Recurrence Rate Of Cholesteatoma Research Articles

The Safety and Efficacy of Hydroxyapatite Repair of Cholesteatoma Skull Base Defects.

To investigate the possibility of hydroxyapatite as a safe and effective alternative to currently used bioavailable materials for repair of tegmen defects and labyrinthine fistulas in the setting of cholesteatoma. Retrospective study. Tertiary-level-care hospital. Electronic medical records of patients 18+ years undergoing cholesteatoma-removal surgery between 2013 and 2022 were reviewed. Twenty-two patients diagnosed with cholesteatoma who underwent repair of either a tegmen defect or labyrinthine fistula using hydroxyapatite were evaluated. There were 17 canal wall up (CWU) and 5 canal wall down (CWD) surgeries. The cholesteatoma recidivism rate was 18.2% (n = 4) and the recurrence rate was 4.5% (n = 1). To ensure that these rates were similar to cholesteatoma-removal surgeries in which hydroxyapatite was not used, a 22 age, gender, and operative technique-matched cohort was evaluated. For patients with CWU surgeries, the rate of recurrence and recidivism were identical between both cohorts (0% and 23.5%, respectively; P = 1 for both). While in CWD surgeries, there was a nonstatistically significant difference in the recurrence as there was only 1 patient with recurrence in the hydroxyapatite group (P = 1). Three (13.5%) patients in the hydroxyapatite group had a local infection and 1 (4.5%) had a subacute mastoid infection. All patients with semicircular canal fistulas had consistent bone lines on postoperative audiograms, with no worsening sensorineural hearing loss. In our cohort, hydroxyapatite was safe and successful in repairing skull base defects and inner-ear fistulas in the setting of cholesteatoma with a low rate of postoperative infection and no evidence of a higher rate of cholesteatoma recurrence. Further studies are needed to assess population generalizability.

Cholesteatoma Severity Determines the Risk of Recurrent Paediatric Cholesteatoma More Than the Surgical Approach

Objective: To evaluate factors that influence the rate of cholesteatoma recurrence (growth of new retraction cholesteatoma) in children. Methods: Review of children with primary acquired or congenital cholesteatoma. Severity was classified by extent and EAONO-JOS stage, and surgery by SAMEO-ATO. Primary outcome measure was 5-year recurrence rate using Kaplan–Meier or Cox regression analysis. Results: Median age was 10.7 years for 408 cholesteatomas from which 64 recurred. Median follow up was 4.6 years (0–13.5 years) with 5-year recurrence rate of 16% and 10-year of 29%. Congenital cholesteatoma (n = 51) had 15% 5-year recurrence. Of 216 pars tensa cholesteatomas, 5-year recurrence was similar at 14%, whereas recurrence from 100 pars flaccida cholesteatomas was more common at 23% (log-rank, p = 0.001). Sub-division of EAONO-JOS Stage 2 showed more recurrence in those with than without mastoid cholesteatoma (22.1% versus 10%), with more in Stage 3 (31.9%; p = 0.0003). Surgery without mastoidectomy, including totally endoscopic ear surgery, had 11% 5-year recurrence. Canal wall-up tympanomastoidectomy (CWU) and canal wall-down/mastoid obliteration both had 23% 5-year recurrence. Multivariate analysis showed increased recurrence for EAONO-JOS Stage 3 (HR 5.1; CI: 1.4–18.5) at risk syndromes (HR 2.88; 1.1–7.5) and age < 7 years (HR 1.9; 1.1–3.3), but not for surgical category or other factors. Conclusion: Young age and more extensive cholesteatoma increase the risk of recurrent cholesteatoma in children. When controlling for these factors, surgical approach does not have a significant effect on this outcome. Other objectives, such as lower post-operative morbidity and better hearing outcome, may prove to be more appropriate parameters for selecting optimal surgical approach in children.

