Resection Of Cholesteatoma Research Articles

Augmented Reality-Assisted Transcanal Endoscopic Ear Surgery for Middle Ear Cholesteatoma.

Background: The indications for transcanal endoscopic ear surgery (TEES) for middle ear cholesteatoma have expanded for cases involving mastoid extension. However, TEES is not indicated for all cases with mastoid extension. In addition, predicting the extent of external auditory canal (EAC) removal needed for cholesteatoma resection is not always easy. The purpose of this study was to use augmented reality (AR) to project the lesion onto an intraoperative endoscopic image to predict EAC removal requirements and select an appropriate surgical approach. Methods: In this study, patients showing mastoid extension were operated on using a navigation system with an AR function (Stryker). Results: The results showed that some cases with lesions slightly extending into the antrum required extensive resection of the EAC, while cases with lesions extending throughout the antrum required smaller resection of the EAC, indicating TEES. Conclusions: By predicting the extent of the needed EAC removal, it is possible to determine whether TEES (a retrograde approach) or canal wall-up mastoidectomy, which preserves as much of the EAC as possible, should be performed. We believe that our findings will contribute to the success of middle ear surgeries and the implementation of robotic surgery in the future.

First Case Report of Bacteroides Thetaiotaomicron Cerebral Abscess after Cholesteatoma Resection (P2-10.005)

<h3>Objective:</h3> To describe the first case of <i>Bacteroides Thetaiotaomicron</i> Brain Abscess following Cholesteatoma Resection <h3>Background:</h3> Brain abscess can be fatal if not adequately treated. Recent advancements in neurosurgical techniques and culturing methods have allowed for better identification of causative pathogens, and subsequently improved outcome of targeted antibiosis. In the setting of recent cranial instrumentation, different microbes are more likely culprits than <i>streptococcus</i> and <i>staphylococcus</i> species. We report the first case in the literature of a brain abscess caused by <i>Bacteroides thetaiotaomicron</i> after recent resection of an invasive cholesteatoma, we also discuss changes in <i>this anaerobe</i> pathogenicity. <h3>Design/Methods:</h3> Novel Case Report <h3>Results:</h3> A 36-year-old female presented with left otalgia, vertigo, and diminished alertness for two days. She had undergone radical mastoidectomy for invasive cholesteatoma two weeks earlier, and has since received clindamycin, ciprofloxacin-dexamethasone, and methylprednisolone. A gadolinium-enhanced brain MRI visualized a 2.1×2.8 cm enhancing temporal lobe lesion adjacent to the tegmen mastoideum consistent with intraparenchymal abscess with surrounding vasogenic edema. Empiric antibiotics, and dexamethasone were initiated. Stereotactic drainage revealed purulent material whose cultures grew <i>Bacteroides Thetaiotaomicron and Enterococcus avium</i>. The patient started to improve and was eventually discharged home after antibiotics were tailored per susceptibility results. <h3>Conclusions:</h3> Our case represents the first isolation of <i>Bacteroides Thetaiotaomicron</i> in a brain abscess. There has been one reported case of meningitis with <i>Bacteroides Thetaiotaomicron</i> in the literature. Notably, both cases were associated with cholesteatoma. Cholesteatomas create an oxygen-deprived thriving environment for anaerobes to grow and seed into adjacent tissue. Environmental and host factors may favor a diverse gene expression of <i>Bacteroid</i> proteases that could change its behavior, potentially playing a role in exhibiting pathogenicity. This is important as it drives choice of empiric antibiotic coverage and, given the changes in the pathogenicity of bacteroid species, more aggressive forms of brain infections may be a concern in such settings. <b>Disclosure:</b> Mrs. McGovern has nothing to disclose. Dr. Garcia Rodriguez has nothing to disclose. Dr. Kaddouh has nothing to disclose.

Inside-Out Transcanal Endoscopic Mastoidectomy: Literature Revision.

