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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