The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Minimally Invasive Functional Approach for Cholesteatoma Surgery €s, MD, PhD; Yi-Hsuan Wu, MD; Lee J. Guo, MD; Bassem M. Hanna, MSc, MD; Ilkka Kiveka Huang Lin, PhD; Jessica Guidi, MD; Dennis Poe, MD, PhD Objectives/Hypothesis: Report the efficacy of a functional minimally invasive approach for cholesteatoma surgery. Study Design: Retrospective review of surgical cases performed between 1996 and 2008. Methods: One hundred sixty-nine patient charts were reviewed in which ears with primary cholesteatomas that extended beyond the mesotympanum were operated on with a plan for canal wall up (CWU) mastoidectomy. The surgical approach consisted of progressive exposure from transcanal to postauricular tympanoplasty to CWU mastoidectomy, as needed, to identify and lyse the fibrous attachments that bind the capsule to the surrounding mucosa. Endoscopic guidance was employed as appropriate to minimize exposure needs. Any planned second-stage operations were attempted with a transcanal approach if appropriate and with endoscopic assistance. Results: One hundred eighty-four ears of 169 patients were included. The median age was 32 years (range, 1–79 years). The mean follow-up was 3.2 years (range, 1–11 years). Eighty-three (45%) were planned for a second-look operation, and three (2%) required unplanned second operations. The overall recurrence rate was 24/184 (13%), and the unexpected residual rate was 5/184 (3%). The residual rate with endoscopy (5/119, 4%,) or without endoscopy (1/65, 2%), were not significantly different. Hearing results in 156 ears improved significantly, from a preoperative pure-tone average (PTA) of 41 dB to a postoperative PTA average of 29 dB (P 3 years follow-up. It is possible that the operating surgeon may have developed improved techniques over time, which would complicate comparisons between earlier and later patients. Children and adults were combined in this study, which endeavored to describe the functional approach. Future analysis with long-term follow-up of age cohorts would be important.
CONCLUSION A functional approach to CWU cholesteatoma surgery aims at reducing the incidence of residual disease, preventing recurrent disease, and restoring hearing while maintaining as much anatomy as possible through a minimally invasive approach. Cholesteatoma is generally loosely attached to surrounding tissues, and the capsule can be optimally removed by concentrating on the interspersed adhesive bands that tether the capsule. Endoscopic assistance for more extensive cholesteatomas was effective in minimizing residual disease. The functional minimally invasive approach was superior in both disease control rates and preservation of function than classically described CWU techniques. Nevertheless, recurrence rates remained higher than those achieved via CWD techniques reported in the literature. The low rate of unexpected residual disease supports reducing the need for routine second-look surgery.
BIBLIOGRAPHY 1. Dornhoffer J. Cartilage tympanoplasty: indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003;113:1844–1856. 2. Kaylie DM, Gardner EK, Jackson, CG. Revision chronic ear surgery. Otolaryngol Head Neck Surg 2006;134:443–450. 3. Smyth GDL. Cholesteatoma surgery: the influence of the canal wall. Laryngoscope 1985;95:92–96. 4. Wright WK. Management of otitic cholesteatomas. Arch Otolaryngol 1977; 103:144–147. 5. American Academy of Otolaryngology-Head Neck Surgery. Committee on Hearing and Equilibrium guidelines for evaluation of results of treatment of conductive hearing loss. Otolaryngol Head Neck Surg 1995;113: 186–187. 6. Jackson CG, Glasscock ME, Nissen AJ, Schwaber MK, Bojrab DI. Open mastoid procedures: contemporary indications and surgical technique. Laryngoscope 1985;95:1037–1043. 7. Robinson JM. Cholesteatoma: skin in the wrong place. J R Soc Med 1997; 90:93–96. 8. Sheehy JL, Crabtree JA. Tympanoplasty: staging the operation. Laryngoscope 1973;83:1594–1162. 9. Sheehy JL. Recurrent and residual disease in cholesteatoma surgery. Clin Otolaryngol 1978;3:393–403.
