MANAGEMENT OF
CHOLESTEATOMA
PRESENTED BY Maj Avinash Sitaraman12. 12. 11
INTRODUCTIONKeratin producing squamous epithelium in the
middle ear, mastoid or petrous apexExhibits independent growth, replaces mucosa,
resorbs boneHistologically :
INTRODUCTIONClassification
Congenital
Acquired Primary acquired
Metaplasia Basal layer proliferation Eustachian tube dysfunction Retraction pockets
Secondary acquired Migration through perforation Repeated infections through perforation
Metaplasia Iatrogenic implantation Penetrating or blast injuries
HISTORY17th century – Riolan the younger- first trephination procedure of the mastoid
1873 - Schwartze and Eysell – Cortical mastoidectomy
1890 – Zaufal – First radical mastoidectomyBondy – Revised the technique – leave
uninvolved middle ear alone and exteriorise the epitympanum
HISTORYWullstein – described tympanoplasty
1958 - William House- intact canal wall mastoidectomy
CLINICAL FEATURESHistory of
Otorrhoea- scanty, foul smellingHearing loss – increases in ossicular discontinuity
- ‘cholesteatoma hearer’Giddiness- possibility of labyrinthine fistula
- during aural toiletTinnitus – indication of a possible sensorineural
componentBleeding – from granulations or aural polyps while
cleaning
CLINICAL FEATURESHistory of-
Frequent ear infections as a childPrevious ear surgeries
Grommet insertion Tympanoplasty or mastoid surgery
Nasal symptomsSuggestive of complications
Headache Swelling behind the ear Facial weakness Seizures
EXAMINATIONTuning fork tests
Conductive hearing lossMixed hearing loss
OtoscopySwab of discharge- culture and ABSTRetraction pocketTM PerforationAttic erosion
OtomicroscopyConfirm otoscopy findingsIdentify sac of retraction pocket
EXAMINATIONFunctional hearing status
Conversational voiceForced whisper
Pneumatic otoscopyFistula test
Otoneurological examinationSpontaneous or gaze evoked nystagmusFacial nerve weakness
Head and neck examinationPost auricular swellingNeck swelling
Examination of nose
INVESTIGATIONSPure tone audiometry
Degree and type of hearing lossPreoperative record
TympanometryOssicular discontinuity
X- ray mastoid Schuller’s view
INVESTIGATIONSHigh resolution CT Temporal bone
CT is not essential for preoperative evaluationShould be obtained for:
Revision cases due to altered landmarks from previous surgery
Previous history of recurrent Chronic suppurative otitis media
Suspected congenital abnormalitiesCases of cholesteatoma in which sensorineural
hearing loss, vestibular symptoms, or other complication evidence exists
INVESTIGATIONSHigh resolution CT Temporal bone
Erosion of scutumDestruction of ossicular chainErosion of the labyrinth (fistula)Low tegmen / tegmen defectFacial nerve dehiscencePetrous Apex Involvement
INVESTIGATIONSRole of MRI
Determine between recurrence or persistent cholesteatoma vs. scar tissue or granulation tissueDural involvement or invasionSubdural or epidural abscessFacial nerve involvementTegmen defect / brain herniationSigmoid sinus thrombosis
T1 weightedHomogenous lesion hypointense to brain
T2 weighted- non enhancing, similar to CSF
INVESTIGATIONSRoutine hematological and biochemistry
As a part of preoperative evaluation
TREATMENTMEDICAL
Treat the infectionRegular aural toiletTopical ear drops
Antibiotic drops - culture and sensitivity specific Steroid drops – to reduce inflammation
Systemic antibiotics Constitutional symptoms In presence of complications
TREATMENTSURGICAL- PATIENT EVALUATION
Preoperative counseling is an absolute necessity prior to surgery
Primary objective of surgery is a safe dry ear which is accomplished by: Treating all supervening complications Removing diseased bone, mucosa, granulation polyps,
and cholesteatoma Preserving as much normal anatomy as possible
Improvement of hearing is a secondary goal
TREATMENTPossible adverse outcomes must be discussed
Facial paralysisVertigoFurther hearing lossTinnitus
Patient should understand that long-term follow-up will be necessary and that they may need additional surgeries
A written Informed consent must be obtained once preoperative counselling is done
CONGENITAL CHOLESTEATOMAPotsic staging
Stage I – single quadrant, no ossicular or mastoid involvement ~ 40%
Stage II – multiple quadrants, no ossicular or mastoid involvement ~ 14%
Stage III – ossicular involvement, no mastoid involvement ~ 23 %
Stage IV – mastoid extension ~ 23%
CONGENITAL CHOLESTEATOMANelson staging
Type 1 – mesotympanum, no incus or stapes erosion ~ 15%
Type 2 – mesotympanum or attic, ossicular erosion, no mastoid extension ~ 59%
Type 3 – mesotympanum, mastoid extension ~ 26%Recurrence rates
Type 1 – nilType 2 – 34%Type 3 – 55%
CONGENITAL CHOLESTEATOMASURGICAL MANAGEMENT
Type 1 – Controlled by extended tympanotomy. - No second-look re-operation.Type 2 – Extended tympanotomy. - Possibly atticotomy and canal wall up
tympano- mastoidectomy with or without opening of the facial recess.
- Possible ossicular reconstruction.Type 3 – Similar to type 2, but occasionally need a
canal wall down tympanomastoidectomy
CONGENITAL CHOLESTEATOMASURGICAL MANAGEMENT
INDICATIONS OF CANAL WALL DOWN MASTOIDECTOMY *
Unreconstuctible EAC defects Labyrinthine fistula Poor health Poor compliance
* Jackson CG, Glasscock ME, Nissen AJ. Open mastoid procedures : contemporary indications and surgical technique. Laryngoscope 1985; 95 : 1037- 43
SURGICAL MANAGEMENTType of mastoidectomy based on :
Extent of diseasePreoperative health of the patientStatus of the opposite earSurgeon’s and the patient’s preference
MastiodectomyTo help eradicate disease Gain access to antrum, attic or middle earIncreases air containing space – better
accomodation to pressure changes without TM retraction
SURGICAL MANAGEMENTMastiodectomy
INDICATIONS*
Absolute Cholesteatomas Tumours with extension into mastoid
Relative History of profuse otorrhoea Previous tympanoplasty failure Secondary acquired cholesteatoma Tympanic membrane perforations not correctable
without further exposure
* Haynes DS. Surgery for chronic ear disease. Ear Nose Throat J 2001 ; 80 : 8 - 11
SURGICAL MANAGEMENTCortical Mastoidectomy
Removal of mastoid cortex and air cellsTo unroof the mastoid cortex To drain a coalescent mastoiditis or subperiosteal
abscess
SURGICAL MANAGEMENTIntact canal wall or Complete Mastoidectomy
Removing mastoid air cells lateral to facial nerve while preserving the posterior and superior EAC walls
Gives access to epitympanumMaintains natural barrier between EAC and
mastoidCan be combined with facial recess dissection for :
Removal of disease from facial recess Better exposure of posterior mesotympanum around
oval and round windows Better visualisation of tympanic segment of facial nerve Better middle ear aeration postoperatively
SURGICAL MANAGEMENTModified Radical Mastoidectomy
A canal wall down mastoidectomy with TM graftingPreoperative Indications*
Disease in an only hearing ear Patients with poor general health Patients in whom follow up is problematic After failed attempt at intact canal wall mastoidectomy
Intraoperative Indications# Unreconstructible posterior EAC defect Labyrinthine fistula Obstructing low lying dura limiting epitympanic access
* House WF. Middle cranial fossa approach to petrous pyramid. Report of 50 cases . Arch Otol 1963 ; 78 : 460- 9
# Sheehy JL. Mastoidectomy: the intact canal wall procedure. In: Otologic surgery. Chapter 18. 212- 24
SURGICAL MANAGEMENTRadical Mastoidectomy
Leaves the middle ear and mastoid air cells exteriorized as a single cavity with no attempt at reconstruction
The Eustachian tube is occludedMalleus and Incus are removedIndications
Severe eustachian tube dysfunction Irreversible middle ear disease Unresectable cholesteatoma
SURGICAL MANAGEMENTCANAL WALL UP
MASTOIDECTOMYCANAL WALL DOWN MASTOIDECTOMY
Maintains natural anatomy Increased visibility and access to meso- and epitympanum
Heals quicker Reduced rate of recurrences *
Do not require regular debridements
Serial debridements of the cavity
Hearing outcome better # Intense postoperative care* Dornhoffer J. Retrograde mastoidectomy with canal wall reconstruction : a follow up report. Otol Neurotol 2004; 25: 653- 60# Dodson EE, Lambert PR. Intact canal wall mastoidectomy with tympanoplasty for cholesteatoma in children. Laryngoscope 1998; 108(7): 977- 83
SURGICAL MANAGEMENTPostauricular incision
1 cm behind the postauricular crease
Temporalis fascia graft harvested
SURGICAL MANAGEMENT
SURGICAL TECHNIQUE-CORTICAL MASTOIDECTOMY
CORTICAL MASTOIDECTOMY Keep drilling till
antrum is reachedKeep walls slopingPost. EAC is thinnedBone between tegmen
and sup. EAC removedfor zygomatic cells
Epitympanum opened toview incus and malleus
