TREATMENT OF CHOLESTEATOMA-INDUCED LABYRINTHINE FISTULA

Maurizio Barbara, Carlo Iacolucci, Francesca Atturo, Maria Giovanna Bucci

NESMOS Department Sapienza University, ENT CLinic, Rome, Italy

Introduction

Labyrinthine fistula (LF) is the most common complication of cholesteatoma, with an estimated incidence of 0.2–12.9%.14 In 90% of the cases, LF occurs in the lateral semicircular canal (the remaining 10% involving the basal turn of the cochlea).

Symptoms such as vertigo, sensorineural hearing loss and even acute meningitis may ensue if a fistula is left untreated for a long period of time. Complications of cholesteatoma-induced LF can be divided into pathological and functional. The most common pathological consequence is a higher residual rate due to incomplete matrix removal; total deafness is the most threatening functional complication.

Adequate surgical management of LF is still debated, the majority of authors adopting routinely the open tympanoplasty technique;58 this attitude is nowadays slowly changing, some surgeons preferring the closed technique.911 A further option consists of applying the middle ear exclusion technique.12

The size of the fistula and the hearing threshold, as pure tone average (PTA), are the main factors to take in account in the choice of the surgical approach.

When the surgeon has to deal with a type I fistula (according to Dornhoffer and Milewski’s fistula grading system13) (Fig. 1), being smaller than two mm with a mild to moderate conductive or mixed hearing loss, in our opinion the preferable surgical approach is intact-canal-wall tympanoplasty with ossicular reconstruction by mean of passive middle ear implant, associated to a fistulaplasty.

image

Fig. 1. Classification of the cholesteatoma-associated labyrinthine fistula according to Dornhoffer and Milewski. Type 1: bone erosion without penetration of the endosteal layer of the canal; Type 2a: bone erosion with penetration of the endosteal layer of the canal; Type 2b: as type 2a, with spontaneous perilymphatic leakage; Type 3: complete invasion of the canal.

When considering a type IIb or III fistula, with a concomitant profound hearing loss or anacusis, a middle ear exclusion technique with fistulaplasty may be proposed, simultaneously associated to a bone conduction hearing prosthesis such as B.A.H.A. or similar, provided that the pre-operative audiological tests have considered it as a practicable option for rehabilitating as single-sided deafness.

Another point to take into consideration is to leave or not the cholesteatoma matrix over the exposed labyrinthine spaces. Traditionally, the majority of otologists advised to leave the cholesteatoma matrix over the bone defect, in order not to jeopardize the delicate structures of the membranous labyrinth, therefore avoiding a jatrogenic sensorineural hearing loss.11,14

On the other hand, leaving residual cholesteatoma tissue may increase the risk for the infective/inflammatory process to grow or spread from the cholesteatoma matrix to the perilymph and the membranous labyrinth, with a possible consequent late-occurring sensorineural hearing loss.1,13,15,16

In our personal experience, out of 153 patients who underwent surgical treatment for cholesteatoma at Sant’Andrea Hospital Sapienza University of Rome between 2005 and 2011, 22 LF (14.4%) were found. The location of the LF was in 85% the lateral semicircular canal (dome 70%, superior aspect 25%, anterior aspect 5%), in 10% the superior semicircular canal and in 5% of the cases the posterior semicircular canal.

The surgical technique was canal-wall-up in 80% of the patients, the modified radical cavity in 15% of them and the subtotal petrosectomy with middle ear exclusion by blind-sac closure of the external auditory canal in 5%.

Fistula repair was performed as one of the last surgical steps, after removal of the major cholesteatoma mass and before performing tympanic or ossicular reconstruction. Our three-layer sealing procedure consisted of:

Gentle dissection of the matrix over the bony defect, helped by fine suction tip and dissector;

Immediate covering with temporalis fascia;

Placement of bone paté collected from the cortical bone and successive fixation with fibrin glue (Fig. 2).

image

Fig.2. Three-layer fistulaplasty technique.