Hanna et al.: Functional Approach for Cholesteatoma Surgery
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10. Thomassin M, Korchia D, Duchon Doris JM. Endoscopic-guided otosurgery in the prevention of residual cholesteatomas. Laryngoscope 1993;103: 939–943. 11. Edelstein DR, Parisier SC. Surgical techniques and recidivism in cholesteatoma. Otolaryngol Clin North Am 1989;22:1029–1039. 12. Sheehy J, Patterson, M. Intact canal wall tympanoplasty with mastoidectomy: a review of eight years’ experience. Laryngoscope 1967;77:1502– 1542. 13. Sheehy JL. The intact canal wall technique in management of aural cholesteatoma. J Laryngol Otol 1970;84:1–31. 14. Sheehey JL, Brackmann DE, Graham MD. Cholesteatoma Surgery: Residual and Recurrent Disease. A review of 1,024 cases. Ann Otol. 1977;86: 451–462.
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15. Vartiainen E. Factors associated with recurrence of cholesteatoma. J Laryngol Otol 1995;109:590–592. 16. Glasscock ME, Miller GW. Intact canal wall tympanoplasty in the management of cholesteatoma. Laryngoscope 1976;86:1639–1657. 17. Shelton C, Sheehy JL. Tympanoplasty: review of 400 staged cases. Laryngoscope 1990;100:679–681. 18. Syms M, Luxford W. Management of cholesteatoma: status of the canal wall. Laryngoscope 2003;113:443–448. 19. Huisman MA, de Heer E, Ten Dijke P, Grote JJ. Transforming growth factor beta and wound healing in human cholesteatoma. Laryngoscope 2008;118:94–98. 20. Dornelles Cde C, da Costa SS, Meurer L, Rosito LP, da Silva AR, Alves SL. Comparison of acquired cholesteatoma between pediatric and adult patients. Eur Arch Otorhinolaryngol 2009;266:1553–1561.
Hanna et al.: Functional Approach for Cholesteatoma Surgery
Rhinological and Otological Society, Inc.
Minimally Invasive Functional Approach for Cholesteatoma Surgery €s, MD, PhD; Yi-Hsuan Wu, MD; Lee J. Guo, MD; Bassem M. Hanna, MSc, MD; Ilkka Kiveka Huang Lin, PhD; Jessica Guidi, MD; Dennis Poe, MD, PhD Objectives/Hypothesis: Report the efficacy of a functional minimally invasive approach for cholesteatoma surgery. Study Design: Retrospective review of surgical cases performed between 1996 and 2008. Methods: One hundred sixty-nine patient charts were reviewed in which ears with primary cholesteatomas that extended beyond the mesotympanum were operated on with a plan for canal wall up (CWU) mastoidectomy. The surgical approach consisted of progressive exposure from transcanal to postauricular tympanoplasty to CWU mastoidectomy, as needed, to identify and lyse the fibrous attachments that bind the capsule to the surrounding mucosa. Endoscopic guidance was employed as appropriate to minimize exposure needs. Any planned second-stage operations were attempted with a transcanal approach if appropriate and with endoscopic assistance. Results: One hundred eighty-four ears of 169 patients were included. The median age was 32 years (range, 1–79 years). The mean follow-up was 3.2 years (range, 1–11 years). Eighty-three (45%) were planned for a second-look operation, and three (2%) required unplanned second operations. The overall recurrence rate was 24/184 (13%), and the unexpected residual rate was 5/184 (3%). The residual rate with endoscopy (5/119, 4%,) or without endoscopy (1/65, 2%), were not significantly different. Hearing results in 156 ears improved significantly, from a preoperative pure-tone average (PTA) of 41 dB to a postoperative PTA average of 29 dB (P 3 years follow-up. It is possible that the operating surgeon may have developed improved techniques over time, which would complicate comparisons between earlier and later patients. Children and adults were combined in this study, which endeavored to describe the functional approach. Future analysis with long-term follow-up of age cohorts would be important.