Introduction Recently, there have been significant advancements in transcanal endoscopic ear surgery (TEES). The combination of rigid and thin otoendoscopes with high-definition cameras enabled a less invasive transcanal access to the middle ear and a clearer view of the surgical field. Several surgeons have recently published studies about cholesteatoma resection via transcanal endoscopic surgery, even in cases where the disease has extended to the mastoid, requiring transcanal endoscopic mastoidectomy. Objectives To analyze the currently available literature on transcanal endoscopic inside-out mastoidectomy, and to determine its efficacy as a surgical technique by evaluating the disease's relapse/recurrence rate. Data Synthesis Initially, the titles and abstracts of articles identified were analyzed. At this stage, 117 articles were analyzed, 97 of which were excluded for not meeting the inclusion criteria. The 20 remaining articles were further evaluated. The articles were classified on the basis of five levels of scientific evidence. Final Comments The analysis of the studies showed that the transcanal endoscopic approach is effective in providing access to the attic or antrum, especially in cases of sclerotic mastoids. There was only one study with grade A recommendation, which showed the efficacy of endoscopic ear surgery in the treatment of cholesteatoma. Furthermore, there were three studies with grade B recommendation, showing less relapse/recurrence after TEES. More studies with grade A and B recommendations are needed to better evaluate the effectiveness of TEES, especially compared with that of traditional microscopic surgery.

Outcomes of Endoscopic Congenital Cholesteatoma Removal in South Korea

Transcanal endoscopic ear surgery (TEES) provides minimally invasive transcanal access to the middle ear and improves middle ear visibility during cholesteatoma resection. However, the literature on outcomes following TEES alone for the removal of congenital cholesteatoma (CC) is lacking and limited to small series. To assess outcomes of TEES for CC limited to the middle ear and/or mastoid antrum and to explore the risk factors associated with recidivism (ie, recurrent and/or residual cholesteatoma). This cohort study evaluated retrospective, multicenter data for 271 children with CC who underwent TEES at 9 tertiary referral hospitals in South Korea between January 1, 2013, and December 31, 2021, and had a follow-up of at least 6 months after surgery. Outcomes included the incidence of residual cholesteatoma and audiometric data after TEES. A multivariable analysis using Cox proportional hazards regression models was used to assess associations between cholesteatoma characteristics and recidivism, with hazard ratios (HRs) and 95% CIs reported. Of the 271 patients (mean [SD] age, 3.5 [2.9] years; 194 [71.6%] boys, 77 [28.4%] girls), 190 had Potsic stage I CC (70.1%), 21 (7.7%) had stage II, 57 (21.0%) had stage III, and 3 (1.1%) had stage IV. Thirty-six patients (13.3%) with residual cholesteatoma were found, including 15 (7.9%) with Potsic stage I, 3 (14.3%) with stage II, and 18 (31.6%) with stage III. In the multivariable analysis, invasion of the malleus (HR, 2.257; 95% CI, 1.074-4.743) and posterosuperior quadrant location (HR, 3.078; 95% CI, 1.540-6.151) were associated with the incidence of recidivism. Overall, hearing loss (>25 dB on auditory behavioral test or >30 dB of auditory evoked responses) decreased from 24.4% to 17.7% after TEES. This cohort study involved the largest known population to date of CC removed by TEES. The findings suggest that TEES may be feasible and effective for the removal of CC limited to the middle ear and/or mastoid antrum in children.

Surgical management of petrous apex cholesteatomas in the pediatric population: A systematic review.

Cholesteatomas are growths of squamous epithelium that can form inside the middle ear and mastoid cavity and damage nearby structures causing hearing loss when located at the petrous apex. The primary goal of petrous apex cholesteatoma resection is gross total removal with tympanoplasty and canal-wall up or canal-wall down tympanomastoidectomy. At present, there is no definitive surgical approach supported by greater than level 4 evidence in the literature to date. A systematic review was conducted utilizing PubMed, Embase, and Scopus databases. Articles were screened and selected to be reviewed in full text. The articles that met inclusion criteria were reviewed for relevant data. Data analysis, means, and standard deviations were calculated using Microsoft Excel. After screening, five articles were included in the systematic review. There were a total of eight pediatric patients with nine total cholesteatomas removed. Conductive hearing loss was the most common (77%) presenting symptom. Perforations were noted in seven ears (86%). Recurrence was noted in 50% of patients with an average recurrence rate of 3.5 years (SD = 1.73). Average length of follow-up was 32.6 months (SD = 21.7). Canal-wall up was the most utilized technique (60%) and there were zero noted surgical complications. Five of the seven (71%) patients that experienced hearing loss from perforation noted improved hearing. Due to its rarity, diagnostic evaluation and treatment can vary. Further, multi-institutional investigation is necessary to develop population-level management protocols for pediatric patients affected by petrous apex cholesteatomas.

Comparative Analysis of Recidivism After Endoscopic and Microscopic-Based Cholesteatoma Resection.

1) To analyze outcomes of cholesteatoma resection utilizing postauricular microscopic and endoscopic ear surgery (EES) approaches.2) To analyze predictors of residual and recurrent cholesteatoma. Retrospective cohort study. Tertiary referral center. Three hundred seventy-five adult and pediatric patients with cholesteatoma (2012-2017). Patients underwent surgical resection of cholesteatoma with EES (n = 122) and microscopic (n = 253) approach. Residual cholesteatoma, recurrent cholesteatoma, second-look procedures. The endoscopic cohort included significantly more pediatric cases (p = 0.0008). There was no difference in laterality, gender distribution, congenital or acquired cholesteatoma, and revision cases between the cohorts. Out of 122 EES cases, 16 (13%) developed residual disease and 9 (7%) developed recurrent disease. Of 253 microscopic cases 16 (6%) developed residual disease while 11 (4%) developed recurrent disease. Second look procedures were more commonly used in EES cohort (50 vs 18%). Single predictor analysis revealed 12 predictors for residual disease and 5 for recurrent disease. Multivariable model identified pediatric case distribution and higher disease stage to be significant predictors for both residual (p = 0.04, 0.007) and recurrent disease (p = 0.02, 0.01). EES approach was associated with a weak significance for residual disease (p = 0.049) but not recurrent disease (p = 0.34). EES approach for cholesteatoma resection seems to perform similarly to microscopic approach with no difference in rates of recurrent disease. However, it is associated with a higher rate of residual disease; this may be a reflection of a greater rate of second look procedures done in this group.

Post-operative hearing among patients with labyrinthine fistula as a complication of cholesteatoma using “under water technique”

IntroductionDuring surgery in patients with labyrinthine fistula the mandatory complete removal of the cholesteatoma while preserving inner ear and vestibular function is a challenge. Options so far have been either the complete removal of the cholesteatoma or leaving the matrix on the fistula. We evaluated an alternative “under water” surgical technique for complete cholesteatoma resection, in terms of preservation of postoperative inner ear and vestibular function.MethodsFrom 2013 to 2019, 20 patients with labyrinthine fistula due to cholesteatoma were operated. We used the canal wall down approach and removal of matrix on the fistula was done as the last step during surgery using the “under water technique”. The pre and postoperative hearing tests and the vestibular function were retrospectively examined.ResultsThere was no significant difference between pre and post-operative bone conduction thresholds; 20% experienced an improvement of more than 10 dB, with none experiencing a postoperative worsening of sensorineural hearing loss. Among seven patients who presented with vertigo, two had transient vertigo postoperatively but eventually recovered.ConclusionOur data show that the “under water technique” for cholesteatoma removal at the labyrinthine fistula is a viable option in the preservation of inner ear function and facilitating complete cholesteatoma removal.

Effect analysis on endoscopic transnasal resection of epidural cholesteatoma at paracentral skull base

Objective: To indicate the clinical features of endoscopic transnasal resection of epidural cholesteatoma at paracentral skull base and to analyze its efficacy. Methods: The total excision rate, postoperative complications and postoperative curative effect of 7 patients (4 males and 3 females, aging from 32 to 63 years old) who underwent middle skull base surgery for epidural cholesteatoma resection under transnasal endoscope at Tianjin Huanhu Hospital between August 2017 and August 2020 were retrospectively reviewed. All patients were followed up for 6 to 36 months. The postoperative MRI, clinical symptoms and recurrence were reviewed. Descriptive statistical methods were used for analysis. Results: Among the 7 patients, there were total resection (complete resection of cyst contents and capsule) in 4 patients, near-total resection (complete resection of cyst contents, incomplete resection of cyst capsule) in 1 patient, and subtotal resection (incomplete resection of cyst contents and capsule) in 2 patients. The clinical symptoms of all patients were improved postoperatively with 1 patient who had no clinical symptoms. One case had postoperative cerebrospinal fluid rhinorrhea, which was cured after lumbar drainage and nasal iodoform gauge packing. Up to now, 7 patients (including patients with partial resection) had no recurrence. Conclusion: Endoscopic transnasal approaches may be effectively used for resection of epidural cholesteatoma in the paracentral skull base in carefully selected cases.

The pterional approach for the surgical resection of an orbital cholesteatoma: a case report

BackgroundCholesteatomas are benign tumors mainly composed of cholesterol crystals that rarely arise within the orbit. However, orbital cholesteatomas require a complete surgical resection due to their recidivating potential. Transcranial approaches offering a broad surgical exposure of the orbital cavity have been scarcely used for the management of these tumors. Here, we provide evidence of the benefits of the pterional craniotomy for the surgical resection of orbital tumors by sharing our experience in the surgical management of a cholesteatoma of the superotemporal orbital wall.Case presentationA 45-year-old Hispanic man with a 2-year history of progressive proptosis of the left eye attended to our center complaining of diplopia and migraine. At his arrival, physical examination revealed ptosis, palpebral edema, and exophthalmos of the left eye, as well as the abolishment of the ipsilateral photomotor and consensual responses. Fundoscopy showed mild optic atrophy, whereas a T2-weighted magnetic resonance imaging (MRI) of the head showed a hyperintense mass arising at the superotemporal wall of the orbit that was displacing the eyeball. The tumor was resected using a pterional craniotomy without postoperative complications. The histopathological analysis of the tumor revealed a cholesteatoma. The patient recovered the functionality of the left eye with no visual sensitive deficits nor tumor recurrence 1 year after the surgery.ConclusionsOur results support the use of the pterional craniotomy as a safe procedure for the surgical resection of cholesteatomas arising at the superotemporal walls of the orbit, with low postoperative morbidity.

Non-echoplanar diffusion weighed imaging and T1-weighted imaging for cholesteatoma mastoid extension

ObjectivesA broad mastoid extension limits cholesteatoma resection via a transmeatal approach including endoscopic ear surgery. Therefore, a preoperative diagnosis of mastoid extension is a the most critical factor to determine whether to perform mastoidectomy. The purpose of this study was to assess the efficacy of non-echoplanar diffusion-weighted imaging (non-EPI DWI) and T1-weighted imaging in the evaluation of mastoid extension in cholesteatomas of the middle ear. MethodsPatients who underwent magnetic resonance imaging (MRI) for pretreatment evaluation before primary surgery for pars flaccida or tensa cholesteatoma, which revealed a high-signal intensity in the mastoid on T2-weighed imaging were retrospectively evaluated. Two board-certified radiologists retrospectively evaluated the extent of cholesteatomas on MRI with non-EPI DWI, non-EPI DWI- and T1-weighted axial imaging. The presence of a high signal intensity on non-EPI DWI or low or high signal intensity on T1-weighted imaging in the mastoid was evaluated. All cases were subclassified as M+ (surgically mastoid extension-positive) or M- (surgically mastoid extension-negative). ResultsA total of 59 patients with middle ear cholesteatoma were evaluated. There were 37 M+ cases and 22 M- cases. High-signal intensity on non-EPI DWI exhibited a sensitivity of 0.89 and specificity of 0.82, whereas partial low-signal intensity on T1-weighted imaging exhibited a sensitivity of 0.84 and specificity of 0.91 for detecting mastoid involvement. Complete high-signal intensity on T1-weighted imaging exhibited a sensitivity of 0.73 and specificity of 0.89 for detecting non-involvement of the mastoid. The sensitivity (0.92) and specificity (0.96) of combined non-EPI DWI and T1-weighted imaging evaluation were higher than those of with non-EPI DWI or T1-weighted imaging alone. The interobserver agreement for the presence of high-signal intensity in the mastoid cavity on non-EPI DWI was very good at 0.82, that of a partial low-signal intensity area in the mastoid cavity lesions on T1-weighted imaging was good, at 0.76 and that of complete high-signal intensity in the mastoid cavity lesions on T1-weighted imaging was good, at 0.67. ConclusionsThe signal intensity on non-EPI DWI and T1-weighted imaging of the mastoid could be used to accurately assess the extent of middle ear cholesteatoma, which could facilitate surgical treatment planning.