On completion- Tegmen plate, sinus plate, tip cells, zygomatic cells, Posterior EAC, Lateral SCC
CORTICAL MASTOIDECTOMY Remove cells between tegmen plate and sigmoid
sinus to expose the sinodural angle
CORTICAL MASTOIDECTOMY
CORTICAL MASTOIDECTOMY
CORTICAL MASTOIDECTOMY
POSTERIOR TYMPANOTOMYAllows a view of middle ear from posterior aspect2 mm wide strip drilled out between vertical part
of facial nerve and bony EAC
POSTERIOR TYMPANOTOMYFacial nerve, stapes, promontory and lateral SCC
MODIFIED RADICAL MASTOIDECTOMYThe aim of this procedure is to make a common
cavity the mastoid air cells, the antrum, the epitympanum and the EAC.
To convert a cortical mastoidectomy to a modified radical the posterior and superior walls of the EAC have to be removed.
The most medial 2-3mm of the posterosuperior EAC bridges over the incus, lateral semicircular canal and the second genu of the facial nerve.
Once the bridge is breached use a curette to remove its anterior and posterior buttresses.
The facial ridge is lowered medially to the level of the annulus and inferiorly to the level of the floor of the EAC.
MODIFIED RADICAL MASTOIDECTOMY
MODIFIED RADICAL MASTOIDECTOMYAmputate the head of the malleus by placing the
House Dieter malleus nipper at the neck of the malleus immediately superior to the cochleariform process
MODIFIED RADICAL MASTOIDECTOMY
MODIFIED RADICAL MASTOIDECTOMYMEATOPLASTY
MODIFIED RADICAL MASTOIDECTOMYKeys to the procedure *
Aggressive saucerization of mastoidEliminating irregularities or bony overhangsRemoving the posterior bony EAC down to the level
of the facial nerveCreating a large meatus
GOAL- to create a smooth, self cleaning cavity with no corners, edges or depressions in which debris can accumulate
* Jackson CG, Touma B. A Surgical solution for the difficult chronic ear. Am J Otol 1996 ; 17: 7- 14
RADICAL MASTOIDECTOMYAn operation performed to eliminate all middle
ear and mastoid disease through complete removal of mucosa, TM, annulus, malleus and incus
Eustachian tube is occluded with a fascial plugLabyrinthine fistulas
Flattening of lateral SCCDefects in the medial wall of cholesteatomaPalpate suspected areas with blunt instrumentsLeaving a small matrix on fistula
Preserves function in 93% patients Only in 80% patients if matrix is removed
POSTOPERATIVE CARECheck facial nerve functionPain reliefMastoid dressing removed after 24 hrsFollow up after 1 and 3 weeksGentian violet may be used on granulation tissue
in canal wall down cavitiesWater precautions maintained for 02 months or
until the TM has fully healed
COMPLICATIONSFacial nerve injury
In revision surgery- difficult landmarks03- 04 mm nerve must be exposed proximal and
distal to injured area by diamond burr< 40% nerve injured, facial muscle contraction
ellicired by <0.1 mAmp stimulation- No treatment>50% nerve injured- Nerve graftingSegment of nerve missing- Cable graft using great
auricular or sural nerveImmediate postop paralysis- If persists beyond 04
hrs- prompt exploration
COMPLICATIONSHearing loss
Sensorineural Cholesteatoma removal over labyrinthine fistulas Inadvertent contact between drill and ossicular chain-
high frequency SNHL Labyrinthitis
Conductive Middle ear adhesions Ossicular fixation Failed ossicular chain reconstructions
COMPLICATIONS Infection
Occur in 2% to 5% of mastoidectomiesWound infectionContinued chronic ear diseasePerichondritis occurs in 1% of canal wall down
mastoidectomiesVertigo
Labyrinthine fistulas and injuries during mastoid surgery
COMPLICATIONSIntracranial injury
Exposure of dura avoided generallyNot consequential unless
Large defects in tegmen Dural abrasions Cerebrospinal fluid leak
Repair Layered closure with soft tissue support Muscle and fascia grafts with fibrin glue
COMPLICATIONSBleeding
Controlled with gelfoam, soaked cotton balls and pressure