CONCLUSION A functional approach to CWU cholesteatoma surgery aims at reducing the incidence of residual disease, preventing recurrent disease, and restoring hearing while maintaining as much anatomy as possible through a minimally invasive approach. Cholesteatoma is generally loosely attached to surrounding tissues, and the capsule can be optimally removed by concentrating on the interspersed adhesive bands that tether the capsule. Endoscopic assistance for more extensive cholesteatomas was effective in minimizing residual disease. The functional minimally invasive approach was superior in both disease control rates and preservation of function than classically described CWU techniques. Nevertheless, recurrence rates remained higher than those achieved via CWD techniques reported in the literature. The low rate of unexpected residual disease supports reducing the need for routine second-look surgery.
BIBLIOGRAPHY 1. Dornhoffer J. Cartilage tympanoplasty: indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003;113:1844–1856. 2. Kaylie DM, Gardner EK, Jackson, CG. Revision chronic ear surgery. Otolaryngol Head Neck Surg 2006;134:443–450. 3. Smyth GDL. Cholesteatoma surgery: the influence of the canal wall. Laryngoscope 1985;95:92–96. 4. Wright WK. Management of otitic cholesteatomas. Arch Otolaryngol 1977; 103:144–147. 5. American Academy of Otolaryngology-Head Neck Surgery. Committee on Hearing and Equilibrium guidelines for evaluation of results of treatment of conductive hearing loss. Otolaryngol Head Neck Surg 1995;113: 186–187. 6. Jackson CG, Glasscock ME, Nissen AJ, Schwaber MK, Bojrab DI. Open mastoid procedures: contemporary indications and surgical technique. Laryngoscope 1985;95:1037–1043. 7. Robinson JM. Cholesteatoma: skin in the wrong place. J R Soc Med 1997; 90:93–96. 8. Sheehy JL, Crabtree JA. Tympanoplasty: staging the operation. Laryngoscope 1973;83:1594–1162. 9. Sheehy JL. Recurrent and residual disease in cholesteatoma surgery. Clin Otolaryngol 1978;3:393–403.
Hanna et al.: Functional Approach for Cholesteatoma Surgery
2391
10. Thomassin M, Korchia D, Duchon Doris JM. Endoscopic-guided otosurgery in the prevention of residual cholesteatomas. Laryngoscope 1993;103: 939–943. 11. Edelstein DR, Parisier SC. Surgical techniques and recidivism in cholesteatoma. Otolaryngol Clin North Am 1989;22:1029–1039. 12. Sheehy J, Patterson, M. Intact canal wall tympanoplasty with mastoidectomy: a review of eight years’ experience. Laryngoscope 1967;77:1502– 1542. 13. Sheehy JL. The intact canal wall technique in management of aural cholesteatoma. J Laryngol Otol 1970;84:1–31. 14. Sheehey JL, Brackmann DE, Graham MD. Cholesteatoma Surgery: Residual and Recurrent Disease. A review of 1,024 cases. Ann Otol. 1977;86: 451–462.
Laryngoscope 124: October 2014
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15. Vartiainen E. Factors associated with recurrence of cholesteatoma. J Laryngol Otol 1995;109:590–592. 16. Glasscock ME, Miller GW. Intact canal wall tympanoplasty in the management of cholesteatoma. Laryngoscope 1976;86:1639–1657. 17. Shelton C, Sheehy JL. Tympanoplasty: review of 400 staged cases. Laryngoscope 1990;100:679–681. 18. Syms M, Luxford W. Management of cholesteatoma: status of the canal wall. Laryngoscope 2003;113:443–448. 19. Huisman MA, de Heer E, Ten Dijke P, Grote JJ. Transforming growth factor beta and wound healing in human cholesteatoma. Laryngoscope 2008;118:94–98. 20. Dornelles Cde C, da Costa SS, Meurer L, Rosito LP, da Silva AR, Alves SL. Comparison of acquired cholesteatoma between pediatric and adult patients. Eur Arch Otorhinolaryngol 2009;266:1553–1561.
Hanna et al.: Functional Approach for Cholesteatoma Surgery
