ON-DEMAND SURGICAL TECHNIQUE FOR CHOLESTEATOMA: ATTIC EXPOSITION ANTRUM EXCLUSION
Introduction
The way to treat cholesteatoma is by surgical removal. Several techniques have been described with variable recurrence rates. Traditionally, they can be classified as open and closed techniques. Open techniques provide adequate control after removal of the cholesteatoma; however, the incidence of infections is higher, they require periodic follow up and the entrance of water is not advisable. A closed technique has a lower rate of infections and allows the entrance of water, but the rate of residual and recurrent cholesteatoma is higher and it also requires periodic follow up.
Several variables must be taken into account when choosing the surgical technique: anatomy of the temporal bone – particularly the aeration of the mastoid and the status of the mucosa – the kind of cholesteatoma, the presence of co-morbidities, environmental features, the age and so on.
Attic exposition and antrum exclusion (AE-AE) is an on-demand surgical technique for the treatment of cholesteatoma. Olaizola described this open technique as the surgical approach of choice for cholesteatoma.1 It has several advantages compared to classical open techniques such as canal-wall-down mastoidectomy. The AE-AE totally exposes the attic by drilling the superior wall of the external auditory canal (classical atticotomy through the canal) and excludes the antrum and the mastoid cells by closing the additus with a cartilage graft (Fig. 1). This last maneuver makes the AE-AE similar to an obliterative technique of the mastoid.
The aim of this study is to describe the indications for the AE-AE technique and analyse its long-term outcomes after the surgical removal of the cholesteatoma.
Fig. 1. Histological representation of the AE-AE technique. The red dotted line represents the division between attic and antrum, blocked by a cartilage.
Demographics
A retrospective study was carried out in a tertiary center, including patients who have undergone an AE-AE surgery to remove a primary acquired cholesteatoma from November 2003 to January 2010. We analysed 42 patients whose ages range from six to 68 years old (average: 48 years), of which 25 were men and 17 woman; with an average follow-up period of 2.58 years (range: six months-seven years).
Indications, surgery and follow up
Depending on the features and location of the cholesteatoma, two types of AE-AE can be carried out. Either technique is applied based on the following criteria:
•AE-AE: 25 patients with cholesteatoma located in the attic, either medial or lateral to the malleus or incus, not invading the additus, with or without erosion of the atical wall (Fig. 2A)
•Extended AE-AE: 17 patients diagnosed of cholesteatoma entering into the additus until de mastoid antrum, where a well-defined cholesteatoma that does not damage the labyrinth (Fig. 2B)
Fig. 2. A. AE-AE indication represented in a CT scan. The cholesteatoma is located in the attic and does not invade the additus. B. Modified AE-AE represented on a CT scan. The cholesteatoma is located on the mastoid antrum.
In case the cholesteatoma did not fulfil these criteria, other surgical techniques were carried out to remove it.
Olaizola,1 Ramirez-Camacho2 and López Villarejo3 report the surgical technique in detail (Fig. 3).
Patients are followed up ten days after surgery, once a month during six months and annually afterwards. Physical examination (Fig. 4) and radiology (CT scan and non-EPI MRI since 2009) are undertaken, the latter after two years of follow-up. Nowadays, non-EPI MRI4,5 is a non-invasive reliable test to diagnose recurrent or residual cholesteatoma.
Statistical analysis
SPSS v15.0 is used to determine the rate of recurrence, pathological findings during surgery and otomicro-scopic examination, auditory performance and the reliability of imaging tests such as CT and non-EPI MRI.
Results
Surgical details, such as extension and location of the cholesteatoma, lesions of the ossicular chain and the presence or absence of the membranous labyrinth, are summarized in Table 1.
Fig. 3. Surgical procedure for performing the AE-AE. (Figure adapted with permission from Lopez Villarejo P et al.3)
Pre-operative mean auditory thresholds are 41.04 for the air conductive and 26.3 dB for the bone conductive. The pre-operative air-bone gap is 29.69 ± 21.39 dB (range, 5–100 dB).
Post-operative auditory thresholds are 51,50 for the air conductive and 27.68 for the bone conductive. The post-operative air-bone gap is 25.17 ± 17.74 dB (range, 1,25–100 dB). The average difference pre-post-operative is 4.5 ± 16.9 dB (range [-22.5]- 56.6 dB).
From the forty-two patients included in the study, two patients have been diagnosed of residual choles-teatoma located in the posterior region of the mesotympanum (4.8%); both detected four years after surgery. They have been removed under local anesthesia through a trans-canal approach. No recurrences have been observed to date.