From a functional point of view, among these 22 patients, two were pre-operatively deaf, 12 (54.6%) showed a mixed hearing loss, seven (31.9%) a conductive hearing loss and one (4.5 %) had a sensorineural hearing loss. Post-operatively, one patient developed anacusis.

In most of the cases presenting with a conductive and mixed hearing loss, a serviceable post-operative hearing was preserved. Only one patient with a pre-operative conductive hearing loss developed anacusis after the surgery. Also, the only patient in our series affected with a sensorineural hearing loss developed anacusis.

Conclusion

Our experience seems to suggest that hearing function may be preserved in the majority of the cases, especially in early stage (grade I), associated with a conductive and mixed hearing loss.

Therefore, when dealing with small fistulas (< 2 mm), it is our attitude to apply always a canal-up technique with fistulaplasty.

References

1.Palva T, Ramsay H. Treatment of labyrinthine fistula. Arch Otolaryngol Head Neck Surg 115:804–806, 1989

2.Antonio SM, Miguel BS. Surgical treatment of labyrinthine fistula caused by cholesteatoma. Otolaryngol Head Neck Surg 122:739–742, 2000

3.Gacek RR. The surgical management of labyrinthine fistulae in chronic otitis media with cholesteatoma. Ann Otol 83:1–19, 1974

4.Suh JS, Choi EC, Lee WS, Lee SE, Park IY, Kim YM. A clinical evaluation of chronic otitis media with cholesteatoma. Korean Jotolaryngol 26:593–603, 1983

5.Herzog JZ, Smith PG, Kletzker GR, Maxwell KS: Management of labyrinthine fistulae secondary to cholesteatoma. Am J Otol 17:410–415, 1996

6.Parisier SC, Edelstein DR, Han JC. Management of labyrinthine fistulas caused by cholesteatoma. Otolaryngol Head Neck Surg 104:110–115, 1991

7.Ahmad I, East DM. Hearing preservation in patients with labyrinthine fistulae. Rev Laryngol Otol Rhinol 123:49–52, 2002

8.Soda-Mehry A, Betancourt-Suarez MA. Surgical treatment of labyrinthine fistula caused by cholesteatoma. Otolaryngol Head Neck Surg 122:739–742, 2000

9.Sheehy JL, Brackmann DE. Cholesteatoma surgery: management of the labyrinthine fistula – a report of 97 cases. Laryngoscope 89:78–87, 1979

10.Romanet P, Duvillard C, Delouane M, Vigne P, De Raigniac E, Darantiere S, Brogniard P. Labyrinthine fistulae and cholesteatoma. Ann Otolaryngol Chir Cervicofac 118:181–186, 2001

11.Sanna M, Zini C, Bacciu R. Management of the labyrinthine fistula in cholesteatoma surgery. ORL 46:165–172, 1984

12.Sanna M, Dispenza F, Flanagan S, De Stefano A, Falcioni M. Management of chronic otitis by middle ear obliteration with blind sac closure of the external auditory canal. Otol Neurotol 29(1):19–22, 2008

13.Dornhoffer JL, Milewski C. Management of the open labyrinth. Otolaryngol. Head Neck Surg 112:410–414, 1995

14.Ritter FN. Chronic supportive otitis media and the pathologic fistula. Laryngoscope 80:1025–1035, 1970

15.Ostri B. Surgical management of labyrinthine fisula in chronic otitis media with cholesteatoma by a one stage closed technique. ORL J Otorhinolaryngol Relat Spec 51:295–299, 1989

16.Kobayashi T, Sakurai T, Okitsu T, et al. Labyrinthine fistulae caused by cholesteatoma. Improved bone conduction by treatment. Ann J Otol 10:5–10, 1989


Address for correspondence: Prof. Maurizio Barbara, ENT Clinic, Sapienza University, Ospedale Sant’Andrea, via di Grottarossa 1035, Rome, Italy. mrzbrbr@gmail.com

Cholesteatoma and Ear Surgery – An Update, pp. 103–105

Edited by Haruo Takahashi

2013 © Kugler Publications, Amsterdam, The Netherlands