Residual Cholesteatoma Research Articles

A Prospective Study Evaluating Indications & Outcomes of Revision Mastoid Surgery.

Mastoid surgeries are surgical procedures, wherein surgical failures are prevalent due to the fundamental complexities involved, especially in the understanding of microscopy and pathophysiology of the disease. A revision mastoidectomy is an utmost, a post-procedure decision, wherein the patient continues to exhibit signs and symptoms that are concerning. This is proved by a prospective, cross-sectional research which was conducted upon a group of patients who were referred to a tertiary health care centre. This selection of twenty-three (23) patients who underwent mastoidectomy prior to their participation in this research, were exhibiting signs of recurrent diseases. The observations of trends seen in revision mastoidectomy are detailed and inferences gleaned from it. These trends and observations direct us towards the understanding that the majority of failure of previous mastoidectomy was due to persistent diseased air cells and recurrent or residual cholesteatoma. This is further corroborated by the trends observed from exhausting literature readings of previous similar studies. Revision mastoid surgeries are an important follow-up process, after the mastoidectomy, if the patients continue to exhibit diseased states.

A French Preoperative Cholesteatoma Management: Current Preoperative Consultation and Tendencies.

Objectives: This study aimed to characterize the information delivery during preoperative consultations for cholesteatoma removal surgery in 2024. The secondary objective was to identify any factors influencing the information delivered. Methods: This study was a practice survey which included 33 closed-ended questions and 1 open-ended question. Seven questions concerned the participants' characteristics and 2 questions concerned the physiopathology of cholesteatoma. Nine questions focused on surgical information, six questions focused on the procedure modalities and ten questions focused on the risks of complications from the intervention. Results: Eighty-two surgeons answered the survey. In 75% of the cases, an information form written by a professional society was provided. The risk of recurrence or residual post-operative cholesteatoma was systematically stated in 78% of cases (n = 64), while the risk of aesthetic sequelae was only stated in 1% (n = 1). Participants working in a university hospital were more likely to inform patients about the risks of vertigo (p = 0.04), aesthetic risks (p = 0.04), poor functional outcomes (p = 0.04), surgical revision (p = 0.05) and the risk of peripheral facial paralysis (p = 0.05). Surgeons who mainly practiced otology were more likely to inform patients about the risks of recurrence and/or residual cholesteatoma (p = 0.02) and taste disturbances (p = 0.02). Conclusions: Cholesteatoma surgery was well explained to patients during the preoperative consultation, mostly with written support, even if the information given was not the same for all complication risks. It could be useful to create an information form dedicated to cholesteatoma surgery to improve comprehensive information and maintain a trustworthy relationship with patients.

MRI-DWI detection of residual cholesteatoma: moving toward an optimum follow-up scheme.

To analyse diagnostic accuracy of MRI-DWI in detecting residual disease after cholesteatoma surgery and propose an optimum follow-up (FU) scheme. A retrospective chart review of patients who had cholesteatoma surgery in a tertiary referral centre. 3.0 T non-echo planar diffusion weighted imaging was performed as part of routine FU or indicated on the basis of clinical suspicion of disease. Imaging outcome was verified per-operatively during a second-look procedure or ossicular chain reconstruction. Diagnostic parameters were calculated and stratified by FU length. For the FU of 664 cholesteatoma surgeries, 1208 MRI-DWI were obtained and 235second-look procedures were performed. Most MRI-DWI were obtained within 1.5yrs of surgery. In this period, significantly less true positive MRI-DWI and significantly more false negative MRI-DWI for residual diseasewere found compared to other FU periods. Scanning after approximately 3yrs yielded a significantly higher rate of true positive MRI-DWI, while sensitivity surpassed 80%. Younger patients had a higher risk of developing residual disease. Patients undergoing canal wall up surgery, as well as patients < 12yrs, were at risk for false negative MRI-DWI. Obliteration reduces the risk of residual disease, while leading to less false negative MRI-DWI. A novel radiologic FU scheme for detecting residual disease is suggested for stable ears after cholesteatoma surgery: standard MRI-DWI approximately 3 and 5yrs after primary surgery, as well as MRI-DWI after approximately 9yrs for patients with specific risk factors (i.e., patients < 12yrs or patients undergoing canal wall up surgery without obliteration).

