Retraction Cholesteatoma Research Articles

Cartilage palisade tympanoplasty in sinus and tensa retraction cholesteatoma.

The aim of this study was to investigate whether reconstruction of the eardrum with palisade cartilage technique could prevent retraction of the new eardrum after surgery for sinus and tensa retraction cholesteatoma in children and to investigate the postoperative hearing. In 32 children aged 5 to 15 years, operated on from June 1995 to October 2000 for cholesteatoma (21 with sinus cholesteatoma and 11 with tensa retraction cholesteatoma) the eardrum was reconstructed with the palisade cartilage technique. Postoperatively, the children were seen as outpatients and were recently reevaluated with otomicroscopy, tympanometry, and audiometry. All patients (100%) were reevaluated on an average of 37 months (range 3-63 months). Postoperative retractions, perforations, cholesteatoma recurrence, and hearing. At the final examination, posterosuperior retraction was observed in two patients, both operated on for sinus cholesteatoma with reconstruction of the ossicular chain. In those cases, the palisades were not placed in the posterosuperior drilling defect behind the interpositioned incus. All the patients had an intact tympanic membrane at the final follow-up visit. One small perforation was surgically closed during the observation period. No patients developed cholesteatoma during the follow-up period. The postoperative hearing was good, and the hearing did not deteriorate with increasing observation time. The palisade technique effectively prevented postoperative retraction of the eardrum. The postoperative hearing was good.

초기 중이 진주종의 치료

Chronic otitis media with cholosteatoma had been one of the most prevalent forms of otological disease. However, recently, the incidence of chronic otitis media have decreased owing to better economic status and health care. Thus, cases of middle ear surgery have also decreased relatively in number. So it seems that otologists nowadays should be engaged in revision surgery of the middle ear and management of early cholesteatoma. While the incidence of extensive or complicated cholesteatoma has dramatically decreased for last decades, the early staged or less extensive cholesteatoma and retraction pockets are more frequently found. Especially localized adhesive otitis media, usually posterior tympanic membrane, is one of the most difficult dilemmas for the otologist. There are several controversial issues for managing patients with early cholesteatoma : 1 ) conservative care or surgical treatment 2) techniques of surgery 3) whether or not mastoidectomy. So surgery for early cholesteatoma is thought to be reconstructive rather than destructive and it can be a prophylactic operation. I proposed a strategy for the management of early cholesteatoma which was based on safe marsupialization of retraction pocket or cholesteatoma, preservation of the mucosa, adequate ventilation, and prevention of retraction pocket. In case of attic retraction pocket or cholesteatoma, atticotomy with scutumplasty was made. On the other hand, the procedure to remove posterior annular bone and posterior scutum to allow access tympanic sinus and posterior attic space designated as posterior sinusectomy with reconstruction were applied to sinus retraction pocket or cholesteatoma. Early tensa retraction cholesteatoma would be managed as the combination of atticotomy and posterior sinusectomy. So I preferred the term “atticosinoplasty” which includes attic reconstruction with scutumplasty after atticotomy and posterior sinusectomy. If the disease seems to extend to mastoid, endoscopes were introduced transmeatally. If cholesteatoma occupies in mastoid, complete mastoidectomy is made, and sometimes mastoid cavity is obliterated to eliminate the cavity problems. During the last 7 years, I managed surgically 208 cases of attic or sinus cholesteatoma, so-called early cholesteatoma, among which there were 45 cases of atticosinoplasty. I analysed 45 cases with atticosinoplasty with special reference to period of postoperative care and hearing result, as compared to cases with mastoid obliteration and open cavity mastoidectomy. In conclusion, I personally think that middle ear cholesteatoma has a possibility of different clinical entity rather than a kind of chronic otitis media, eustachion tube dysfunction can not be always a prerequisite of middle ear cholesteatoma but it can be a secondary phenomenon, and finally surgury for early cholesteatoma is reconstructive rather than destructive ant it can be a prophylactic operation. (J Clinical Otolaryngol 2002;13:13–19)

A Study of Postoperative Attic Retraction and Retraction Cholesteatoma

Shimizu, Takeshi*; Takeuchi, Kazuhiko*; Harada, Teruhiko*; Ukai, Kotaro†; Sakakura, Yasuo‡; Majima , Yuichi*Author Information

Is an isthmus block a prerequisite for the development of an attic retraction cholesteatoma?

Computed tomography (CT) was used to investigate whether an isthmus block was present in 57 cases with attic retraction cholesteatomas. A ventilation route between the mesotympanum and attic was considered to exist in 30% of the cases and occurred predominantly in those ears with a cholesteatoma that did not extend into the antrum. Four cases were also found to have this ventilation route in CT scans taken before and after the development of cholesteatoma. These findings suggest that an isthmus block is not a prerequisite for the development of an attic retraction cholesteatoma.