Clinical features and surgical treatment of external auditory canal cholesteatoma in 149 cases

Objective:The aim of this study is to explore the clinical characteristics, surgical management and treatment results of type Ⅰto type Ⅳ external auditory canal cholesteatoma（EACC）. Method:One hundred and forty-nine patients（150 ears） with EACC underwent different surgical approach according to the classification of EACC and the lesion range: ① 44 ears: external auditory canal lesion resection with or without reconstruction of external auditory canal ② 23 ears: external auditory canal lesion resection with reconstruction of external auditory canal and the tympanoplasty（TypesⅠto Ⅲ）; ③ 32 ears: external auditory canal lesion resection with reconstruction of external auditory canal and modified mastoidectomy and reconstruction of the posterior wall of external auditory canal; ④ 28 ears: external auditory canal lesion resection with reconstruction of external auditory canal and tympanoplasty（Types Ⅰ to Ⅲ） and modified mastoidectomy and reconstruction of the posterior wall of external auditory canal; ⑤12 ears: canal wall down mastoidectomy （CWD） with plasty of the cavity of auricular concha; ⑥ 11 ears: epitympanum dectomy and reconstruction with tympanoplasty. Result:In the 150 ears, there were 38 ears classified as Type Ⅰ, 52 as Type Ⅱ, 58 as Type Ⅲ and 2 as Type Ⅳ based on the Shin classification. All patients were followed up for more than half a year. The postoperative outcomes were satisfactory with low rate of cholesteatoma recurrence and the hearing was improved to varying degrees. Conclusion:Base on the variety of lesions, the surgical treatment method of choice depends on the extent of the lesion. Effective postoperative follow-up can reduce recurrence and avoid the second operation.

Prospective Study of the Mastoid Plasties Using Resorbable Bioceramic MBCP<sup>®</sup> in Surgery of Cholesteatoma

Tympanoplasty is the reference for cholesteatoma treatment in ear, nose, and throat (ENT surgery), with the realization of a closing technique, which preserves the external auditory canal. An insufficient pneumatisation is an element favoring the occurrence and recurrence of cholesteatoma. In a prospective clinical pilot study, we have realized the reconstruction of the mastoid cortical bone by a Micro Macroporous Biphasic Calcium Phosphate bioceramics disks (MBCPTM Biomatlante France) using the closed technique, in order to maintain or increase the mastoid pneumatisation. Eleven patients were used for this study, and some of them have a sample collection for histomorphometry and histopathological analysis. Bone regeneration at the expense of the bioceramic was observed. The size and shape of the disk was not preserved due to the large resorption and bone ingrowth at the expense of the implant. However 6 patients presented cholesteatoma recurrence. The MBCPTM disks are able to reconstruct the mastoid cortical and maintain the mastoid pneumatisation contrarily to the technique of filling the mastoid cavity. However, the high rate of cholesteatoma recurrence observed in our study, confirmed the interest to fill mastoid that suppress airspace posterior cavities.

Recurrent and residual cholesteatoma rates after different types of sanitation surgery on middle ear

Aim. To compare the recurrent and residual cholesteatoma rates after four variants of sanitation operations on the middle ear (open and closed techniques, mastoidal cavity obliteration and posterior wall reconstruction using the allogeneic cartilage).Methods. The study involved 231 patients: 123 men and 108 women aged 15 to 64 years. Patients were divided into four groups depending on the type of surgery. Patients of all groups were examined in the distant period - a minimum within 1 year (range 1-15 years). The surgery results were evaluated using otomicroscopy (OPMI Sensera microscope) by two parameters. The first parameter - the presence or absence of recurrent and residual cholesteatoma in postoperative period. The second parameter - «bad», adverse retraction pockets occurrence in postoperative period. We referred to them cases when the pocket was in medial section of the external auditory canal (i.e. closer to neotympanic membrane or tympanic membrane remnants), had a narrow or convoluted entrance (i.e. epidermal masses evacuation from pocket was difficult) and was filled with epidermal, sulfur or fungal masses.Results. Open type of sanitation operation showed the lowest likelihood of cholesteatoma recurrence - 1.27%. Trepanation cavity obliteration method using fascial-muscle flap on the lower pedicle showed the highest rate of cholesteatoma recurrence - 33.33%.Conclusion. The minimum probability of recurrent and residual cholesteatoma occurrence is characteristic for open type of sanitation operation; method of trepanation cavity obliteration using fascial-muscle flap is not recommended for use because of the high rate of adverse outcomes.

Recurrence rate of cholesteatoma with autoclaved incus autograft.

