HOW TO DEAL WITH CHOLESTEATOMA IN A DEVELOPING COUNTRY
Will the canal-wall-up (CWU) technique provide an opportunity to control the disease?
Introduction
Early diagnosis, accurate CT scan data, good training and surgical skills, and good communication with patients (or parents in case of children) are key elements that influence the successful treatment of cholesteatoma. Although the procedures for diagnosing and treating cholesteatoma in the developing countries are the same as in developed countries, the possibilities for earlier diagnosis and treatment are not the same.1,2
In developing countries, like Albania, canal-wall-down (CWD) mastoidectomy is still the preferred technique for control of the disease. However, in the last decade, with the improvement of medical care and hospital infrastructure, we more often perform the closed technique.
The goal of this study is to evaluate the likelihood of success for controlling disease after performing the closed technique in our clinic.
Material and method
The study considered 23 cases of patients with cholesteatoma, including a cross section of children and adults that underwent surgery between 2007 and 2010. The main focus of the analysis was to study the management of cholesteatoma and not the functional outcomes. Cases of simple retraction pockets were excluded. All patients received a CT scan prior to the surgery. Follow-up CT scans and/or MRI were performed 1–1.5 years after the surgery. CT scans were considered conclusive in cases where the middle ear and mastoid cavity were well aerated without presence of soft tissue (Fig. 1), or in cases with a round, well-delineated lesion which was highly suggestive of residual cholesteatoma (Fig. 2). When the CT scan was not considered conclusive, an MRI procedure was performed to identify the possibility of residual cholesteatoma. The MRI sequences obtained to evaluate the soft tissue in the middle ear and mastoid cavity are ‘delayed gadolinium enhanced T1 weighted’ and ‘non-echo-plannar (non-EPI) diffusion weighted (DW)’ imaging (Fig. 3).
Closed mastoidectomy was the operating technique in all cases. The removal of cholesteatoma was done through the transcanal-transmastoid approach. Cartilage-shield tympanoplasty was the preferred technique for the reconstruction of the tympanic membrane.
Statistical analysis was performed using SPSS statistical software (version 15; SPSS, Chicago, IL, USA).
Fig. 1. The CT scan shows a well-aerated middle ear cavity and attic without presence of soft tissue.
Fig. 2. This round lesion is highly suggestive for residual cholesteatoma (arrow).
Fig. 3. Non-echo-plannar (non-EPI) diffusion weighted (DW) imaging shows cholesteatoma as a hyper-intense lesion (arrow).
The average age of 23 operated patients was 26 years old (range 6–59). Of the patients, 17.4% was child and 82,6% adults. Sex ratio was 1:1.5 (9 males, 14 females). Three patients (13 %) never returned for the follow up.
Regarding the surgical findings: in 17 patients (73.9%) diffuse cholesteatoma was observed; in the remaining cases (26.1%) cholesteatoma was well encapsulated.
Cholesteatomas were epitympanic (attic) in nine patients (39.1%); mesotympanic (middle ear) in eight patients (34.8%) and were arising from both areas in six cases (26.1%).
Although the patients were treated pre-operatively for three to six months, inflammation was present at the time of surgery in six of them (26.1%).
Considering the availability of the devices, a CT scan was the method of choice for the follow up. A CT scan was performed in 19 patients (95%) at an interval of 1–1,5 years following the first operation. One patient presented with retro-auricular swelling 2,5 years after the first surgery and was operated on immediately. In seven cases (36.8%), the data of CT scan were considered conclusive to rule out the residual cholesteatoma (middle ear and mastoid cavity well aerated) or for the positive diagnosis of residual cholesteatoma (round, well-delineated lesion).
MRI exams were done in 12 cases (63.2%). In three cases (25%), the MRI images were suggestive for residual cholesteatoma.
Seven patients (35%) underwent second-look surgery. In five cases (71.4%, or 25% of all patients) residual cholestatoma was present; radical mastoidectomy was the treatment of choice for three cases (42.9%) (in two cases cholesteatoma was diffuse and the mucosa inflammatory; in one case the Eustachian tube was invaded by epidermis); in two cases (28.6%) the residual cholesteatoma was presented as round lesions that were easily removed with the preservation of canal wall. Residual cholestatoma was not found in two patients (28.6%). The ossiculoplasty was done in four patients (57.14%).
Thirteen patients (65%) refused second-look surgery with the purpose to perform the ossiculopasty.
Discussion
During their practice and surgical treatment of cholesteatoma, physicians in developing countries like Albania may face a lot of difficulties, like lack of infrastructure and inadequate training in the field of otosurgery or imaging, patients with huge cholesteatomas that are often diagnosed at an advanced stage with life-threatening complications,1,2 or patients that never return for different reasons.
Considering all this, CWD, as the ‘gold standard’ for control of cholesteatoma3,4 is still the preferred treatment of the disease in Albania. But with the economic development and sociocultural changes of the last two decades, patients are becoming more aware of the benefits of early diagnosis and more often are seeking treatment solutions that can offer them better quality of life. CWU mastoidectomy, as it has been shown in several studies,3,4 is the best technique that offers a better quality of life and the possibility of hearing improvement. The results of our study (residual cholesteatoma in 25% of cases), compared to bigger series,5,6 gave us an optimistic view regarding the eradication of the cholesteatoma with the closed technique, although we still had a significant loss of follow-up patients (13%) and a majority of patients that refused the second-look surgery (65%).
Despite initial difficulties, due to lack of experience in the field of imaging of temporal bone, the close collaboration with radiologists permitted us to obtain appropriate pre-operative CT images and, most importantly, suitable radiological approach for follow-up patients. MRI, with its high sensitivity and specificity,7–9 has become the best exam for the detection of residual cholesteatoma. Considering the lower cost and higher accessibility, the CT scan remains the test of choice in Albania. We think that a CT scan might be conclusive in cases with perfect pneumatization of the middle ear and mastoid cavity as well as in cases with round, well-delineated lesion. In other cases, MRI and/or second look are mandatory to rule out the possibility of residual cholesteatoma (Fig. 3).
The results of the study indicate that the closed technique can be considered as a good option for treatment of cholesteatoma in developing countries. The role of the patient is essential in succeeding.
The likelihood of eradication of cholesteatoma using this approach is directly related to anatomical patterns (pneumatization of the mastoid, position of the sigmoid sinus, position of the dura, exposed dura or dehiscent facial nerve), extension of the cholesteatoma (on supratubal recess, retrotympanum, superstructure or footplate of stapes), and concomitant pathology (inflammation, polyps, fistula of LSCC).
The CT scan, and especially MRI with its high sensitivity, have obviously changed our attitude toward the management of cholesteatoma. However, the necessity of the second look still depends on the opportunities to control the disease.
Address for correspondence: Dritan Vasili MD, American Hospital, Rr. ‘Lord BAJRON’, prane S.U.Q.U., Laprake, 1024, Tirana, Albania. dvasili@spitaliamerikan.com
Cholesteatoma and Ear Surgery – An Update, pp. 63–66
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands