longer than 1 year was available, with the FN functions: two grade 1, eight grade 3, nine grade 4, three grade 5, and three grade 6. Patients with a preoperative deficit lasting more than 1 year demonstrated the worst recovery. Primary FN tumors are rare lesions that include different histologic types. FN deficit represents the most common symptom, but it is not present in all cases. A conservative strategy is often adopted in presence of a normal preoperative facial function. When surgical management is selected, the decision on surgical approach to use depends on tumor size and location, as well as on preoperative hearing. FN integrity may be spared in rare occasions, but more frequently nerve reconstruction is required. Final facial function recovery is mainly dependent on the preoperative presence of FN deficit and its duration.

Long-term observation after soft posterior meatal wall reconstruction in ears with cholesteatoma.

We performed tympanoplasty with reconstruction of the soft posterior meatal wall for the prevention of post-operative retraction pocket formation. Our method is characterized by the reconstruction of the soft posterior meatal wall, non-obliteration with permanent or temporary materials, including Gelfoam, no use of a Palva flap and the use of fibrin glue for attaching the fascia to the posterior meatal skin. None of the patients experienced post-operative narrow-neck retraction pocket formation, and whenever aeration of the middle ear was disturbed, a balloon-like retraction was observed. Not all the posterior meatal walls retracted. The final position of the posterior meatal wall varied among the subjects. No serious cavity or hearing problems have occurred since surgery. Due to the strong possibility of post-operative retraction pocket formation in cases with a large balloon-like retraction, we rejected adopting the canal wall up technique or hard posterior meatal wall reconstruction.

真珠腫性中耳炎の術後成績

Surgical treatment of middle ear cholesteatoma was evaluated from the point of postoperative hearing and recurrence of cholesteatoma. Of the 36 ears operated on in the previous 5 years and 5 months, intact canal wall tympanoplasty was performed in 27 ears, and tympanoplasty with posterior canal wall removal in 9 ears. The patients were evaluated for a follow-up period of more than 6 months after tympanoplasty. The rate of success in hearing improvement was 82.4% according to the criteria of the Japan Otological Society. Recurrence of the cholesteatoma was found in 2 ears (5.6%), which had been treated by intact canal wall tympanoplasty. A retraction pocket in the attic was found in 5 ears (17.9%), following intact canal wall tympanoplasty. Reconstruction of the attic defect with cartilage and obliteration of the mastoid cavity were useful in the prevention of postoperative retraction pocket.

Summary Staged tympanoplasty in the treatment of cholesteatoma : prevention of postopera tive retraction pocket

In the treatment of cholesteatoma employing intact canal wall tympanoplasty staging the operation has been employed to re-establish aeration of the middle ear and to eradicate possible causes of recurrence, cholesteatoma residue and retraction pocket. The paper describes the surgical procedures evolved by the authors to prevent postoperative retraction pocket. At the first stage operation following three procedures are important to re-establish aeration of the tympanic cavity ; 1) widening of the tympanic isthmus with posterior hypotympanotomy in conjunction with removal of the incus and the head of the malleus, 2) scutum plasty with use of bone pate and 3) placement of a silastic sheet in the tympanic cavity. At the second stage operation, one of the following three types of operations is performed according to the grade of aeration of the tympanic cavity : type S-1, only ossiculoplasty ; type S-2, ossiculoplasty and scutum plasty ; and type S-3, ossiculoplasty, scutum plasty and mastoid obliteration. Details of the surgical technics were described together with some of the results of long term follow-up study. Emphasis was placed on the importance of long term follow-up examinations with aid of operation microscope and CT.

Congenital cholesteatoma of the middle ear and mastoid. A third report.

Six cases of congenital cholesteatoma of middle ear and mastoid are presented as a third report, thereby increasing the number of such cases reported by the author and his associates to 23. Our first case of congenital cholesteatoma of the petrous pyramid, Cawthorne type, is reported. Most importantly, five cases of recurrent cholesteatoma thought to be due to incomplete primary excision (residual cholesteatoma) are described. One postoperative retraction pocket is described as potential secondary cholesteatoma which required corrective revision surgery. In spite of relatively high incidence of revision surgery for postoperative cholesteatoma, the author reaffirms his belief in using closed technique to preserve near-normal external auditory canal anatomy and an intact tympanic cavity regardless of the primary fate of the ossicular chain.