To study the long-term recurrence rate of cholesteatoma with autoclaved incus autograft. Prospective observational study between 1994 and 2009. The incus remnants were autoclaved at 134°C for 24 minutes at 205 kPa. The mean follow-up duration was 65.5 months, with a minimum follow-up duration of 31 months and a maximum follow-up duration of 186 months. Secondary referral center in a district general hospital. Thirty-seven cases of cholesteatoma treated with canal wall down mastoidectomy with primary ossicular reconstruction with autoclaved incus autograft were included. The age range of the patients was from 11 years to 67 years. The mean age was 38 years. Fifty-four percent was male, and 46% was female. Therapeutic and rehabilitative--to treat and improve the patients' hearing loss secondary to cholesteatoma by using autoclaved autologous incus. Primary end point is the recurrence rate of cholesteatoma with a mean follow-up period of more than 5 years. Secondary end point is the audiometric outcome with air-bone gap (ABG) and air conduction improvement. No recurrence of cholesteatoma was observed. No graft extrusion was seen. Preoperative mean ABG was 29.8 dB. Postoperative mean ABG was 25.6 dB at the final review, with the air conduction improvement at final review at 4.2 dB. Autoclaving the incus remnant harvested from cholesteatomatous middle ear cleft is a safe and effective method to prepare an incus autograft for primary ossicular reconstruction.

Tympanoplasty with Intact Canal Wall Mastoidectomy for Cholesteatoma: Long‐Term Surgical Outcomes

With different mastoidectomy approaches available to the surgeon for treatment of cholesteatoma, we review long-term outcomes of intact canal wall (ICW) mastoidectomy with tympanoplasty. Case series with chart review. Academic medical center. All cases of cholesteatoma treated with ICW mastoidectomy by the senior author over a period of 9 years for which at least 2 years of follow-up data exist. Patient and disease information was collected retrospectively and analyzed. One hundred forty-eight patients with 156 affected ears were treated and followed for a median of 5.3 years (range, 2.1-14.8). The majority of the operations (144/156, 92%) were staged. Of those that were staged, 51/144 (35%) had residual cholesteatoma at the second stage. Thirteen patients (8%) had recurrence of their cholesteatoma, of which 6 required a subsequent canal wall down (CWD) mastoidectomy. ICW mastoidectomy with tympanoplasty continues to be a successful treatment for cholesteatoma. We found a substantial residual rate at the second stage, justifying the necessity of staging in most cases. Recurrence rate of cholesteatoma using this technique is low, as is the progression to CWD mastoidectomy.

Retrograde mastoidectomy on demand with soft-wall reconstruction in pediatric cholesteatoma

Conclusion: Retrograde mastoidectomy with soft-wall reconstruction is an effective technique that can be used to lower the recurrence rate of cholesteatoma in the pediatric population. Objective: To evaluate surgical outcomes of retrograde mastoidectomy when using soft-wall reconstruction in pediatric cholesteatoma. Methods: A total of 25 children underwent cholesteatoma removal surgery employing soft-wall reconstruction. The cases were retrospectively reviewed. Average follow-up time was 48.7 months. In order to fully expose and extirpate the disease, the bony canal wall was removed in association with a retrograde-type mastoidectomy in all cases. The posterior ear canal defect was then reconstructed using soft tissue; i.e. temporal fascia and canal wall skin. The incidence and localization of residual and recurrent cholesteatoma, preoperative and postoperative audiogram results, pure-tone average (PTA), and air–bone gap (ABG) were assessed. Results: Residual cholesteatoma was detected in 5 (20%) of 25 ears while recurrent cholesteatoma occurred in 1 (4%) of 25 ears. The mean preoperative PTA of air conduction (AC) was 39.1 dB, while the preoperative PTA of the ABGs was 28.8 dB. The mean postoperative PTA-AC and PTA-ABG were 20.9 dB and 11.7 dB, respectively. The mean hearing gain was 18.2 dB. The differences between the pre- and postoperative values were statistically significant (p < 0.05).

Mastoid and Epitympanic Bony Obliteration in Pediatric Cholesteatoma

The primary goal of cholesteatoma surgery is complete eradication of the disease. To lower the recurrence rate in the pediatric population in canal wall up techniques and to avoid the disadvantages of canal wall down techniques, the bony obliteration technique with epitympanic and mastoid obliteration has been developed. The objective of this study was to evaluate the long-term surgical outcome and recurrence rate of this technique in children. Retrospective case review. : Tertiary referral center. Fifty-two children (<16 yr) were operated on in 90.4% (n = 47) for a primary or recurrent cholesteatoma and in 9.6% (n = 5) for an unstable cavity. In all cases, we closed the tympanoattical barrier and the posterior tympanotomy with sculpted cortical bone and then completed obliteration of the epitympanum and mastoid with bone pâté. A reconstruction of the middle ear was performed by means of an allograft tympanic membrane including the malleus handle and a sculpted allograft malleus or incus for columellar reconstruction. Recurrent rate; residual rate; functional outcome; hygienic status of the ear; long-term safety issues. The mean follow-up time was 49.5 months (range, 12-101.3 mo). Recurrent cholesteatoma occurred in 1.9% (n = 1). Residual cholesteatoma was detected in 15.4% (n = 8) of the cases. Postoperative hearing results revealed a median gain on pure-tone averages of 14.3 dB and a median postoperative air-bone gap of 25.6 dB. The mastoid and epitympanic BOT is an effective technique to lower the recurrence rate of cholesteatoma in the pediatric population. Follow-up by magnetic resonance imaging provides a safe, noninvasive method for postoperative detection of residual cholesteatoma.