Efficacy of Otoendoscopy for Residual Cholesteatoma Detection During Microscopic Chronic Ear Surgery.

The aim of this article is to determine the efficacy of otoendoscopy during microscopic cholesteatoma surgery on residual cholesteatoma rates postoperatively. The medical records of patients (aged 4-90) with primary acquired cholesteatoma who underwent microscopic cholesteatoma surgery (exclusively transcanal approach or canal wall-up tympano-mastoidectomy) with subsequent otoendoscopic examination (80 ears) for intraoperative cholesteatoma residues were retrospectively reviewed. All cases with mixed microscopic/endoscopic, fully endoscopic, or fully microscopic dissection were excluded, as well as cases where a canal wall-down technique was used. After microscopic cholesteatoma removal, the otoendoscope was used to inspect the middle ear recesses for intraoperative cholesteatoma residues. The intra- and postoperative cholesteatoma residue rate were evaluated. On endoscopic examination, intraoperative cholesteatoma residues were encountered in 24 patients (30%). A total of 30 foci were detected. Most of them were found in the superior retrotympanum (15 foci). In 9 cases an antral remnant guided the surgeon to convert to a canal wall up tympanomastoidectomy. During the postoperative follow-up period, residual cholesteatoma was detected on postoperative magnetic resonance imaging in 6 patients (7.5%). Adding an otoendoscopic examination to microscopic cholesteatoma surgery reduced the postoperative cholesteatoma residues rate (odds ratio=0.16). A negative otoendoscopic examination led to a cholesteatoma residue-free follow-up period in 95% of cases(NPV=0.95). Otoendoscopy is effective in identifying intraoperative cholesteatoma residues after microscopic cholesteatoma surgery. It reduces the postoperative cholesteatoma residue rate, and a negative otoendoscopic examination increases the likelihood of a cholesteatoma residue-free follow-up.

ESR Essentials: imaging of middle ear cholesteatoma-practice recommendations by the European Society of Head and Neck Radiology.

Although non-malignant,middle ear cholesteatoma can result in significant complications due to local bone erosion and infection. The treatment of cholesteatoma is surgical, but residual disease is common and may be clinically occult, particularly when the canal wall is preserved or reconstructive techniques are employed. Imaging plays a pivotal role in the management of patients with middle ear cholesteatoma-aiding clinical diagnosis, identifying complications, planning surgery, and detecting residual disease at follow-up. Computed tomography is the primary imaging tool in the preoperative setting since it canprovide botha surgical roadmap and detect erosive complications of cholesteatoma. The ability of magnetic resonance imaging with non-echoplanar diffusion-weighted sequences to accurately detect residual disease has led to a shift in the diagnostic paradigm for post-surgical follow-up of cholesteatoma, such that routine "second-look" surgery is no longer required. The following practice recommendations are aimed athelping the radiologist choose appropriate imaging approaches and understand the key diagnostic considerations for the evaluation of pre- and post-surgical middle ear cholesteatoma. KEY POINTS: In the preoperative setting, CT is the first-line imaging modality and MRI is reserved for rare clinical scenarios (low evidence). Non-echoplanar imaging (EPI) DWI is the optimal MRI sequence for the detection of residual cholesteatoma (moderate evidence). Non-EPI DWI plays an important role in the postoperative surveillance of cholesteatoma (moderate evidence).

The Role of Trublue Laser in Cholesteatoma Surgery.

