Clinical Otolaryngoloa 1978, 3, 349-352

Cholesteatoma in children* CLAUS JANSEN WinterbeckestrasseII, 527 Gummershach I , West Germany

Accepted for publicution 17 February 1978 JANSEN

C. (1978) Clinical Otolar,yngology3, 349-352

Cholesteatoma in children This paper is based on 313 posterior tympanotomies for cholesteatoma carried out between 1959 and 1973, on children between the age of 4 and 10. Keywords cholesteatoma mastoidectomy posterior tympanotonav tympanoplasty

The discussion on the surgical removal of cholesteatoma in children continues. The main reason for the very different points of view is the extensive and very fast growth of cholesteatoma in children. The invasive squamous epithelium penetrates into all spaces of the middle ear and the mastoid. I n most cases it takes almost a year to destroy the ossicular chain and the lateral wall of the attic. Because of these characteristics the aural surgeon cannot be sure of having removed completely all parts of a cholesteatoma; he also is particularly worried about the potential risk of a fast growing recurrent cholesteatoma. Besides the special behaviour of cholesteatoma in children, it is also difficult to select the best technique for a child. There are z different opinions : many authors prefer the classical modified radical mastoidectomy : the technical procedure is fast, simple and safe, and recurrent cholesteatoma can be seen early in an open cavity. Their criticism is directed towards the high rate of recurrent cholesteatoma which were published by supporters of the so-called intact canal wall technique.'-' But preservation of the osseous canal wall is prefered in cholesteatoma in children by a number of other authors. There is evidence that a significantly better hearing can be achieved through a nearly normal anatomical structure of the external meatus and the middle ear. If it is agreed that the most important aim of chronic ear surgery is to eradicate the disease completely, the intact canal wall technique must be done properly. About 10% of the recurrences reported are failures of insufficient attic reconstruction : the formation of retraction pockets is the logical consequence. Apart from the recurrence of retraction pockets the remaining cholesteatoma plays an important part. Early detection of recurrent cholesteatoma can be difficult, as is the detection of a recurrent cholesteatoma behind a solid wall of temporalis muscle. Thus, second stage surgery seems to be wise, not only in intact canal wall surgery. The risk of recurrent disease is the same for the tympanic area in all techniques. The newly reconstructed tympanic membrane does not allow inspection of the tympanic cavity if tympanoplasty has been performed. * Read at the first international meeting of the Politzer Society, February 1978. 0307-777217811100-0349 $02.00 0 1978 Blacknell Scientific Publications

349

350

CLAUS JANSEN

Figure I a-d The wide access to the epitympanic space, the mesotympanum and the hypotympanum: Left ear: a (top left) Wide access to posterior mesotympanum. Ponticulus pyramidalis intact; b (top right) Cholesteatoma in between short process of incus and chorda tympani. Right ear: c (bottom Zef2) Cholesteatoma blocking the access to hypotympanum; d (bottom right) Extensive opening to inspect round window niche.

35'

Cholesteutomu in children

What does happen when cholesteatoma reforms ? After 20 years of doing the posterior tympanotomy technique it can be said that no serious complication has been seen. The recurrent cholesteatoma destroys the thinned posterior bony canal wall to form an open cavity spontaneously. I n some cases the recurrent cholesteatoma follows the pathway of least resistance and perforates the retroauricular skin, because the bony cortex has been removed prevously. Instead of second stage surgery, endoscopy of the closed cavity seems to be an adequate alternative. It has been done very successfully in our department for 3 years under local anaesthesia. It should be mentioned that in children the bony cortex can regrow within several years. In that case endoscopy cannot be done. There are no special difficulties in removing the disease in children by posterior tympanotomy. The wide access to the epitympanic space, Table I Results Year of surgery '959

No. of cases I8

Year of recurrence 1959: I wet 1960: 2 wet 1963: I dry

Location Attic Meso, Attic Pocket Attic

1960

I2

1960: I wet 1962: I dry

Mesotymp. Pocket Attic

2

1961: 1964:

I I

wet dry

Attic Pocket Attic

2

1964: 1964:

I

wet

I

dry

Attic Pocket Mesotymp.

2 I

1961 I 962

'4 22

Total 4

'963

16

1963:

I

wet

Mesotymp.

I964

'4

1965:

I

wet

I

I965

9

1966:

I

wet

HYPOtYrnP. Mesotymp. Attic

I

I 966

'5

'967

16

1968

20

I969 I970

25 32

1971

36

'972

35

'973

29

1968: I wct

I

0

1970: I wet 1972: I dry

Mesotymp. Pocket Hypotymp.

2

1969: I wet 1971: I wet

Attic Attic

2

1970: I Wet 1973: 1 dry 1975: I wet

Mesotymp. HYPotYmP.

2

1972: I wet 1974: I dry

HYPotYmP. Attic Mesotymp.

2

1976: I dry 1977: I wet

Attic Attic

2

I

352

C L A U S JANSEN

the mesotympanum and the hypotympanum is shown in (Figures Ia-d).

2

children of 7 and 9 years old

Results

The results (Table I) show a recurrence rate of 7.75%. I n most cases the recurrent cholesteatoma grew very quickly and was seen within z years in 18 children. Recurrent cholesteatoma was observed after 3 years in 3 patients and after 4 years in 4 patients. Seventeen ears were wet and 8 ears were dry when the diagnosis was made, the latter being retraction pockets. Five cholesteatoma developed after 3 and 4 years in the above mentioned 8 dry ears Discussion

The most destructive technique seems to be the safest but the functional result is poor. Second stage surgery is needed to improve the hearing. Partial reconstruction of the posterior wall is thus needed, but this increases the potential risk of recurrent cholesteatoma. I n our experience an occult regrowing process behind a posterior wall rebuilt with fascia, cartilage, bone etc., has the same risk as preserving a thinned posterior bony canal wall. Compared to reconstructions using soft tissue, posterior tympanotomy has the great advantage of preserving the original physiological anatomy. It is well known that soft tissue is a bad compromise for reconstructing bone if only because of retraction which can persist for years. I n our hands posterior tympanotomy is an excellent procedure. It is to be hoped it will stand the test in the long run. The high incidence of recurrent cholesteatoma is typical of a kind of swing back of a new surgical technique after some years of practising. I t will help us to get more perfection after more experiences. References SMYTHG.D.L. (1977) Postoperative cholesteatoma. First International Conjerence on Cholesteatonia, p. 355. Aesculapius, Birmingham, Alabama. z ALJSTIN D.F. (1977) The significance of the retraction pocket in the treatment of cholesteatoma. First International Conference on Cholesteatoma, p. 379. Aesculapius, Birmingham, Alabama. 3 CODYD.T.R. & TAYLOR W.F. (1977) Mastoidectomy for acquired cholesteatoma: Long-term results. First International Conjerence on Cholesteatoma, p. 337. Aesculpuis, Birmingham, Alabama. 4 GLASSCOCK M.E. (1977) Results in cholesteatoma surgery. First International Conference on Cholesteatonza, p. 401. Aesculpius, Birmingham, Alabama. 5 SADEJ. (1977) Postoperative cholesteatoma recurrence. First International Conference on Cholesteatoma, p. 384, Aesculapius, Birmingham, Alabama. 6 SHEEHY J.L., BRACKMANN D.E. & GRAHAM M.D. (1977) Complications of cholesteatoma. First International Conference on Cholesteatoma, p. 420. Aesculapius, Birmingham, Alabama. 7 WRIGHTW.K. (1977) A concept for the management of otitic cholesteatomas. First International Conference on Cholesteatoma, p. 374. Aesculapius, Birmingham, Alabama. I