METHODS FOR PREVENTION OF RECURRENT CHOLESTEATOMA

Maurizio Barbara, Luigi Volpini, Martina Romeo, Isotta Musy

NESMOS Department Sapienza University, ENT Clinic, Rome, Italy

In cholesteatoma surgery, the primary goal is the complete eradication of the pathology with no residual disease, while secondarily the prevention of recurrences and the preservation or improvement of hearing are searched. After cholesteatoma surgery, relapsing of the disease is due either to residual or recurrent cholesteatoma and this may occur anywhere from the ear canal, to the eardrum, the middle ear, the mastoid, to the petrous apex. Residual cholesteatoma results from leaving squamous epithelium in the mastoid and middle-ear cleft. Therefore, in order to reduce the risk of new cholesteatoma formation, the radical removal of all the matrix is mandatory.1,2

The incidence of recurrent cholesteatoma is reported to vary from 5 to 71%, depending on the type of cholesteatoma, the surgical technique, the follow-up rate, the length of the post-operative observation period and the statistical method applied.36

The surgical techniques used in cholesteatoma surgery can be divided in those where the posterior canal wall is removed to achieve a better exposure of the surgical field (open technique or canal-wall down, CWD), and those where the posterior canal wall is kept intact (closed technique or canal-wall up, CWU). The choice between them has largely been debated over the years, without reaching any general agreement, thus leaving each otologist free to decide.7

CWD tympanoplasties, as radical cavities, rarely require a revision surgery and offer hypothetically better chances for reducing the recurrence rate of cholesteatoma. On the other hand they offer less chances for the reconstruction of a functional sound-conducting system and for fitting of a hearing aid. Moreover, the creation of a large cavity not infrequently results in annoying symptoms such as ear discharge, water intolerance, dizziness or headache, with frequent need to have the mastoid bowl periodically cleaned.810

In CWU tympanoplasties, preservation of the normal anatomy should allow better functional results, avoiding those disadvantages associated with large cavities, although it is susceptible to a higher rate of recurrences, often requiring a second look surgery.5,11

Some authors, in order to achieve the best exposure of the disease and to prevent recurrences advice to apply ‘à la demande’ techniques that encompass a partial drilling the posterior canal wall, its temporary re-moval,10 or its total removal.

The use of a large variety of materials and autologous tissues, like flaps, silastic sheeting, cement, hy-droxyapatite, cartilage, bone paté, demineralized bone matrix,12 silicon block, titanium (or a combination) has been described in order to cover defects of the posterior canal wall, reaching good functional results and preventing recurrences of the disease.13,14,1518

Some authors have stated that recurrent cholesteatoma after CWU procedures occurs in four sites: the attic, with erosions of the canal, at the posterosuperior pars tensa, and as borderline patterns, between the attic and the pars tensa (occurring after purely attic disease).19 It usually happens when the newly reconstructed tympanic membrane undergoes a progressive retraction toward the attic, the antrum and the mastoid cavity.20 This condition has been associated with a malfunctioning Eustachian tube, the blockade of communication between the Eustachian tube and the attic-antrum region, a bony defect of the tympanic scutum and the chronic inflammation in the attic.1,11,21 In order to prevent these lesions it is mandatory to close all canal defects, to stiffen a collapsed tympanic membrane and carefully repair attic and epitympanic defects.4,22,23 Many techniques that include the use of bone paté,24 autologus cartilage,2527 hydroxyapatite plates, silastic and bone chips,28 have been described in literature, especially for the repair of the attic defects, with a high reduction in the recurrence rate.5,22,29

Personal experience

In our department, type-II epitympanic retraction pockets, that are at risk for developing a secondary acquired cholesteatoma, have been preventively treated by using the lateral attic reconstruction (LAR) technique in order to prevent the recurrence of a retraction pocket.30 This technique has not only proved to enable to prevent the relapse of these pre-cholesteatomatous conditions, but it has also proved not to impair the hearing function. After primary surgery, which in our experience has privileged the CWU technique, an extensive use of cartilage for reconstructing the surgical defects can play a crucial role for the prevention of cholesteatoma recurrence, also considering that the follow up is nowadays carried out by diffusion non-epi (HASTE) MRI that, in negative cases, allows to avoid a second-look surgery.