Imaging tests have been used to diagnose residual cholesteatoma, especially in those areas not visible through the otoscopy such as the mastoid. Before the non-EPI MRI was available, a CT was requested if a recurrence was suspected during the physical examination. It was carried out in six cases (14.3%). In one case (2.4%) out of six there was no evidence of disease in the mastoid cavity; in the rest of them (11.9%) there was evidence of mastoid occupation. A surgical second look was carried out in two cases, finding inflammatory tissue in the antrum. In another two cases a non-EPI MRI showed no evidence of disease and in the last one, a wait-and-see option was chosen. From January 2009, MRI’s are conducted after two years of follow up. To date, it has been executed in 12/42 cases (28.6%). No signs of cholesteatoma have been described.
Fig. 4. Otoscopy of a three-month post-op AE-AE.
No pathological findings were encountered during otoscopy in 35/42 cases (83.3%). In the rest, the following lesions were observed: atelectasis in the mesotympanum in two cases (4.8%), a polyp in the posterior wall of the external auditory canal (2.4%), two cases of attic membranous partition (4.8%) and two cases of serous tympanic cavity occupation (4.8%).
Table 1: Cholesteatoma characteristics between the two groups.
Discussion
The principal objective of the cholesteatoma surgery is its removal. The surgical technique chosen for the procedure must provide a full visualization of the cholesteatoma. AE-AE, when properly indicated, fulfils this requirement. The atticotomy through the EAC gives excellent exposure of the attic. Also, the mastoidectomy in the context of an extended AE-AE allows a good control of a cholesteatoma that invades this region.
The ratio of residual cholesteatoma varies from 5% to 57%,6–9 depending on the authors and the selected technique. In our series we had no residual cholesteatoma located in the attic or mastoid area. The two cases of residual cholesteatoma were located on the sinus tympani and were diagnosed four years after the AE-AE. We estimate these recurrences were not directly associated with the surgical technique, but with the poor visualization of the posterior area of the mesotympanum.10 These results are similar to those of other authors who have used the AE-AE to treat cholesteatoma.3,11
The main advantage of this technique to avoid recurrence is the attic exposition towards the external auditory canal. This maneuver, aside from controlling the attic adequately to reduce the risk of residual cholesteatoma, also prevents the formation of retraction pockets, thereby reducing the risk of recurrent cholesteatoma. Also, the surgery creates a micro-tympanic cavity formed by the mesotympanic and hypotympanic space. This means less air volume for the Eustachian tube to ventilate, reducing the possibility of pars tensa atelectasis.
Antrum exclusion ‘obliterates’ the mastoid cavity. The normal epithelium is plain, with no cilium and no secretory glands.12 Therefore, its obliteration should not generate any effusion unless inflammatory disease is left on the mastoid cavity. In our series, some cases of effusion have been detected either by CT scan or MRI. In any case, no pathological findings or clinical symptoms have been found. In the same way obliterative techniques,13 avoiding an extensive removal of the EAC walls, have a faster recovery in terms of cicatrization, allowing the entrance of water, and shortening the follow-up period. Only two cases of othorrea have been recorded in our group.
Since 2009 we are using a specific diffusion-MRI protocol to detect cholesteatoma, as described by De Foer.4,5 This technique is especially effective when the lesion is over two mm, and gives the surgeon the chance to avoid a second-look surgery. For this reason, we recommend this exploration two years after the initial cholesteatoma surgery.
It is very important to highlight that the AE-AE does not change the surgical attitude towards ossicular reconstruction, as it depends only on the condition of the remaining ossicules. The global analysis shows that the hearing levels during the pre- and post-surgical procedure are virtually the same.
AE-AE is a variant of an open technique, in which the attic is exposed through the EAC while the antrum is excluded from the tympanic cavity. With this surgical procedure, the disease control is excellent with low recurrence rates of cholesteatoma, allowing the entrance of water and offering a good quality of life.
Diffusion MRI is a reliable technique for cholesteatoma follow up and it is helpful to surgeons in avoiding unnecessary surgical procedures.
References
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Address for correspondence: Dr. Manuel Manrique Rodriguez, Otorhinolaryngology Department, University Clinic of Navarra, Pio XII 36, Pamplona 31008, Navarra, Spain. mmanrique@unav.es
Cholesteatoma and Ear Surgery – An Update, pp. 91–95
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands