FROM RETRACTION POCKETS INTO EARLY-STAGE CHOLESTEATOMA: PATHOGENESIS AND MANAGEMENT
Introduction
Most of the early-stage cases of cholesteatoma have their genesis from retraction pockets; attic cholesteatoma from epitympanic retractions, sinus cholesteatoma from posterosuperior tensa retractions, and tensa cholesteatoma from tensa retractions. These retractions may vary from a simple retraction, to an atelectasis, a retraction pocket, an invagination or an adhesive otitis. Some of these retraction pockets are unsafe, if they are marginal, or with keratine debris or wet, and may lead to early cholesteatoma.
Pathogenesis of cholesteatoma
The epithelium covering the surface of the tympanic membrane has a property of clearence mechanism, which is called ‘centrifugal migration’ or ‘keratin dispersion’. Once there is a formation of a atelectasis or retraction pocket, this clearance mechanism is disturbed and the surface dead cells that contain keratin are trapped and cannot clear themselves out. This is the essence of a cholesteatoma.1
When the drum has been retracted for a long time, the most important histological change is the disappea-rence of the fibrous layer of pars tensa. The fibers of the middle layer become thinner and longer under the effect of the negative pressure, and disappear in time, which means that the tympanic membrane will later be formed of two layers: outer epithelium and inner mucosa. This dimeric tympanic membrane is not anymore resistant enough to negative pressure and retraction pockets will be formed.2 Furthermore, the epithelium sends papillas inside the mucosa (papillary ingrowth) which means that the skin touches the middle ear space.3
Should there be any difference in our clinical attitude between a cholesteatoma and debris accumulation? Is it important that debris may be cleaned or not by suction? There may be a lot of different comments on this subject but in our opinion, a retraction pocket which may not be cleaned by suction, accompanied by proliferation, or accompanied by bone resorption may develop a cholesteatoma.
The pathogenesis of cholesteatoma varies according to middle ear conditions, but also to immunological status; to mention some: cytokines and epidermal growth factors.
A short evaluation of retraction pockets
An evaluation of a retraction pocket and an early cholesteatoma should begin by stating its position. It is known that the posterosuperior quadrant is the most likely quadrant to be prone to pressure effects, to easy loose its lamina propria and to adhere to ossicules to cause ossicular problems.2
The criteria should include the following points:
•Is the bottom of the pocket visible? – Stage I
•What is the depth of the pocket? (contact?) – Stage II
•Is the pocket fixed? (evaluated by Valsalva manoevre, by pneumatic otoscopy or by suction); is it a self-cleaning retraction? – Stage III
•Does the interior of the pocket indicate any wetness, irregularity, debris? – Stage IV
A radiological examination will be of great value to evaluate a retraction in case of an erosion at the bony annulus; a deep and invaginated retraction; a suspicion or presence of a cholesteatoma or symptoms of fistula; or when an operation is planned on the only hearing ear. This should cover a multi-sliced, high-resolution CT in both coronal and axial plans.
Management of retraction pockets
In a case of a retraction pocket we have three options: to observe, to ventilate, or to operate.
When to observe?
Observing and watchful waiting is almost always a rule in stage-I and -II retraction pockets. That is also true for deep retraction pockets if there is no infection, no hearing loss and no CT finding; and even for total adhesive otitis cases if there is no cholesteatoma, no hearing loss and under 12 years old.4 This observation period should include a watchful waiting which will cover regular microscopic examinations, regular audiologic follow up, debridement of crusts, and so on.
During this observation period a medical treatment also may take part in case of allergy, or sinonasal disease; or an adenoidectomy should be done when indicated.
When to ventilate?
A ventilation tube should be considered in retractions type II or III, progressive, but also without adhesion, without keratin debris, without bony erosion, and without significant conductive hearing loss. But, the possible complications of ventilation tubes must be remembered.5
When to operate?
Surgery is absolutely indicated to prevent early-stage cholesteatoma in cases of retraction pockets with debris, with Herodion formation, or draining.
Indications for surgery cover retraction pockets stage III or IV, with unavoidable accumulation of keratin, repetitive inflammation, in evidence of progression or cholesteatoma, and/or in cases with significant conductive hearing loss.
Surgery of early-stage cholesteatoma (stage IV retraction pocket) may cover, in our hands, transcanal attico-antrotomies with scutum removal and reconstruction, or endaural approaches for attic cholesteatomas; or endaural or retro-auricular approach for sinus cholesteatomas; or retro-auricular approach for tensa cho-lesteatomas.
In cases with posterosuperior quadrant self-cleaning retractions of stage II, excision of the retraction may be sufficient for a self reparation or it may be reinforced by a cartilage tympanoplasty or a palisade technique, as in stage III-IV retractions.6,7
In cases of a retraction of the pars flaccida stage III or over, an atticotomy and cartilage reconstruction is convenient.
Cases with complete atelectasis and adhesion but without hearing loss may be followed up; or if operated, as needed for cases with hearing loss, a mastoid management should also be considered.8
1.Sadé J. Treatment of cholesteatoma. Am J Otol 8:524–533, 1987
2.Paco J, Branco C, Estibeiro H, Oliveira e Carmo D. The posterosuperior quadrant of the tympanic membrane. Otolaryngology-Head and Neck Surgery 140:884–888, 2009
3.Akyildiz N, Akbay C, Ozgirgin ON, Bayramoglu I, Sayin N. The role of retraction pockets in cholesteatoma development: an ultrastructural study. Ear Nose Throat J 72:210–212, 1993
4.De Beer BA, Schilder AG, Zielhuis GA, Graamans K. Natural course of tympanic membrane pathology related to otitis media and ventilation tubes between ages 8 and 18 years. Otol Neurol 26:1016–1021, 2005
5.Vlastarakos PV,Nikolopoulos TP, Korres S, Tavoulari E, Tzagaroulakis A, Ferekidis E. Grommets in otitis media with effusion: the most frequent operation in children. But is it associated with significant complications? Eur J Pediatr 166:385–391, 2007
6.Yung M. Cartilage tympanoplasty: literature review. J Laryngol Otol 122:663–672, 2008
7.Dornhoffer JL. Surgical Management of the Atelectatic Ear. Am J Otol 21:315–321, 2000
8.Doyle WJ. The mastoid as a functional rate-limiter of middle ear pressure change. Int J Pediatr Otorhinolaryngol 71:393–402, 2007
Adress for correspondence: Ibrahim Hizalan, Ibrahim@hizalan.com
Cholesteatoma and Ear Surgery – An Update, pp. 87–89
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands