PRE-OPERATIVE MIDDLE-EAR AERATION PREDICTING LONG-TERM AERATION IN STAGED CANAL-UP TYMPANOPLASTY

Masahiro Komori,1,2 Naoaki Yanagihara,1 Yasuyuki Hinohira,1,3 Ryosei Minoda1,4

1Department of Otolaryngology, Takanoko Hospital, Matuyama, Ehime, Japan; 2Department of Otolaryngology, Kochi University, School of Medicine, Nankoku, Kochi, Japan; 3Department of Otolaryngology, Showa University, School of Medicine, Tokyo, Japan; 4Department of Otolaryngology, Kumamoto University, School of Medicine, Kumamoto, Japan

Introduction

Post-operative middle-ear aeration must be important for the prevention of recurring cholesteatomas and good surgical outcomes. Based on this assumption, we have been developing the staged canal-up tympanoplasty (SCUT) for cholesteatoma.1 Since 1995, we have performed scutumplasty using bone paté and silastic sheets in the first-stage operation.2 The incidence of retraction pocket development in the second operation was reduced significantly from 20% to 6%. Since 1997, we have performed mastoid cortex plasty using bone paté to prevent soft tissue ingrowth into the mastoid cavity.3,4 This facilitated aeration of the mastoid cavity significantly. Our recent report demonstrated that a total mastoid obliteration technique for SCUT effectively controls cholesteatomas arising in poorly ventilated middle ears because of restoring good tympanic aeration.5 Here, we investigated the change in the middle-ear aeration to determine whether the aeration improved with these procedures, continued for the long term.

Materials and methods

Subjects

The study included 37 ears of 37 patients with extended middle-ear cholesteatoma who underwent SCUT. They were followed up more than three years.

Operations

In the first stage of the operation, the cholesteatoma was removed with a combined transmastoid and transcanal approach.2 After inserting a silastic sheet as support, we reconstructed the tympanic scute with bone paté, and the eardrum with fascia. One year later, at the second stage of the operation, ossicloplasty was carried out after removal of residual cholesteatoma. Then the tympanic scute was enforced with the sliced cartilage, and the obliteration or cortex plasty was performed based on the assessment of middle-ear aeration.2,5

Grades of middle-ear aerations

Computed tomography (CT) was carried out before the first- and second-stage operation, and every one year after the operation. In the study, aeration of the tympanum was assessed from pre-operative and most recent CTs and was graded. Grade 0: no aeration in the tympanic cavity; Grade 1: only the mesotympanum was aerated; Grade 2: the entire tympanic cavity including attic was aerated; Grade 3: the tympanic and mastoid cavities were aerated.4

Results

Figure 1 shows the change in middle-ear aeration. Twenty-seven of the 37 ears (73%) improved the aeration with the staged operation. All ears with a grade-3 middle-ear aeration at the second-stage operation maintained aeration for a long time. Twelve of 16 ears (75%) with grade 2 also kept aeration. Four of 16 ears grade 2, three of nine ears grade 1, and one ear grade 0 was improved from the second-stage operation to the latest follow up. On the other hand, the ears with grade-2 and grade-3 middle-ear aeration at the first stage maintained the same grade for a long time. Deep retraction pocket was found in two ears with grade 1 or 0 aeration.

image

Fig.1. Change of middle ear aeration. Black numbers: numbers of ears of each grade and at each time point. Colored numbers: numbers of changing aeration indicated by arrows. ( ): numbers of recurrent case.

Discussion

Middle-ear aeration is well known to play an important role in prevention of recurrent cholesteatomas and sound conduction. To secure both tympanic and mastoid aerations or at least tympanic aeration, we modified the surgical procedure in the SCUT such as the scutum plasty, cortex plasty and obliteration. Accordingly, these techniques facilitated aeration significantly.4,5

The study revealed the middle-ear aeration improvement maintained for a long period of time, suggesting that the techniques were valuable for long-term outcomes of aeration. On the contrary, because well-aerated middle ears (grade 3) at the assessment before the first stage operation maintained aeration for a long period of time, we also noted that we can perform a one-stage operation if we eliminate the residual cholesteatoma and mucosal inflammatory disease.

References

1.Yanagihara N, Gyo K, Sasaki Y , Hinohira Y. Prevention of recurrence of cholesteatoma in intact canal wall tympanoplaty. Am J Otol 14(6):590–594, 1994

2.Hinohira Y, Yanagihara N, Gyo K. Surgical treatment of retraction pocket with bone pate: scutum plasty for cholesteatoma. Otolaryngol Head Neck Surg 133:625–628, 2005

3.Yanagihara N, Hinohira Y, Sato H. Mastoid cortex plasty using bone pate. Otol Neurotol 23:422–424, 2002

4.Minoda R, Yanagihara N, Hinohira Y, Yumoto E. Efficacy of mastoid cortex plasty for middle ear aeration in intact canal wall tympanoplasty for cholesteatoma. Otol Neurotol 23(4):425–430, 2002

5.Yanagihara N, Komori M, Hinohira Y. Total Mastoid Obliteration in Staged Intact Canal Wall Tympanoplasty for Cholesteatoma Facilitates Tympanic Aeration. Otol Neurotol 30(6):766–770, 2009


Address for correspondence: Masahiro Komori, MD, PhD, Department of Otolaryngology, Kochi University, School of Medicine, Kohasu, Oko-cho, Nankoku, Kochi 783–8505 Japan. komori@kochi-u.ac.jp

Cholesteatoma and Ear Surgery – An Update, pp. 221–222

Edited by Haruo Takahashi

2013 © Kugler Publications, Amsterdam, The Netherlands