Systematic Review of Endoscopic Ear Surgery Outcomes for Pediatric Cholesteatoma.

Endoscopic ear surgery (EES) has been increasingly adopted to enhance visualization during otologic surgery including pediatric cholesteatoma resection. The purpose of this study is to systematically review the current literature reporting rates of residual cholesteatoma to evaluate outcomes of EES in the pediatric population. PubMed, Embase, Cochrane. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations (PRISMA), we systematically reviewed studies that reported outcomes for cholesteatoma surgery in children using the endoscope. Studies were included if they described the use of the endoscope for middle ear surgery and measured outcomes following cholesteatoma resection in pediatric patients. Identified articles were assessed for study design, sample size, inclusion of pediatric population, the presence of a comparison group, outcomes measured such as: residual disease rate, recurrent cholesteatoma, audiologic outcome, quality of life measures, and complications. Fourteen articles in the literature discussed cholesteatoma outcomes in children when the endoscope was employed. Residual disease rate ranged from 0 to 22% when endoscope was used for dissection compared with 11 to 55% when endoscope was used for inspection or not at all. A meta-analysis was conducted on 11 studies. There was a significant risk reduction in residual disease rates for endoscopic dissection when compared with microscope (RR = 0.48, 95% CI = 0.37-0.63, p < 0.001). Among the studies included in this review, EES was associated with lower rates of residual cholesteatoma compared with traditional microscopic techniques. Additional prospective studies are needed to further assess these findings.

Evaluation of Residual Disease Following Transcanal Totally Endoscopic vs Postauricular Surgery Among Children With Middle Ear and Attic Cholesteatoma

Transcanal totally endoscopic ear surgery (TEES) improves tympanic cavity visibility during cholesteatoma resection but does not readily permit 2-handed surgery, which is possible with a postauricular approach and use of an operating microscope. Improved visibility and 2-handed access may reduce rates of incomplete surgical clearance and residual cholesteatoma. To compare rates of residual cholesteatoma after TEES vs those after open surgery with a postauricular approach for initial disease limited to the middle ear and/or attic. This propensity score-matched cohort study considered a consecutive sample of 209 pediatric cases of cholesteatomas resected at a tertiary referral center between January 1, 2005, and December 31, 2017, by either TEES or postauricular approach. The 177 cases (84.7%) in 172 patients that were eligible for inclusion in the study had undergone at least 1 of the following assessments: second-look tympanoplasty, diffusion-weighted magnetic resonance imaging, or in-clinic follow-up examination at least 2 years after the operation. Ears were matched on the basis of the propensity score, a function of age, sex, comorbid diagnoses, etiology, disease extent, ossicular chain condition, presence or absence of tympanic membrane perforation, and otorrhea status at the time of surgery. Transcanal totally endoscopic ear surgery was defined as a transcanal approach with surgeon-reported use of an endoscope for resection of cholesteatoma. Use of an operating microscope was permitted in the TEES group for graft placement during tympanoplasty. The postauricular approach was characterized by a postauricular incision and use of an operative microscope with or without adjunct use of an endoscope. Residual cholesteatoma. Of 177 cases included in the study, the unmatched cohort consisted of 65 ears that had undergone TEES (mean [SD] age, 9.9 [3.6] years; 33 [50.8%] female) and 112 ears of patients who had undergone surgery with a postauricular approach (mean [SD] age, 9.9 [3.5] years; 72 [64.3%] male). Propensity score matching was accomplished for a total of 128 cases, with 64 in each group. After matching, standardized differences between TEES and postauricular approaches were less than 0.20 for all measured baseline characteristics, indicating balanced groups. The TEES group had a residual disease incidence of 4 of 64 (6.3%) compared with 7 of 64 (10.9%) in the propensity score-matched postauricular approach group (absolute risk difference, -4.7%; 95% CI, -14.8% to 5.4%). This study's findings suggest that there was no apparent advantage of the 2-handed postauricular microscopic approach with respect to surgical clearance of cholesteatoma limited to the middle ear and/or attic. Transcanal totally endoscopic ear surgery may be an effective alternative to a postauricular approach for removal of limited cholesteatoma in children.

Analysis of human nasal mucosal cell sheets fabricated using transported tissue and blood specimens.

Previously, we succeeded in transplanting autologous nasal mucosal cell sheets in the middle ears of 5 patients, who underwent cholesteatoma resection, which prevents recurrence of cholesteatoma in clinical settings. Current good manufacturing practice (GMP) standards for human cell cultivation requires the establishment of cell processing centers (CPC) which act as germ-free facilities. However, due to practical difficulties involved in establishing and maintaining such facilities at each individual hospital, a functional transport system is felt to be needed for the continuation of effective regenerative therapy. In the current study, nasal mucosal tissue and autologous blood obtained from 3 human volunteers were transported for over 3 h. Disinfected nasal tissues were cultured using keratinocyte culture medium, which included autologous serum prepared from blood. After 24 d, cultured nasal mucosal cells were transported for over 3 h and subsequently assessed for cell number, viability and purity. Moreover, CK4, CK8, and CK18 were analyzed the suitability of these nasal mucosal cell sheets for middle ear regenerative therapy.Overall, we confirmed that nasal mucosal cell sheets can be fabricated using transported nasal mucosal tissue and blood. This study would be contribute to establish a new regenerative therapy for clinical application, accompanied with transportation between companies and hospitals.

Congenital microtia with aural atresia or stenosis accompany with first branchial cleft anomaly: report of 5 cases

Objective: To summarize the experience of the diagnosis, treatment and effects of the cases with coexistence of first branchial cleft anomaly(FBCA) and microtia with congenital aural atresia or stenosis(external auditory canal stenosis, EACS). Method: This was a retrospective study. The clinical data of 5 patients with microtia and EACS in Beijing Tongren Hospital of Capital Medical University from October 2015 to March 2018 were collected, including 3 males and 2 females, aged from 5 to 28 years. The clinical characteristics, imaging findings, treatment methods and effects of 5 patients were analyzed. Result: The 5 cases were all coexistence of EACS and FBCA, three of who associated with cholesteatoma of external auditory canal. CT showed external auditory canal stenosis with soft tissue shadow, sometimes gas or bone septum found inside, filling in the external auditory canal, combined with canal bone destruction irregularly. All patients underwent surgical resection of FBCA, 3 patients accompanied by cholesteatoma resection and canalplasty. The postoperative follow-up ranged from 10 to 39 months, and no recurrence of infection was observed. Conclusions: EACS and FBCA both result from maldevelopment of the first branchial cleft. These two malformations, FBCA and EACS with or without cholesteatoma, can occur simultaneously, in which situation CT shows external auditory canal stenosis with soft tissue shadow inside. These patients underwent surgical resection of FBCA combined with cholesteatoma resection with good result.