The Investigation of the Recurrence Rate of Cholesteatoma Using Kaplan-Meier Survival Analysis

To investigate the recurrence rate of cholesteatoma using Kaplan-Meier survival analysis. Retrospective study. Tertiary referral center. Three hundred forty-five patients with middle ear cholesteatoma operated on by the same surgeon between 1987 and 2002. The cumulative recurrence rate of cholesteatoma during a 5-year follow-up period was calculated using Kaplan-Meier survival analysis. The overall 5-year recurrence rate was 11.8%. The recurrence rate increased with the follow-up time. The 5-year recurrence rate was 3.9% in patients treated with canal wall down tympanoplasty (CWDT) and 16.7% in patients treated with intact canal wall tympanoplasty (ICWT) or canal wall reconstruction (CWR) after CWDT with a significant difference (p < 0.01). The 5-year recurrence rate was 26.0% in patients operated on between 1987 and 1996 and 0.7% in patients operated on between 1997 and 2002, again with a significant difference (p < 0.001). Kaplan-Meier survival analysis should be used for calculating the recurrence rate of cholesteatoma. Although this analytic method further demonstrates that CWDT is a more reliable surgical method than ICWT/CWR in reducing cholesteatoma recurrence, clinical judgment should be exercised, and we continue to recommend that a flexible approach should be adopted in deciding whether to perform CWDT or ICWT/CWR for individual cases.

A study of recurrence of retraction pockets after various methods of primary reconstruction of attic and mesotympanic defects in combined approach tympanoplasty.

The major drawback of combined approach tympanoplasty (CAT) is a relatively high rate of cholesteatoma recurrence compared to open-cavity techniques, which is thought to occur primarily by recurrence of retraction pockets. In this series of 63 CATs carried out by one surgeon, scutum reconstruction to prevent recurrent attic retraction was carried out in 43 cases. Repair with bone pate proved much more successful in achieving this (20.7%; 6/29 recurrent retraction pockets) compared to tragal cartilage (57.1%; 8/14) (Fisher's exact test, P = 0.0205) and was found to be a result of the greater incidence of cartilage resorption. Recurrence of retraction in pars tensa defects was more common as the only material used was a simple temporalis fascia graft. The mean time to development of recurrences was 21.1 months and that has important implications for follow-up. We conclude that the use of bone pate for scutum reconstructions reduces the incidence of attic retraction pockets, and therefore the risk of cholesteatoma recurrence following CAT.

Ten-year results of canal wall down mastoidectomy for acquired cholesteatoma

Objective: To examine 10-year results of canal wall down mastoidectomy (CWDM) for acquired cholesteatoma. Methods: Medical records of 136 patients with cholesteatoma who has undergone CWDM in a university hospital and who had a follow-up of at least 10 years were checked. Results: During follow-up, 21% of patients had undergone one revision operation and 3% two revisions. The recurrence rate of cholesteatoma was 17% and in three patients the cholesteatoma recurred twice. Ten years after CWDM, 98% of the operated ears were dry, 1% moist, and one ear (0.7%) was discharging. The tympanic membrane was intact in 92% and perforated in 8%. Only 14% of patients had hearing levels of 20 dB or better and 46% had 40 dB or better. Conclusion: It is concluded that the surgical technique of CWDM should be improved in order to lower the recurrence rate and to improve hearing results.

Revision surgery for chronic otitis media: a learning experience. Report on 389 cases with a long-term follow-up.

