Atticotomy

Middle ear anatomy

Surgical management of cholesteatoma: The two main options and the third way – atticotomy/limited mastoidectomy

T.P. Nikolopoulos *, P. GerbesiotisInternational Journal of Pediatric Otorhinolaryngology 73 (2009) 1222–1227

Middle ear anatomy

Posterior mesotympanium

Prussak’s space

Tos

• TOS Pars flaccida– Grade I - retraction towards malleus– Grade II – retraction onto malleus– Grade III – retraction onto malleus neck / beyond

annulus fundus visualised no erosion– Grade IV – beyond annulus fundus visualised with

erosion– Grade V – fundus not visualised = epitympanic

cholesteatoma

Sade

• Sade– Grade 1 – slightly retracted TM without adherence

to ossicles– Grade 2 – adherence of TM to ossicles– Grade 3 – TM draping over promontory without

adhering to it– Grade 4 – adherent to promontory– Grade 5 (added later) – perforated TM in same

position as grade 4

Attic cholesteatoma

Atticotomy

• Definition• Indication/Contraindication• Pre-Op consult• Surgical procedure• Complication• Post op

Atticotomy

• Limited cholesteatoma (ME,Epitympanum)• Entails removal of the scutum for access to

limited attic disease• Aditus obliterated• Scutal defect can be reconstructed (cartilage)

to decrease possibility of recurrent cholesteatoma

Indication/contraindicaiton

• small, localised attic cholesteatoma / retraction pocket +/- OCR

• Patients with medical conditions precluding GA

Pre-op Counseling - Risks of Surgery

• Facial paralysis• Vertigo• Tinnitus• Hearing loss• Staged procedure• Need for long term follow-up and routine

aural toilet

Surgical procedure

Temporalis fascia graft

complication

• Perioperative complications Facial nerve injury Sensorineural hearing loss Dysgeusia Brain herniation Cerebrospinal fluid leakage Bleeding

• Late complications Postoperative infection Posterior canal

breakdown Perichondritis Mucosalization of mastoid bowl Stenosis of external canal

Residual disease/recurrence

Bondy procedure

• Attic and mastoid disease• Lateral to ossicles, not in middle ear space• Cholesteatoma marsupalised• Requires good eustachian tube function and

intact pars tensa