The retrospective cohort study aimed to determine the safety and efficacy of TruBlue laser application in cholesteatoma surgeries. All cholesteatoma surgeries conducted from January 2018 to January 2022 in two tertiary referral hospitals in Hong Kong, with and without use of TruBlue laser, were included. Pure tone audiogram was done pre- and post-operatively to assess hearing. Disease extent was graded with ChOLE score and ChOLE staging. Residual disease was determined clinically, radiologically, or surgically with second look operation. One hundred twenty cholesteatoma cases were identified. There are 39.2% (n = 47) of the cholesteatoma surgeries that utilized TruBlue laser, while 60.8% (n = 73) did not. Overall follow-up duration was 21 ± 12.4 months, ranging from 2 to 47 months. Both groups were similar in demographics, pre-operative hearing and ChOLE staging. The length of stay was comparable in both groups (2 ± 2 days in nonlaser, 1 ± 1 day in laser, p = 0.31). There was no facial nerve injury related to surgery in both groups, and overall complication rates were similar (4.1% in nonlaser, 4.3% in laser, p = 0.97). The postoperative hearing was comparable with good hearing preservation in both groups. Residual cholesteatoma occurred in 17.8% (n = 13) in nonlaser group, and 21.3% (n = 10) in laser group, which was not statistically significant (p = 0.64). Seventy percent of the cholesteatoma residual in laser group occurred at area that TruBlue LASER cannot be applied. TruBlue LASER was safe in cholesteatoma surgeries, though no added benefits were shown in reducing cholesteatoma residual rate. A larger controlled study is warranted to discern the true effect of TruBlue LASER. Level 3.

Computed Tomography Analysis of the Anterior Epitympanic Recess and Sinus Tympani Depths Among Filipino Adults at the De La Salle University Medical Center

Objective: To assess the depths of the anterior epitympanic recess (AER) and the sinus tympani (ST) among Filipino adults and to classify the AER and ST according to grade and type, respectively. Methods: Design:Retrospective Review of CT Scans Setting: Tertiary Private Teaching Hospital Participants:Scans of 182 non-pathologic ears from patients aged 18 and above with non-pathologic temporal bones (paranasal sinus, screening sinus, temporal bone, facial and cranial) with 0.62mm cuts seen from CT scans from January 01, 2010 to September 31, 2022 were analyzed. The depths of the AER and ST were measured separately and classified according to AER grade and ST type. Results: The mean depth of the AER (AER-D) was 3.64 mm (SD 1.17). No significant difference was seen between right and left ears. The AER grading of the anterior-posterior depth was found to be Grade 1 (&lt;3mm) in 54 ears (29.7%), Grade 2 (3-5mm) in 106 ears (58.2%), and Grade 3 (&gt;5mm) in 22 ears (12.1%). The mean depth of the sinus tympani (ST-D) was 3.30 mm (SD 0.80). Out of the 182 ears, 121 (66.5%) had Type A, 50 (27.5%) had Type B while 11 (6%) had Type C. Conclusion: Majority of the AER depths measured 3-5mm while most of the sinus tympani were Type A. These hidden recesses should be separately analyzed in preoperative planning for cholesteatoma surgery in order to prepare the adequate equipment to be used and approach towards these areas thereby reducing the risk for residual cholesteatomas and recurrence.

Impact of Otoendoscopy in Cholesteatoma Surgery.

To study the Impact of Otoendoscopy at the end of apparent microscopic clearance of disease during primary Cholesteatoma surgery in detecting the residual cholesteatoma. A prospective, interventional, non randomized and non comparative study was conducted at the ESIC Medical College and PGIMSR. All patients of chronic otitis media of squamosal type undergoing modified radical mastoidectomy were included in the study. Otoendoscopy was performed after apparent clearance of cholesteatoma under microscope. If any residual cholesteatoma detected during otoendocsopy was recorded. Total of 63 cases were included in the study. Residual cholesteatoma was seen in 14% of the cases. Commonest site of residual cholesteatoma was sinus tympani. Otoendoscopy helps in visualizing the deep recesses of the middle ear cleft for residual cholesteatoma after apparent clearance under the operating microscope. It also helps in clearing the cholesteatoma from these deep recesses there by it helps in reducing the recurrence rate of cholesteatoma.

Cost-Effectiveness of Diffusion Weighted MRI Versus Planned Second-Look Surgery for Cholesteatoma.

