A PROPOSAL ON THE CLASSIFICATION SYSTEM OF AURAL CHOLESTEATOMA IN KOREA

Hyung-Jong Kim

Department of Otorhinolaryngology and Head-and-Neck Surgery, Korea

Introduction

The incidence of cholesteatoma is difficult to estimate accurately due to wide spectrum and long duration of the disease. Sadé1 presumed five million people were affected with cholesteatoma world-wide in 1982, and Ruben2 estimated its incidence was approximately 4.2 of 100,000 per year in the USA. Tos3 reported incidence corresponding to three children and 13 adults of 100,000 per year in Denmark, two decades ago. On the other hand, the Korean otologic society4 reported that 10,000 cases of chronic otitis media (COM) surgery were performed in 2005 in Korea. As about one fourth of those were cholesteatoma cases, and Korean census reported fifty million of population in Korea, an incidence of cholesteatoma would be approximatetly five of 100,000 in a year.

Various classifications or staging of cholesteatoma have been described, although none became complete, so far. As for congenital cholesteatoma of the middle ear, Postic5 proposed the staging system, in 2002, in which stage I was designated as involvement of a single quadrant of the eardrum and no ossicular involvement or mastoid extension; stage II as multiple quadrant, but no ossicular involvement or mastoid extension; stage III as ossicular involvement without mastoid extension; and stage IV as mastoid extension. As for acquired cholesteatoma, one category consisted of primary acquired cholesteatoma, and another of acquired cholesteatoma. In 1989, Tos6 proposed a new classification: attic-, sinus-, and tensa-type cholesteatoma, which became popular world-wide.

In this study, the author established the modified classification systems for congenital and acquired choles-teatoma, respectively, by analyzing the clinical database of cholesteatoma surgery, and by assessing whether they could provide reliable guides for surgical interventions, and postoperative outcomes.

Materials and methods

For this study, 1069 surgically-treated cases of cholesteatoma were retrieved from the database of 3880 COM clinical records, the database program7 of which was released by the Korean Otologic Society in 2005, and all 1069 cases of surgery in the database were done by one surgeon. Ninety-eight of those cases were congenital cholesteatoma cases (83 primary and 15 recurred; 2.5%), and 971 were acquired cholesteatoma (826 primary and 145 recurred; 25.0%). Using the database of 1069 records, surgical approach, and postoperative outcomes including recurrence and hearing success were analyzed for the congenital and acquired cholesteatoma group, respectively.

Congenital cholesteatoma

As Postic’s staging system was somewhat overlapping and confusing, a combined posterior group was set up instead of Postic’s stage II and III, and a group representing recurrent or residual disease after surgery was included. The new staging system consisted of an anterior quadrant group without ossicular involvement or mastoid extension (A); a posterior quadrant group with/without ossicular involvement but no mastoid extension (P); a mastoid extension group (M); and a recurrent group (R) (Fig. 1). In total there were 98 cases of congenital cholesteatoma: primary congenital cholesteatoma in 29 cases of the anterior location group; 34 cases of posterior location without mastoid extension; 20 cases of mastoid extension; and 15 cases of recurrent cholesteatoma.

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Fig. 1. A proposed classification system of congenital cholesteatoma of the middle ear: anterior group; Posterior group; mastoid extension group; recurrent or residual group.

Acquired cholesteatoma

Modifying a recently proposed classification by Semaan and Megerian,8 the author established a classification system of acquired cholesteatoma. The new system consisted of retraction pocket with aerated middle ear (RPa); retraction pocket with unaerated middle ear (RPua); epithelial migration cholesteatoma (EM); combined type; recurrent or residual type; and unclassified cholesteatoma (Fig. 2). In total there were 971 clinical cases of acquired cholesteatoma: acquired middle-ear cholesteatoma including 227 cases of the RPa type, 415 cases of the RPua type, 163 cases of the EM type, and 21 unclassifiable primary cases of the acquired group; recurred or residual cholesteatoma of the acquired type included 145 cases.

Results

Congenital cholesteatoma

Of the 29 congenital anterior cases, exploratory tympanotomy was performed in 22, and mastoidectomy in seven cases. Of the 34 posterior cases, exploratory tympanotomy was performed in ten, and mastoidectomy in 24 cases. Of the 20 mastoid extension cases, canal-wall-up (CWU) mastoidectomy was performed in 19 cases, and canal-wall-down (CWD) mastoidectomy in one case. Seven cases of residual cholesteatoma of congenital origin were operated with exploratory tympanotomy, and eight with CWU mastoidectomy. More exploratory tympanotomy surgeries were performed in the anterior group than in the posterior and mastoid groups; in the mastoid extension group and the recurrent group more mastoidectomy surgeries were performed (Fig. 3). In the anterior group either no ossiculoplasty or T1 tympanoplasty was performed; in the posterior and mastoid extension groups more ossiculoplasty (Fig. 4). Overall results of recurrence or perforation, or adhesion after surgery were five to 20%. The mastoid extension and recurrent groups showed worse results than the anterior and posterior groups (Fig. 5).