Long-term results of surgical treatment in different cholesteatoma types.

Results of surgical treatment in different types of cholesteatoma were analyzed in 431 chronic ears. Mean follow-up period was 6.9 years. The total recurrence rate (including both residual and recurrent cholesteatoma) was 8.6 percent. The recurrence rate was lowest (7.4%) in attic cholesteatoma and highest (10.0%) in pars tensa retraction cholesteatoma. The great majority (98%) of the operations were one-stage procedures. Canal wall down mastoidectomy was the procedure in 297 cases, with a recurrence rate of 7.7 percent; canal wall up mastoidectomy, in 86 cases, yielded a recurrence rate of 9.3 percent, and in 48 ears the cholesteatoma was removed by a transcanal procedure without mastoidectomy, giving a recurrence rate of 12.5 percent. Hearing results in attic and sinus cholesteatoma were significantly better than in pars tensa retraction cholesteatoma. Of the whole series, hearing improved in 36 percent and deteriorated in 28 percent. It is concluded that surgery should be individualized according to site and size of the cholesteatoma, but all large cholesteatomas require canal wall down procedure to avoid recurrence.

Immunohistologic analysis of the cholesteatoma matrix in children

The immunohistological characteristics of retraction pockets, cholesteatoma matrix and granulomatous tissue were compared in 14 samples from pediatric cholesteatoma. The junction between epidermis and the middle ear mucosa appeared as the most inflammatory area, displaying the characteristics of delayed type hypersensitivity. CD1 + Langerhans cells were observed in all epidermic areas, but expressed class II molecules only in the vicinity of polymorphonuclear infiltrates. Numerous mast cells and IgA producing cells were also observed, suggesting that defenses from the mucosal immune system are summoned and contribute to the pathogenesis of cholesteatoma.

Tensa retraction cholesteatoma: treatment and long-term results.

To obtain the best possible results of treatment of acquired cholesteatoma, we made a subdivision of cholesteatoma types into attic and pars tensa cholesteatomas, and subdivided the latter further into tensa retraction cholesteatoma and sinus cholesteatomas. Tensa retraction cholesteatoma is defined as arising from a retraction or perforation of the whole pars tensa, whereas sinus cholesteatoma is defined as arising from a retraction or perforation of the postero-superior part of the tensa. We present the long-term results obtained in tensa retraction cholesteatomas treated with one stage surgery from 1964 to 1980. Median observation time was 9 years, range 2 to 19 years. Sixty-one ears were treated without mastoidectomy, whereas 71 ears had canal wall-up mastoidectomy and 64 ears had canal wall-down mastoidectomy. The total recurrence rate was 13.3 per cent; 17 ears had residual cholesteatoma, and nine ears had recurrent cholesteatoma. The best results were obtained in ears with an intact ossicular chain where mastoidectomy was not performed. In 49 per cent of the cases, the cholesteatoma was confined to the tympanic cavity without reaching the aditus, antrum or mastoid process. About one-third to one-quarter of the ears had tympanoplasty only, with removal of the cholesteatoma through the ear canal.

Late results of surgery in different cholesteatoma types.

Our series of 740 cholesteatomas, operated during the period 1969 to 1980, were seen at follow-up several times with a median observation period of 9.2 years (range 3-21 years). There were; 273 attic cholesteatomas with retraction (perforation) of Shrapnell's membrane; 271 sinus cholesteatomas with superioposterior retraction (perforation) of pars tensa, and 196 tensa retraction cholesteatomas extending from a retraction of the whole pars tensa. The late results were analyzed for each type separately, and compared. The recurrence rate was lowest (6.6%) in attic cholesteatoma and highest (13.3%) in tensa retraction cholesteatoma. In all three types no residual cholesteatomas were detected after the 4th postoperative year, whereas recurrent cholesteatomas occurred up to 10 years after surgery. The reoperation rate was lowest (15%) in attic cholesteatoma and almost the same (21%) in sinus and tensa retraction cholesteatoma. The hearing results were best in attic cholesteatoma and poorest in tensa retraction cholesteatoma. It is concluded that cholesteatoma surgery should be individualized and that both the canal wall up and canal wall down methods have their place in cholesteatoma surgery.

Treatment of sinus cholesteatoma. Long-term results and recurrence rate.