More in radical and modified radical mastoidectomyImmediate assessment in case of injury to
Sigmoid sinus Jugular bulb Large emissary veins
Canal defects Small defects in EAC- no interventionDefects > 0.5 cm- fixed with bone patte or cartilage
grafting
RETROGRADE MASTOIDECTOMYTemporary removal of the upper canal wall in
association with a retrograde type mastoidectomy followed by reconstruction of canal defect using cymba cartilage
AutologousBoneCartilage
AlloplasticHydroxyapatite cementTitanium
Posterior tympanic membrane reconstucted by cartilage pallisade technique in approximation with canal reconstruction
RETROGRADE MASTOIDECTOMYIndication for staged surgery is involvement of
sinus tympani with uncertain removalPrimary reconstruction of ossicular chain doneRepresents a union of two divergent approaches
Osteoplastic flap of WullsteinSmall cavity technique of Smyth
Extent of canal wall removal betweenAnterior malleolar spine ( 1 ‘o’ clock in rt)Exit of chorda tympani from the bone ( 9 ‘o’ clock in
rt)If more than 30% canal wall is removed,
reconstruction becomes difficult
MASTOID CAVITY OBLITERATIONFree grafts
Bone chips/ bone pateFatCartilageFasciaHydroxyapatite
Local flapsMeatally based musculoperiosteal flap (Palva flap)Inferiorly based periosteal- pericranial flapSuperiorly based musculoperiosteal flapTemporalis muscle flapTemporoparietal fascial flap (TPFF)
OSSICULOPLASTYThe incudostapedial joint and the lenticular
process of the incus are the most common sites of ossicular discontinuity.
This defect can lead to an air-bone gap of up to 60 dB.
Interposition of incus body as a bridge between the stapes and the mallues was the original ossicular reconstruction surgery.
Disadvantages of autograft ossiculoplastyprolonged operative time possible displacement or resorption possibility of the autograft harboring microscopic
cholesteatoma poor fit if the stapes superstructure is absent
OSSICULOPLASTYAdvantages of autograft ossiculoplasty :
low extrusion rate low costexcellent biocompatibility
Irradiated homograft ossicles and cartilage were first introduced in the 1960s in an attempt to overcome some of the disadvantages of autograft implants
In the late 1970s, a high-density polyethylene sponge (HDPS) that had nonreactive properties was developed
The original form was a machined-tooled prosthesis (Plasti-Pore)
OSSICULOPLASTYA more versatile manufactured thermal-fused
HDPS (Polycel) arrived laterApplebaum designed a hydroxyapatite prosthesis
for defects of the incus long processKurz angular prosthesis made of a gold shaft, gold
cup, and titanium clips was also developedIn 1993,the total (Arial) prosthesis and the partial
(Bell) prosthesis were made of TitaniumIn 1996, Spiggle and Theis introduced a new
titanium prostheses that can be trimmed intraoperatively to the appropriate length
OSSICULOPLASTY
PETROUS APEX CHOLESTEATOMAImaging Features of Petrous Apex lesions
PETROUS APEX CHOLESTEATOMASuboccipital ApproachTransethmoid transphenoid
Lateral rhinotomyMaintains labyrinthine function
Transpalatal transclivalMiddle cranial fossa Approach
Good ExposureSevere SNHL
RECIDIVISMA tendency to relapse into former behaviourRecurrent cholesteatoma
Primarily in sinus tympani, oval window area, anterior epitympanum
More following canal wall up procedureCWU vs CWD - 8% vs. 6%Residual or recurrent cholesteatoma over 5 years –
15 to 40% Reported to be up to 67% in the pediatric population
REFERENCESScott-Brown’s Otorhinolaryngology, Head and Neck Surgery.7th
ed. Ballenger’s Otorhinolaryngology ,Head and Neck Surgery. 17th
ed.The otolaryngologic clinics of north america. Vol 22/ No 5;
October 1989The otolaryngologic clinics of north america. 39 (2006) xiInternet References
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