MANAGEMENT STRATEGY FOR CHRONIC OTITIS MEDIA WITH CHOLESTEATOMA IN 2012
Introduction
Management of chronic otitis media with cholesteatoma has been the subject of numerous publications in the past 40 plus years. The open-cavity tympanomastoidectomy has been the gold standard for safety, but not necessarily the easiest for the patient. Intact-canal-wall strategies have emerged, but usually have a very high re-operation rate for residual or recurrent disease. We have elected to use a canal-wall reconstruction and mastoid obliteration strategy first described by Merke. Our long-term results with this technique are described.
Methods
A retrospective review was performed of all patients undergoing CWR tympanomastoidectomy with mastoid obliteration at a single institution from 1997 to 2011. The data included pre- and post-operative audiometry, residual cholesteatoma at second-look surgery with ossiculoplasty, post-operative complications, recurrence rate and location.
Results
Two hundred eighty-five ears in 273 patients underwent CWR tympanomastoidectomy with a mean age of 35 years (range 2 to 80 years). A second-look ossiculoplasty was performed in 245 (86%). Recurrent otor-rhea occurred in 18 (7.3%) ears. Most otorrhea were secondary to attic retractions due to insufficient bone blocking the attic and were managed with atticotomy (n = 10). Only seven ears (2.5%) required a revision open-cavity mastoidectomy (n = 5) or subtotal petrousectomy (n = 2) for recurrent cholesteatoma. No ears developed recurrent cholesteatoma in the obliterated mastoid cavity. Audiometric follow up on 148 patients who underwent second-look ossiculoplasty demonstrated small improvement in pre-operative versus postoperative air-bone gap (ABG), 28 dB vs. 23 dB respectively. Post-operative infection occurred in 16 (5.6%) patients with one patient requiring conversion to open-cavity mastoidectomy.
Conclusions
A CWR tympanomastoidectomy provides excellent intra-operative exposure of the middle ear and mastoid without the long-term disadvantages of a canal-wall-down mastoidectomy. Long-term follow up demonstrates low rates of recurrent cholesteatoma with stable or improved ABG. Recurrent attic retractions have been eliminated by use of mastoid tip bone instead of bone chips.
Address for correspondence: Bruce J. Gantz MD, Professor and Head, University of Iowa, Dept of Otolaryngology – Head and Neck Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive (21201 PFP), Iowa City, IA, USA. bruce-gantz@uiowa.edu
Cholesteatoma and Ear Surgery – An Update, p. 11
Edited by Haruo Takahashi
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