To compare the cost-effectiveness of serial non-echo planar diffusion weighted MRI (non-EP DW MRI) versus planned second look surgery following initial canal wall up tympanomastoidectomy for the treatment of cholesteatoma. A decision-analytic model was developed. Model inputs including residual cholesteatoma rates, rates of non-EP DW MRI positivity after surgery, and health utility scores were abstracted from published literature. Cost data were derived from the 2022 Centers for Medicare and Medicaid Services fee rates. Efficacy was defined as increase in quality-adjusted life year (QALY). One- and 2-way sensitivity analyses were performed on variables of interest to probe the model. Total time horizon was 50 years with a willingness to pay (WTP) threshold set at $50 000/QALY. Base case analysis revealed that planned second-look surgery ($11 537, 17.30 QALY) and imaging surveillance with non-EP DWMRI ($10 439, 17.26 QALY) were both cost effective options. Incremental cost effectiveness ratio was $27 298/QALY, which is below the WTP threhshold. One-way sensitivity analyses showed that non-EP DW MRI was more cost effective than planned second-look surgery if the rate of residual disease after surgery increased to 48.3% or if the rate of positive MRI was below 45.9%. A probabilistic sensitivity analysis at WTP of $50 000/QALY found that second-look surgery was more cost-effective in 56.7% of iterations. Non-EP DW MRI surveillance is a cost-effect alternative to planned second-look surgery following primary canal wall up tympanomastoidectomy for cholesteatoma. Cholesteatoma surveillance decisions after initial canal wall up tympanomastoidectomy should be individualized. V.

Canal-wall up cholesteatoma surgery with mastoid obliteration leads to lower rates of disease recurrence without affecting hearing outcomes.

The primary objective was to determine whether obliteration of the epitympanic area and mastoid cavity during canal wall up (CWU) cholesteatoma surgery reduces the rate of recurrent and residual cholesteatoma compared to not obliterating the same area. The secondary objective was to compare postoperative hearing outcomes between both techniques. A retrospective cohort study was conducted in a tertiary referral center. One-hundred-fourty-three ears were included of patients (≥18y) who underwent a CWU tympanomastoidectomy for cholesteatoma with or without bony obliteration between January 2015 and March 2020 in the University Medical Center Utrecht. The median follow-up was respectively 1.4 (IQR 1.1-2.2) vs. 2.0 years (IQR 1.2-3.1) (p = 0.013). All patients underwent CWU tympanomastoidectomy for cholesteatoma. For 73 ears bone dust, Bonalive® or a combination was used for obliteration of the mastoid and epitympanic area, the rest of the ears (n = 70) were not obliterated. In accordance with the Dutch protocol, included patients are planned to undergo an MRI scan with diffusion-weighted imaging (DWI) one, three and five years after surgery to detect recurrent or residual cholesteatoma. The primary outcome measure was recurrent and residual cholesteatoma as evaluated by MRI-DWI and/or micro-otoscopy and confirmed by micro-otoscopy and/or revision surgery. The secondary outcome measure was the postoperative hearing. In this cohort, the group treated with canal wall up tympanomastoidectomy with subsequent bony obliteration (73 ears, 51.0%) had significantly lower recurrent (4.1%) and residual (6.8%) cholesteatoma rates than the group without obliteration (70 ears, 25.7% and 20.0%, respectively; p < 0.001). There was no significant difference between both groups in postoperative bone conduction thresholds (mean difference 2.7 dB, p = 0.221) as well as the mean air-bone gap closure 6 weeks after surgery (2.3 dB in the non-obliteration and 1.5 dB in the obliteration group, p = 0.903). Based on our results, a canal wall up tympanomastoidectomy with bony obliteration is the treatment of choice, since the recurrent and residual disease rate is lower compared to the group without obliteration. The bony obliteration technique does not seem to affect the perceptive or conductive hearing results, as these are similar between both groups.

Titanium Implant Obscuring Residual Cholesteatoma on Magnetic Resonance Imaging: A Case Report.

Cholesteatomas are benign growths of squamous epithelial tissue in the middle ear resulting in conductive hearing loss and/or erosion of the structures of the middle ear space. These lesions are surgically removed but require postoperative surveillance due to risk of recurrence or residual disease. Second-look surgery remains the gold standard for diagnosis and treatment of residual or recurrent cholesteatoma; however, advanced imaging modalities such as non-echoplanar diffusion weighted magnetic resonance imaging (non-EPI DWI-MRI) offer a less invasive alternative for surveillance. As surgeons become more reliant on advanced imaging, it is important to understand the limitations of the technology. We present a case of a delay in diagnosis of residual cholesteatoma due to a false-negative finding on non-EPI DWI-MRI screening in the presence of a titanium implant.

The Role of Endoscopic Assistance in Surgery for Pediatric Cholesteatoma in Reducing Residual and Recurrent Disease.

The primary aim of this study was to evaluate long-term recurrent and residual disease after surgery for acquired cholesteatoma in children according to surgical approach. A total of 71 interventions performed on 67 pediatric patients were included in the study. Canal wall-up tympanomastoidectomy (CWUT) was performed in 31 ears (13 with endoscopic assistance), a transcanal esclusive endoscopic approach (TEEA) was used in 22, and canal wall-down tympanomastoidectomy (CWDT) was performed in 18. Overall, the cholesteatoma relapse rate estimated by the Kaplan-Meier method was 47 ± 6% at 12 years; the recurrent cholesteatoma rate was 28 ± 6% and the residual cholesteatoma rate was 26 ± 5%. The relapse rate according to surgical approach was 33 ± 11% for CWDT, 60 ± 9% for CWUT, and 40 ± 11% for TEEA (p = 0.04). The difference for recurrent disease was no recurrent disease for CWDT, 42 ± 9% for CWUT, and 32 ± 11% for TEEA (p = 0.01). The residual disease rate was significantly reduced with endoscopy: 42 ± 8% without endoscopy vs. 9 ± 5% with (p = 0.003). CWDT can still be considered in primary surgery in case of extensive cholesteatomas and small mastoid with poor pneumatization. TEEA can be recommended for small cholesteatoma not extending to the mastoid to reduce morbidity. Endoscopic assistance seems useful to reduce residual disease in CWUT, whereas it does not have a significant impact on preventing recurrent disease.

Predicting residual cholesteatoma with the Potsic staging system still lacks evidence: a systematic review and meta-analysis

PurposeTo investigate the rate of residual disease in the Potsic staging system for congenital cholesteatomas.MethodsA protocol registration was published on PROSPERO (CRD42022383932), describing residual disease as a primary outcome and hearing improvement as secondary. A systematic search was performed in four databases (PubMed, Embase, Cochrane Library, Web of Science) on December 14, 2022. Articles were included if cholesteatomas were staged according to the Potsic system and follow-up duration was documented. Risk of bias was evaluated using the Quality In Prognosis Studies (QUIPS) tool. In the statistical synthesis a random effects model was used. Between-study heterogeneity was assessed using I2.ResultsThirteen articles were found to be eligible for systematic review and seven were included in the meta-analysis section. All records were retrospective cohort studies with high risk of bias. Regarding the proportions of residual disease, analysis using the χ2 test showed no statistically significant difference between Potsic stages after a follow-up of minimum one year (stage I 0.06 (confidence interval (CI) 0.01–0.33); stage II 0.20 (CI 0.09–0.38); stage III 0.06 (CI 0.00–0.61); stage IV: 0.17 (CI 0.01–0.81)). Postoperative and preoperative hearing outcomes could not be analyzed due to varied reporting. Results on cholesteatoma location and mean age at staging were consistent with those previously published.ConclusionNo statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging system’s applicability for outcome prediction could not be proven based on the available data. Targeted studies are needed for a higher level of evidence.

Canal wall up versus canal wall down mastoidectomy techniques in the pediatric population with cholesteatoma: A systematic review and meta-analysis of comparative studies.

The optimal surgical management of cholesteatoma remains controversial. Within pediatric otolaryngology, one of the most vital points of contention is the selection of canal wall-up (CWU) versus canal wall-down (CWD) procedures. Pediatric cholesteatoma has high rates of recurrence (16%-54%). In adults, there is evidence that the selection of surgical techniques affects recurrence rates. This has not been shown in children. 1. To systematically review the literature on recurrent and residual cholesteatoma after CWU and CWD in children and perform a meta-analysis of the data. 2. To assess the rates of recurrent and residual cholesteatoma between CWU and CWD techniques in pediatric patients. 3. To assess hearing outcomes by evaluating postoperative differences in the air-bone gap (ABG) between CWU and CWD techniques. A systematic search of PubMed, Embase, Scopus, and Cochrane Collaboration was performed from inception to May 1st, 2020, to identify studies that compared CWU and CWD procedures for acquired cholesteatoma in children. Search records were screened in duplicate by four reviewers. Inclusion criteria consisted of comparative randomized clinical trials and observational studies assessing outcomes of CWU and CWD techniques in the pediatric population. Studies involving patients with congenital cholesteatoma were excluded. Four reviewers working independently and in duplicate systematically reviewed and extracted study data. Dichotomous variables were analyzed as risk ratios (RR), while continuous variables were compared using weighted mean differences (MD). The risk of bias was assessed using the CLARITY Scale. The outcomes were recurrence, residual disease, air-bone gap (ABG), and air conductive (AC) thresholds. After screening 1036 publications, 17 retrospective cohort studies were selected. 1333 children were included; the overall mean age was ten years (SD 7.9), and the overall mean follow-up time was 5.9 years (SD 6.6). CWU and CWD techniques were performed in 60% (796) and 40% (537) cases. We did not find differences in cholesteatoma recurrence (RR: 1.50, 95% CI 0.94; 2.40; n=544; I2 0%; Tau [2]: 0.00), or rates of residual cholesteatoma (RR 1.51, 95% CI 0.96; 2.38, n=506; I2: 0%; Tau [2]: 0.00) in patients who underwent CWU and CWD mastoidectomy. The mean air-bone gap was lower with CWU than CWD (mean difference: 7.60, 95% CI -10.65; -4.54; n=242; I2: 71%; Tau [2]: 5.98). and relevance: We show similar rates of recurrence and residual disease after either CWU or CWD tympanoplasty. Our results challenge the fundamental principle of CWD surgery as a standard technique, as there is no difference in rates of recurrence and residual disease in CWU and CWD. Moreover, audiometric results support CWU with improved hearing outcomes. PROSPERO identifier: CRD42020184029.

Total Transcanal Endoscopic Ear Surgery for Cholesteatoma.

This study aimed to evaluate the outcomes of total transcanal endoscopic cholesteatoma surgery. Twenty-seven cholesteatoma patients that had undergone transcanal endoscopic ear surgery (TEES) were included in the study. Age, sex, operation date of patients, operated side, need for ossiculoplasty, graft material, and surgical technique were recorded. All patients were evaluated through otoscopic, endoscopic, and audiological examinations and followed up for at least five months after surgery. All patients were staged using the European Academy of Otology and Neurotology/Japan Otological Society (EAONO/JOS) Staging System on Middle Ear Cholesteatoma. Mean age of the patients was 36.4 years (range, 4-67 years). According to the EAONO/JOS Staging System, 11 patients were stage 1, while 11 were stage 2, and five were stage 3. Two had lateral semicircular canal defect, one had facial canal dehiscence, and one had oval window defect. The average follow-up period was 19 months (range, 5-41 months), during which two patients experienced retraction pocket and hearing loss and one patient had perforation. One patient underwent revision surgery during follow-up and no recurrence or residual cholesteatoma was observed. The preoperative and postoperative air-bone gaps were 25.14±13.93 dB and 22.22±12.64 dB with no significant difference. TEES is a minimally invasive and safe procedure with low complication and recurrence rates. As with all surgical procedures, experience is essential, and as experience increases, the capability to perform endoscopic otologic surgery on more complex cases may become possible.

Performance of Non-EPI DW MRI for Pediatric Cholesteatoma Follow-Up.