Clinical Features and Surgical Management of Cerebellopontine Angle Cholesteatoma That Presented as Trigeminal Neuralgia

It is difficult to differentiate patients with cerebellopontine angle (CPA) cholesteatoma and patients with primary trigeminal neuralgia just according to early symptoms. We aimed to explore the clinical characteristics, early diagnosis, and microneurosurgical techniques for CPA cholesteatoma that presented as trigeminal neuralgia. The data of 26 patients who complained trigeminal neuralgia with CPA cholesteatoma between January 2009 and December 2015 were collected and studied retrospectively, they were diagnosed by magnetic resonance imaging preoperatively and confirmed by pathology postoperatively. All the tumors were resected through a retrosigmoidal approach. In 26 cases, 14 patients who underwent cholesteatoma resection and microvascular decompression were assigned to group A and 12 patients who underwent only cholesteatoma resection were assigned to group B. The clinical features and surgical results between groups A and B were compared. The complications and surgical results were followed up, and surgical techniques were summarized. All patients presented as trigeminal neuralgia at the same side of the cholesteatoma. There was no statistical difference between the 2 groups in clinical features and surgical results between groups A and B. All patients with cholesteatoma showed clear and significant imaging characteristics. The tumors were totally removed in 18 patients and subtotally removed in 8 patients. Pain relief was satisfactory in all patients. Surgical complications included transient aseptic meningitis in 2 patients, facial numbness in 2 patients, mild tinnitus in 2 patients, mild and facial weakness in 1 patient. No death, hematoma, or acute hydrocephalus were reported in this series. During the follow-up of 12-80 months, no patient experienced recurrence of pain or tumor. Cholesteatoma of the cerebellopontine angle often presented as trigeminal neuralgia. Magnetic resonance imaging is helpful for early diagnosis according to its distinct signal. Surgical treatment is often the first choice, the neuralgia relief was satisfactory after operation. Microvascular decompression is recommended simultaneously if some offending vessels were founded during the surgical resection of the tumor.

Residual Cholesteatoma during Second-Look Procedures following Primary Pediatric Endoscopic Ear Surgery.

Objectives To determine the rate of residual cholesteatoma during planned second-look procedures in pediatric patients following primary cholesteatoma resection using endoscopic and microscopic operative approaches. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Outcomes from pediatric patients undergoing cholesteatoma surgery from January 2011 through August 2015 were analyzed. Cholesteatoma extent at initial resection was staged, and comparison among endoscopic dissection and microscopic or endoscopic inspection groups was made. Presence of disease at time of planned second look was quantified. Descriptive analysis was performed. Results Fifty-five patients (56 ears) with planned second-look procedures were included and underwent a total of 120 procedures. Median age was 11 years (6.7-13 years). Endoscopes were used for inspection in 25 (39%) primary resections and for dissection in 39 (61%) primary resections. Extent of disease at the time of primary resection was similar among groups (χ2, P = .72). Cases where the endoscope was used for inspection only or not at all during primary resection had a 24% rate of residual cholesteatoma at the time of second look compared with a 23% rate for cases with endoscopic dissection (χ2, P = .93). Rate of mastoidectomy significantly decreased from 63% to 33% over the study period ( P = .04) with similar disease extent ( P = .99). Conclusions Residual cholesteatoma rates during planned second-look procedures were similar between the study groups. Use of the endoscope led to a lower rate of mastoidectomy for cases with similar disease extent.

Endoscopic transcanal modified canal‐wall‐down mastoidectomy for cholesteatoma

Attic cholesteatoma with antral extension in tight sclerotic mastoid cavities is a common presentation that creates difficult decision-making intraoperatively. Drilling through a sclerotic and small mastoid cavity, keeping the canal wall intactis often difficult and increases the risk of serious injury. Consequently, a canal-wall-down mastoidectomy is often performed. The endoscopic transcanal modified canal-wall-down mastoidectomy approach allows the benefits of an open cavity for cholesteatoma resection and the benefits of a closed cavity for better long-term care and a more normal ear canal and middle ear reconstruction.

Temporal bone computed tomography findings associated with feasibility of endoscopic ear surgery

PurposeThere are no formal radiologic criteria to stratify patients for transcanal (TEES) or transmastoid endoscopic ear surgery for resection of cholesteatoma. We aim to determine 1) whether standard preoperative computed tomography (CT) findings are associated with the need for conversion to a transmastoid approach and 2) the amount of time added for conversion from TEES to transmastoid techniques. Materials and methodsRetrospective chart review of consecutive pediatric and adult cases of TEES for primary cholesteatoma from 2013 through 2015 (n=52). TEES cases were defined as endoscope-only procedures that did not require a transmastoid approach (n=33). Conversion cases were defined as procedures that began as TEES however, required conversion to a transmastoid approach due to the inability to complete cholesteatoma removal (n=19). Preoperative CT findings and total operating room (OR) times of TEES and conversion cases were compared. ResultsPreoperative CT scan characteristics that were associated with conversion included tegmen erosion (p=0.026), malleus erosion (p<0.001), incus erosion (p=0.009), mastoid opacification (p=0.009), soft tissue opacification extending into the aditus ad antrum (p=0.009) and into antrum (p=0.006). Total OR time for TEES cases was significantly shorter than conversion cases (median 143min versus 217min, p<0.001). ConclusionsPreoperative CT findings, notably extension of soft tissue in the aditus ad antrum, antrum and mastoid, are associated with need for conversion to transmastoid technique to achieve removal of cholesteatoma. Endoscope-only cases were significantly faster than cases that required conversion to a transmastoid approach.

Endoscopic transcanal approach to the middle ear for management of pediatric cholesteatoma.

To describe outcomes for endoscopic ear surgery (EES) for pediatric cholesteatoma at a tertiary pediatric hospital. Retrospective case series of 65 pediatric cholesteatoma cases in 38 ears. Subgrouping based on cholesteatoma type and EES type. Surgical findings, outcomes, and demographic data were evaluated. Endoscopes were used in 65 pediatric cholesteatoma cases in 38 primary ears (34 patients), followed for an average of 2.6 years (9 months to 4.6 years). The endoscope was used as the primary visualization tool in 31 (81.6%) ears (EES 2 or 3), and as an adjunct to the microscope in seven ears (EES 1). Twenty-two (57.9%) ears and 35 (53.4%) cases were transcanal endoscopic ear surgery (EES 3 or TEES). Overall, there was recurrence in five (13.2%) ears and residual in four (10.5%) ears. Cholesteatoma was acquired in 27 ears, with average age 10.9 years; and congenital in 11 ears, with average age 3.8 years. Surgical time was longer for acquired cases (226 vs. 154 minutes). Hearing outcomes were comparable for both cholesteatoma types. Residual disease was seen in three (11.1%) acquired ears and one (9.1%) congenital ear. Overall, the lowest rates of recurrent and residual disease were seen in EES 3 cases, and relatively low rates in EES 2 and 3 ears, including four (12.9%) recurrences and two (6.5%) ears with residual disease. The endoscopes are a viable tool for resection of pediatric cholesteatoma and provide excellent visualization of the middle ear and associated recesses. 4. Laryngoscope, 127:2653-2658, 2017.

Systematic review of outcomes following observational and operative endoscopic middle ear surgery.

Middle ear surgery increasingly employs endoscopes as an adjunct to or replacement for the operative microscope. We provide a systematic review of endoscope applications in middle ear surgery with an emphasis on outcomes, including the need for conversion to microscope, audiometric findings, length of follow-up, as well as disease-specific outcomes. PubMed, Embase, and Cochrane CENTRAL database. A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. Articles were categorized based on study design, indication, and use of an endoscope either as an adjunct to or as a replacement for a microscope. Qualitative and descriptive analyses of studies and outcomes data were performed. One-hundred three articles met inclusion and exclusion criteria. Of the identified articles, 38 provided outcomes data. The majority of these studies were moderate quality, retrospective, case-series reports. The indications for use of the endoscope were broad, with the most common being resection of cholesteatoma. In cholesteatoma surgery, endoscope approaches routinely identified residual cholesteatoma in primary and second-look cases. Other outcomes, including robust audiometric data, operating room times, wound healing, and quality of life surveys were not well described. Endoscopes have consistently been used as an adjunct to the microscope to improve visualization of the tympanic cavity. Recent reports utilize the endoscope exclusively during surgical dissection; however, data comparing patient outcomes following the use of an endoscope to a microscope are lacking. Areas in need of additional research are highlighted. NA