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Fig. 2. A proposed classification system of acquired cholesteatoma of the middle ear. RP: retraction pocket; ME: middle ear.

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Fig. 3. Surgical approach according to the four groups of congenital cholesteatoma. Explo T: exploratory tympanotomy; CWU: canal-wall-up mastoidectomy; CWD: canal-wall-down mastoidectomy.

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Fig. 4. Surgical approach according to the four groups of congenital cholesteatoma. T: tympanoplasty; Sc: stapes columella; Si: stapes interposition; Fc: footplate columella; Fi: footplate interposition.

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Fig. 5. Post-operative results according to the four groups of congenital cholesteatoma.

Acquired cholesteatoma

Of the 227 cases of the RPa type, CWU mastoidectomy was performed in 128 cases and CWD mastoidectomy in 99 cases. Of the 415 cases of the RPua type, CWU mastoidectomy was performed in 224 cases and CWD mas-toidectomy in 191 cases. Of the 163 cases of the EM type, CWU mastoidectomy was performed in 58 cases, and CWD mastoidectomy in 105 cases. Residual or recurrent cholesteatoma from acquired origin were operated via exploratory tympanotomy in 25, CWU mastoidectomy in 46, and CWD mastoidectomy in 74 cases. As for the type of surgical approach, more CWU mastoidectomy was performed in the RPa or RPua types than in the EM and recurrent types (Fig. 6). More T1 tympanoplasty or Sc or Si was performed in the RPa and RPua types, and more footplate ossiculoplasty was performed in EM and recurrent type (Fig. 6). Overall post-operative hearing success rates were 30–60% using the 2005 guideline of the Korean Otological society. The EM type showed worse results than the RPa type (Fig. 7). Using post-operative air bone gap grading, the EM type also showed worse results than the RPa or RPua types (Fig. 8).

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Fig. 6. Mastoidectomy approach according to the group of acquired cholesteatoma. Rpa: retraction pocket with aerated middle ear; Rpua: retraction pocket with not aerated middle ear; EM: epithelial migration; Recurrent: recurrent or residual type; CW:; canal-wall-up mastoidectomy; CWD: canal-wall-down mastoidectomy; None: no mastoidectomy.

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Fig. 7. Ossiculoplasty approach according to the group of acquired cholesteatoma. Rpa: retraction pocket with aerated middle ear; Rpua: retraction pocket with not aerated middle ear; EM: epithelial migration; Recurrent; recurrent or residual type; T: tympanoplasty; Sc: stapes columella; Si: stapes interposition; Fc: footplate columella; Fi: footplate interposition; T0: no tympanoplasty.

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Fig. 8. Post-operative hearing results according to the group of acquired cholesteatoma. Rpa: retraction pocket with aerated middle ear; Rpua: retraction pocket with not aerated middle ear; EM: epithelial migration; Recurrent: recurrent or residual type; ABG: air bone gap; AC: air conduction threshold.

Conclusion

These modified classifications for congenital and acquired cholesteatoma could play a useful role in planning the surgical procedures, and estimating outcomes after surgery.

References

1.Sadé J, Avraham S, Brown M. Atelectasis, retraction pockets and cholesteatoma. Acta Otolaryngol. 92:501–512, 1981

2.Ruben RJ. Otorhinolaryngologic disorders of adolescents: a review. Int J Pediatr Otorhinolaryngol 9(1):1–30, 1985

3.Tos M. Incidence, etiology, and pathogenesis of cholesteatoma in children. Adv Oto-Rhino-Laryngol 40:110–117, 1988

4.The Korean otologic society. Annual report of the Korean otologic society in 2005 (unpublished data)

5.Postic WP, Korman SB, Samadi DS, Wetmore RF. Congenital cholesteatoma: 20 years’ experience at the children’s hospital of Philadelphia. Otolaryngol Head Neck Surg 126:409–414, 2002

6.Tos M, Lau T. Late results of surgery in different cholesteatoma type. ORL 51:33–49, 1989

7.Kim HJ. A standardized database management of middle ear surgery in Korea. Acta Otolaryngol Suppl. 558:54–60, 2007

8.Semaan MT, Megerian CA. The pathophysiology of cholesteatoma. Otolaryngol Clin N am 39:1143–1159, 2006


Address for correspondence: Hyung-Jong Kim, MD/PhD, Professor and Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, 896 Pyungchon-dong, Dongan-gu, Anyang, Gyeonggi-do 431–070 Korea. hjk1000@hallym.ac.kr

Cholesteatoma and Ear Surgery – An Update, pp. 71–76

Edited by Haruo Takahashi

2013 © Kugler Publications, Amsterdam, The Netherlands