To evaluate the accuracy, sensitivity, and specificity of nonecho planar (non-EPI) diffusion-weighted (DW) magnetic resonance imaging (MRI)to detect residual cholesteatoma in children. Retrospective study. Tertiary comprehensive hospital. Children operated on for a first-stage cholesteatoma procedure from 2010 to 2019 were included. MRIs were performed with non-EPIDW sequences. Initial reports were collected, indicating the presence or absence of hyperintensity suggestive of cholesteatoma. Three hundred twenty-three MRIs were correlated with the subsequent surgery (66%) or year-later MRI (21%), or were considered accurate if performed 5 years or more after the last surgery (13%). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each imaging procedure for the detection of cholesteatoma were calculated. Two hundred twenty-fourchildren with mean age of 9 ± 4 years old presented with cholesteatoma. MRIs were performed 27 ± 24 months after surgery. Residual cholesteatoma was diagnosed in 35%. The sensitivity, specificity, PPV, and NPV of MRI were 62%, 86%, 74%, and 78%, respectively. Accuracy, sensitivity, and specificity increased significantly over time (multivariate analysis). The mean delay after last surgery was of 30 ± 2.0 months for accurate MRI (true positive or negative) versus 17 ± 2.0 months for nonaccurate (false positive or negative) MRIs (p < .001). However, long the delay after the last surgery, the sensitivity of non-EPI diffusion sequence MRI in children has limitations for the detection of residual cholesteatoma. Surveillance for residual cholesteatoma should incorporate findings at primary surgery, surgeon experience, a low threshold for second-look procedures, and routine imaging.

Early Magnetic Resonance Imaging to Diagnose Residual Cholesteatoma in Children and Benefit of Radiological Rereview.

Non-echo-planar diffusion-weighted (DW) magnetic resonance imaging(non-EPI MRI) is the appropriate sequence to detect residual cholesteatoma. In the child, MRI may be clinically useful to determine the timing of the second-look procedure. The aim of this paper was to retrospectively evaluate the performance of early MRI (before the 18th postoperative month) in detecting residual cholesteatoma in children after review by experienced specialized neuroradiologists. Retrospective study. One university center comparative cohort. All patients who had a 2-staged procedure for cholesteatoma with an MRI before the second stage from 2010 to 2020 were included and analyzed. Three pediatric neuroradiologists reviewed all the images blinded to the surgical result. N = 141 cholesteatoma events (140 children) were included with a mean age at MRI of 10 (±4) years old. Non-EPI MRIs were performed 10.7 (±3.8) months after the first-stage surgery and 2.2 (±2.6) months before the second-stage procedure. Non-EPI MRI had a 0.57 sensitivity (SE) and 0.83 specificity (SP). MRI was reviewed in 112 cases. The diagnosis was corrected in 17 cases (15.1%) (3 true positives, 7 false negatives, and 7 false positives). SE = 0.63 (p = 0.1) and SP = 0.92 (p = 0.08) after rereading. Early MRI's SEis poor but SP is excellent after rereading. Evidence does not support the use of early non-EPI MRI to modify the surgical strategy or to postpone the second look. If performed, early non-EPI MRI should be read by specialized experienced radiologists with all 3 sequences (T1, T2, andnon-EPI DW) and apparent diffusion coefficient calculation, especially in cases of otitis media with effusion.

ANATOMICAL VARIANTS OF RETROTYMPANUM - AN ENDOSCOPICAL STUDY

Aim: Methodology: To describe and classify the anatomical variants of retrotympanic structures by using transcanal endoscopy approach. A cross-sectional study was conducted in The Department of Otorhinolaryngology, Government Medical college, Kota, (Raj.) from Jan. 2022 to June 2022. We reviewed 45 endoscopic ear surgery to explore anatomical variations in retrotympanum. The anatomy was documented photographically. The nal classication was tabularized and summarized. 7 cases of ext Results: ended cholesteatoma with bony erosion were excluded. Study was performed in remaining 38. Ponticulus showed high variability among the bony crests. Ridge shape being the most frequent presentation. The subcochlear canaliculus was 50% detectable indicating a connection to the petrous apex. Sinus tympani was mostly of normal shaped (type A). Rarely a type C or D was observed. The retrotympanum bears a high ana Conclusion: tomical variability. If it is affected by disease, the endoscopic approach offers prompt recognition of the disease extension due to the wide-angle view of the whole region and the possibility to use angled scopes which helps the surgeon to completely clean the region from disease. Using the endoscope in the middle ear recesses in cholesteatoma surgery, we may also reduce the residual cholesteatoma

Retrospective Analysis of Postoperative Effect of Supratubal Recess Opened and Bony Obliteration Tympanoplasty.

In the surgical development of cholesteatoma, in order to reduce the recurrence of cholesteatoma, 2 kinds of surgeries were carried out: removal of Cog and Korner's septum to ventilate supratubal recess (supratubal recess opened) and obliteration of the mastoid and attic space (bony obliteration tympanoplasty) were invented, respectively. Their purpose is the same but the theoretical basis is different, and the comparison of these 2 methods is not reported in the current literature. This study aims to evaluate the rates of recurrent and residual cholesteatoma with the simple canal wall up and canal wall up-supratubal recess opened and canal wall up-bony obliteration tympanoplasty mastoidectomy in a large cohort of patients. The secondary objectives were to assess the 3 techniques' infection rates and hearing outcomes. Overall, 352 patients with middle ear cholesteatoma preoperatively underwent temporal bone ultrahigh-resolution computed tomography scan. The shape of the Eustachian tube and the supratubal recess were analyzed, and superior and posterior tympanic recesses, including the supratubal recess, were opened in different surgical groups. After 5 years of follow-up, the results show that the lowest recurrence rate was 6.6% (7/106) for canal wall up-supratubal recess opened, 10.9% (12/101) for canal wall up-bony obliteration tympanoplasty, and canal wall up had the highest recurrence rate of 19.31% (28/145). The postoperative infection rate was 5.7% in the canal wall up-supratubal recess opened group, 10.89% in the canal wall up-bony obliteration tympanoplasty group, and 7.59% in the simple canal wall up group. The postoperative median air conduction was increased 8 dB in the canal wall up-supratubal recess opened group, 1 dB in the canal wall up-bony obliteration tympanoplasty, and 6 dB in the simple canal wall up group. Opening the supratubal recess to ensure the patency of the attic facilitates the gas exchange between the mastoid process and the middle ear and reduces the possibility of cholesteatoma recurrence.

Efficiency of intraoperative endoscopic inspection in reducing residuals in canal-wall-up surgery for pediatric cholesteatoma involving the mastoid.

To investigate the efficiency of additional intraoperative endoscopic inspection in reducing residual cholesteatoma in pediatric cholesteatoma involving the mastoid treated with classic canal-wall-up mastoidectomy and tympanoplasty. 32 cases of pediatric cholesteatoma involving the mastoid were enrolled in this perspective study and treated with classic canal-wall-up mastoidectomy and tympanoplasty. Transmastoid posterior tympanotomy, atticotomy and transecting tendon of tympani tensor were conducted to achieve adequate visualization of hidden spaces in the middle ear. After complete removal of cholesteatoma, endoscopic inspection was additionally performed to check residual cholesteatoma. All cases had at least a 2-year follow-up by routine otoscopy examination, CT scan or MR imaging. Residual rates of both intraoperative and follow-up findings were used to evaluate the efficiency of the endoscopic inspection in reducing residual cholesteatoma and compared with published reports. The additional intraoperative endoscopic inspection did not find any residual in this case series. In the 2-year follow-up, 2 cases (2/32, 6.3%) with residual cholesteatoma and 3 cases with recurrence (3/32, 9.4%) were found. The mean duration of endoscopic inspection and microscopic procedure were 17.9min and 93.6min, respectively. This study suggested that the additional intraoperative endoscopic inspection in microscopic CWU surgery for pediatric cholesteatoma involving the mastoid had no obvious value in reducing residual cholesteatoma but took extra time.