We classified cholesteatomas as attic cholesteatoma, developing from Shrapnell's membrane; tensa cholesteatoma, originating in pars tensa, which is subdivided into tensa retraction cholesteatoma involving the entire pars tensa, and sinus cholesteatomas, developing from a posterosuperior retraction (perforation). From 1964 to 1980, one-stage operations were carried out on 271 ears with sinus cholesteatomas. Follow-up included 90% of the patients, and the median observation time was 9.75 years. The recurrence rate was 10%. The recurrence rate was found to be independent of the mastoidectomy type employed. The best hearing results were obtained in ears with intact ossicular chain. We conclude that, wherever possible, sinus cholesteatoma should be removed through the auditory canal without mastoidectomy just as an intact ossicular chain should be preserved. "Canal wall up" and "canal wall down" appear to be equally valuable mastoidectomy types, and both methods must be employed to obtain optimum results.

Tympanoplasty in Children—When? A Preliminary Report

The results of tympanoplasty in 169 children 15 years of age were evaluated one to four years after the operation, focusing on otomicroscopic signs of Eustachian tube dysfunction, i.e. re-perforations, retraction pockets and retraction cholesteatoma. Inferior results were obtained in the youngest children, in particular in the group < 7 years of age, and accordingly tympanoplasty should be postponed in this group.

慢性中耳炎の再手術例の検討

Reoperation was performed on 76 patients with chronic otitis media during a tenyear period. The annual incidence of reoperation in patients undergoing middle ear surgery was between 12 and 17%. In 38% of the cases, no dry ears were detected following the initial/previous surgery. A dry ear, once occurring rarely recurred within a year following the previous surgery. In 9 ears, the same bacteria were found both before the previous operation and at the time of reoperation. Nine patients underwent tubo-tympanoplasty procedure. Retraction cholesteatoma was found in 7 ears without previous cholesteatoma.

Eustachian tube pathophysiology

Studies of eustachian tube physiology have mainly focused on the ability of the tube to open. For this reason, impaired opening ability has been regarded as the basis of eustachian tube malfunction. Characteristic patterns have been found in pressure measurements in patients with chronic middle ear disease. Simultaneous measurements of nasopharyngeal and middle ear pressures in patients with atelectatic tympanic membranes and retraction cholesteatoma have shown that high negative intratympanic pressure is generated by the voluntary act of sniffing. Eustachian tube malfunction in these patients is thus characterized by failure of the tube to close.

Zur Problematik der postoperativen Trommelfellretraktion

After tympanoplasties of adhesive processes or epitympanic cholesteatomas often retractions of the tympanic membrane can develope both in area of pars tensa or pars flaccida. In some cases we find recidives, as secondary adhesive processes or retraction cholesteatomas. By a follow-up-study over 6 years after tympanoplasties it could be demonstrated that the rate of recidives is not significantly between patients with normal (1/3 of our collective) and such with reduced tube function (2/3 of our collective), examined by the pressure equalisation test. Epitympanic retractions even were found in patients with grommets in the pars tensa. Based on these and other findings of our study, etiology and therapy of postoperative retractions are discussed. Especially it must be concluded that dysfunction of the tube is not the only factor causing postoperative retractions of the tympanic membrane.

Experiences With Residual and Recurrent Cholesteatoma

Moderator, Dr. Victor Goodhill: This panel on residual and recurrent cholesteatomata has a provocative title, that tells us much about the disease and our continuing and persistent inadequacy in cholesteatoma surgery. Dr. Horst Wullstein: When considering recurrent cholesteatoma, we have to search which kind of recurrence we have. First the type with residual matrix which was not completely removed by the first surgery. The second type would be the annulus cholesteatoma, as I would like to call it. Third is the transplant cholesteatoma. Fourth, retraction cholesteatoma. The first type is self-explanatory. The first surgery was not complete. The second type, annulus cholesteatoma, means that the skin of the meatus along the annulus was not completely taken away. So when we insert our graft, our fascia graft, or whatever it may be, it covers a very small area of skin. Generally, tissue does not take on skin; however, in cases where

Otitis media in the newborn. Relationship to duration of rupture of amniotic membrane.

IT IS WIDELY believed that intrapartum factors may produce diseases in the newborn baby. 1-4 Otitis media has been included among these diseases. 5-7 One hypothesis, based on anatomic findings, is that amniotic fluid components enter the middle ear cavity of the fetus via the eustachian tube and, if infected, may produce otitis media. 7 Wittmaack attributes arrested pneumatization to otitis media neonatorum with subsequent development of attic retraction cholesteatoma. 8 This study was undertaken to determine if duration of rupture of the amniotic membranes showed a positive correlation with otoscopic signs of otitis media in babies in the newborn nursery. Duration of membrane rupture was utilized rather than more precise methods of assessing infection of amniotic fluids for convenience as a first step in investigation of the hypothesis. Patients The 84 babies, 46 boys and 38 girls, who were included in this study were examined in the newborn nurseries