The objective of this study was to evaluate, during a long-term follow-up period, the results of revision surgery for chronic otitis media with or without cholesteatoma. Intact canal wall and canal wall down procedures were performed. The surgical history of every patient was assessed before the operation. A dry, relatively safe, and disease-free ear was created in 90% of the reoperated ears (N = 389). The recurrence rate of cholesteatoma was 5% for the total group. Reperforations of the tympanic membrane occurred in 10%, and persistent or recurrent otorrhea was present in 10% of cases. The functional hearing results were quite satisfactory. A residual air-bone gap of < or =30 dB was reached in 70.3% of the cases after revision tympanoplasty only (N = 41). Revision mastoidectomy with revision tympanoplasty as a one-stage procedure led subsequently, in 76% of intact canal wall procedures (N = 113) and 55% of canal wall down procedures (N = 98), to a residual air-bone gap of < or =30 dB.

Cartilage reconstruction of the scutum defects in canal wall up mastoidectomies

Purpose: This study was performed to evaluate whether cartilage reconstruction of scutal wall defects diminishes retraction pocket and recurrent cholesteatoma, as compared with no cartilage reconstruction of the scutal defect. Materials and Methods: A retrospective chart review from 1980 to 1993 was performed on all patients undergoing a canal wall up mastoidectomy. These procedures were done in a large teaching hospital where some surgeons reconstructed with cartilage and others did not. The recurrence rate of cholesteatoma and retraction pockets, as well as the need for further surgery, was assessed. Results: There were 103 canal wall up mastoidectomies performed, and 84 patients were available for long term follow-up. Of these, 52 were not reconstructed with cartilage, whereas 32 were reconstructed with cartilage. Of the 52 patients not reconstructed, 47% did not develop retraction pockets. Of the 53% who did develop a retraction pocket, only one third required further surgery, and the others were managed in the office. Of the 32 patients that were reconstructed with cartilage, 66% did not develop further retractions. Of the 34% who did develop a retraction pocket, one third required further surgery. In both groups, those who did require further surgery did have recurrent cholesteatoma as well. Conclusion: It would appear that reconstruction of scutal wall defects after canal wall up mastoidectomies with cartilage may be of some benefit in preventing further retraction pockets and thus the recurrence of cholesteatoma.

The results of chronic ear surgery in a training programme.

A retrospective study was undertaken of the results of surgery in a series of 782 patients with chronic otitis media. The recurrence rate of cholesteatoma was 20% of patients operated on by trainees and 12% operated on by the faculty. In ears with granulating otitis media, control of infection was achieved by trainees as often as by the faculty. The tympanic membrane healing rate of myringoplasty and tympanoplasty operations was 78% for trainees and 95% for the faculty (P < 0.001). Major surgical complications were relatively rare. It is concluded that the performance of trainees was fairly safe and better than expected, but some failures might have been prevented by closer supervision. Because of the decline in available patients for chronic ear surgery, it is suggested that the training programme should be restructured so that only those trainees who wish to pursue otological surgery as a career are trained in this field.

Summary Advancement in Tympanoplasty and Management of Mastoid Cells

Procedures for tympanoplasty in Japan had been varied from the open method (canal wall down technique) to the closed method (canal wall up technique), and further to the staged operation and the obliterative method (mastoid obliteration). The reasons for the former change had been attributable to the cavity problem after the open method, and the latter to the high recurrence rate of cholesteatoma after closed method. Additionally, these procedures required mastoidectomy, which means destruction of mastoid cells. Recently, severity of inflammatory process of chronic otitis media has been decreasing, and normal mastoid cell mucosa has been recognized to perf orme gas-exchange of the middle ear, as a result, the number of operation for chronic otitis media in which mastoid cells are preserved is increasing gradually.

Management of labyrinthine fistula in middle ear cholesteatoma.

Labyrinthine fistula is a complication of chronic otitis media with cholesteatoma. Canal wall down tympanoplasty with partial mastoid cavity obliteration and complete removal of cholesteatoma matrix was adopted in five cases of labyrinthine fistula. The operation resulted in elimination of vertigo. Sensory hearing has been saved in two cases. Air conduction hearing improved in one case. In three cases whose air conduction deteriorated post-operatively, bone conduction worsened in two cases and remained unchanged in one case (Tympanoplasty type 0 was performed in the other one case.) During the follow-up period, otorrhea improved in all cases and there was no evidence of recurrence of cholesteatoma. If the hearing of the other ear is acceptable, we suggest one-stage canal wall down tympanoplasty with complete removal of cholesteatoma matrix and partial mastoid cavity obliteration. It provides low recurrence rate of cholesteatoma and there is no need of re-operation.