References

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2.Farrior JB, Farrior JB. Recurrent and residual cholesteatoma. Am J Otol 6(1):13–18, 1985

3.Karmarkar S, Bhatia S, Saleh E, DeDonato G, Taibah A, Russo A, et al. Cholesteatoma surgery: the individualized technique. Ann Otol Rhinol Laryngol 104(8):591–595, 1995

4.Sakai M, Shinkawa A, Miyake H, Fujii K. Reconstruction of scutum defects (scutumplasty) for attic cholesteatoma. Am J Otol 7(3):188–192, 1986

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12.Leatherman BD, Dornhoffer JL. The use of demineralized bone matrix for mastoid cavity obliteration. Otol Neurotol 25(1):22–5, discussion 25–26, 2004

13.Takahashi H, Iwanaga T, Kaieda S, Fukuda T, Kumagami H, Takasaki K, et al. Mastoid obliteration combined with soft-wall reconstruction of posterior ear canal. Eur Arch Otorhinolaryngol 264(8):867–871, 2007

14.Zini C, Quaranta N, Piazza F. Posterior canal wall reconstruction with titanium micro-mesh and bone paté. Laryngoscope 112(4):753–756, 2002

15.Cho SW, Cho YB, Cho H-H. Mastoid Obliteration with Silicone Blocks after Canal Wall Down Mastoidectomy. Clin Exp Oto-rhinolaryngol 5(1):23, 2012

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19.DeRowe A, Stein G, Fishman G, Berco E, Avraham S, Landsberg R, et al. Long-term outcome of atticotomy for cholesteatoma in children. Otol Neurotol 26(3):472–475, 2005

20.Anderson J, Cayé-Thomasen P, Tos M. A comparison of cartilage palisades and fascia in tympanoplasty after surgery for sinus or tensa retraction cholesteatoma in children. Otol Neurotol 25(6):856–863, 2004

21.Rosenfeld RM, Moura RL, Bluestone CD. Predictors of residual-recurrent cholesteatoma in children. Arch Otolaryngol Head Neck Surg 118(4):384–391, 1992

22.Black B. Prevention of recurrent cholesteatoma: use of hydroxyapatite plates and composite grafts. Am J Otol 13(3):273–278, 1992

23.Lee W-S, Choi JY, Song MH, Son EJ, Jung SH, Kim SH. Mastoid and epitympanic obliteration in canal wall up mastoidectomy for prevention of retraction pocket. Otol Neurotol 26(6):1107–1111, 2005

24.Bacciu A, Pasanisi E, Vincenti V, Lella F, Bacciu S. Reconstruction of outer attic wall defects using bone paté: long-term clinical and histological evaluation. Eur Arch Otorhinolaryngol 263(11):983–987, 2006

25.East DM. Atticotomy with reconstruction for limited cholesteatoma. Clin Otolaryngol Allied Sci 23(3):248–252, 1998

26.Weber PC, Gantz BJ. Cartilage reconstruction of the scutum defects in canal wall up mastoidectomies. American Journal of Otolaryngology--Head and Neck Medicine and Surgery 19(3):178–182, 1998

27.Luetje CM. Saddle blanket graft tympanoplasty and lateral attic wall reconstruction for defects produced by primary acquired cholesteatoma. Laryngoscope 111(8):1497–1499, 2001

28.Gehrking E. Osteoplastic atticoantrotomy with autologous bone chips and a bony attic strut in cholesteatoma surgery. Eur Arch Otorhinolaryngol 267(7):1055–1066, 2009

29.Vercruysse J-P, De Foer B, Somers T, Casselman JW, Offeciers E. Mastoid and epitympanic bony obliteration in pediatric cho-lesteatoma. Otol Neurotol 29(7):953–960, 2008

30.Barbara M. Lateral attic reconstruction technique: preventive surgery for epitympanic retraction pockets. Otol Neurotol 29(4):522–525, 2008


Address for correspondence: Prof. Maurizio Barbara, ENT Clinic for Medicine and Psychology, Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy. mrzbrbr@gmail.com

Cholesteatoma and Ear Surgery – An Update, pp. 51–53

Edited by Haruo Takahashi

2013 © Kugler Publications, Amsterdam, The Netherlands