Chloesteatoma surgery mukace

Treatment of
Cholesteatoma
Dr. Mukesh Kumar Sah
MS (ORL- HNS) 3rd Year Resident
GMSM Academy of ENT – Head & Neck Studies
MMC-TUTH, IOM

Road Map
•History of the procedures
•Examination under microscope & suction
clearance
•Atticotomy
•Mastoidectomies
•Mastoid cavity obliteration
Dr. Mukesh Kumar Sah/ Surgery for cholesteatoma, 2017 2

History
•1873 – Schwartze described cortical
mastoidectomy
•1890 -Zaufal introduced radical mastoidectomy
•1910 – Bondy reported surgery for disease limited
to pars flaccida

History
•1920- Lempert popularized the use of a drill and
loupe magnification
•1950- Zollner and Wullstein described
tympanoplasty techniques incorporated with
mastoidectomies
•1960 – Jansen, Sheehy and Patterson introduced
intact canal wall mastoidectomy with facial recess
approach.

Aim of cholesteatoma surgery
•Eradication of the disease
•Make the ear safe
•Preservation of hearing, if possible

Conservative management of
cholesteatoma
•Examination under microscope
•Suction clearance

Examination under microscope (EUM)
•binocular vision for 3-
d stereoscopic view
•high power
magnification
•very bright
illumination

Suction clearance
•Microsuction- an
examination and
treatment of the ear
•using a high powered
binocular operating
microscope
•With the use of miniature
vacuum cleaner
•an out-patient procedure
Pic source: clancyent.com

Indications of conservative management
•Large attic defect with shallow cholesteatoma sac
•With good hearing
•Old patient, unfit for GA
•Patient who can follow up regularly
•In only hearing ear(relative indication)

Pic source: clancyent.com

Microsuction contd…
Diagnosis, extent of disease
to remove material blocking the ear canal such
as
•wax
•infected debris, pus and fungal material
•dead skin layers including cholesteatoma
•foreign bodies
•to apply medication to the ear

Contraindication of conservative
management
Radiologic evidence of large cavity
Persistent otorrhea after several cleaning
Very small pocket- painful
Cholesteatoma behind intact drum
Involvement of facial canal, semicircular canal,
cochlea, dura
Hearing loss
Uncooperative patient, unable to frequent follow up

Preoperative counseling
•Information about disease
•Modes of treatment
•Benefit & risk of treatment
•Long term complication of disease, if not treated
•Life long follow up after surgery for cavity care

Classification(M. Tos)
•Canal wall up(CWU)
•Simple mastoidectomy
•Combined approach
mastoidectomy/tympanoplasty
•Canal wall down(CWD)
•Atticotomy and atticoantrostomy
•Modified radical mastoidectomy (MRM)
•Radical mastoidectomy

Approaches and routes
•Approach: method of access to the middle ear
through the soft tissues
Enduaral
Postaural
Extended endaural
Circumferential
•Route: method of access to the middle ear
through the bone
Transcortical
Transmeatal – microscopic and endoscopic

Endaural approach
•Indications
• Head on access to
mesotympanum,
epitympanum, aditus, antrum
• small acellular mastoid
•Disadvantage
• Stenosis of EAC
• Difficult access to mastoid tip
Pic source: Shambaugh 6th ed

Postaural approach
Good exposure to
entire mastoid bowl &
epitympanum
Pic source: Rob & Smith 4th ed Pic source: Dhingra 6th ed

Circumferential approach
Pic source: Rob & Smith 4th ed

Technique
Anterior to posterior(in to out)
•Size of cavity smaller
•Good approach for
sclerotic mastoid
•Safe- early identification
of ossicles
•Less chance of missing
small mastoid
•Technically difficult for
beginners
Posterior to anterior(out to in)
•Technically easier
•Preferred in complication
cases
•Cavity large
•Chance of missing
antrum (Korner septum)

Combined approach tympanoplasty
(CAT)/ classic intact canal wall
mastoidectomy
•CAT : a large mastoidectomy with an intact but thin
bony ear canal wall
•posterior atticotympanotomy.
•2 stages:
• first operation: to remove all cholesteatoma and repair
the tympanic membrane.
•second operation: six months to 1 year later;
reinspection and ossicular reconstruction

Indications of CWU
• Large pneumatized mastoid & well aerated
middle ear
Contraindications of CWU
• Only hearing ear
• Labyrinthine fistula
• Presence of intracranial complications
• Long standing ear disease
• Poor ET function

STEPS OF CAT
1. Cortical mastoidectomy
2. Anterior Tympanotomy : via tympanomeatal
flap
3. Posterior Tympanotomy: via facial recess
approach
4. Tympanoplasty

Advantages of CWU
•Rapid healing
•Easier long term care
•Hearing aid easier to
fit
•No aural precaution
Disdvantages of CWU
•Technically more
difficult
•Staged operation
necessary after 1 year
•Recurrent disease
possible
•Residual disease
harder to detect

Indications of CWD procedures
•Cholesteatoma in only hearing ear
•Erosion of post bony canal
•Labyrinthine fistula
•Poor ET function
•Recurrence of cholesteatoma after CWU
procedure
•Sclerotic mastoid with limited access to
epitympanum

Atticotomy
•Atticotomy (Epitympanotomy)- denotes opening
of the attic, performed through the transmeatal
route
•For attic retraction pocket with debris/
cholesteatoma
•Limited cholesteatoma involving middle ear,
osscicular chain & epitympanum

Incision and widening of canal

Exposure of epitympanum and removal of
cholesteatoma

Repair with fascial graft/cartilage/cortical
bone

Atticoantrostomy
•an extension of the atticotomy
•lateral attic and aditus walls removed
• transmeatal/transcortical route.

Bondy’s operation
• An atticoantrostomy in which the tympanic cavity is
not entered
•marsupialising the cholesteatoma
•If the tympanic cavity is entered- conservative radical
operation.

Bondy’s operation
•Useful for attic & mastoid cholesteatoma
•No involvement of middle ear space
•Cholesteatoma lateral to ossicles
•Procedure same as MRM(canal wall down) except
middle ear not manipulated
•ET function adequate with aerated middle ear with
intact pars tensa

Modified radical mastoidectomy(MRM)
•Removal of the posterior canal wall
•Management of cholesteatoma in a ‘single-stage’
approach (Unlike CAT)

Indications of MRM
•Cholesteatoma with recurring otorrhoea with
sufficient cochlear reserve
•Absolute indication
•Unresectable disease
•Impossibility to follow up
•Unreconstructable post canal wall
•Failure of first stage CWU procedure because
of poor ET function

Contraindications of MRM
1. Chronic otitis media without cholesteatoma
2. Acute otitis media with coalescent mastoiditis,
3. persistent secretory otitis media
4. Chronic allergic otitis media.
5. Tuberculous otitis media.

Operative technique: MRM
•Preparation:
 General anesthesia without paralytic agents and
with continuous facial nerve monitoring
 Tragus and postauricular skin lidocaine with
epinephrine (1: 100,000)
 Betadine scrub

Pic source: dhiru-entsurgery

Incision
Pic source: Shambaugh 6th ed.

Exposure of mastoid cortex

Middle Ear Dissection
•Middle ear dissection prior to mastoidectomy to
control middle ear disease
•state of the ossicular chain
•Protection of stapes

• Tympanomeatal flap
elevation
•Dissection of
cholesteatoma
• Exposure of the
ossicles and facial
nerve

Mastoidectomy
•All mastoid air cells
should be removed
•Exposure of the
middle fossa and
posterior fossa dural
plates, the sigmoid
sinus, digastric ridge,
and bony canal wall

Mastoidectomy
•Cholesteatoma and
granulations filling the
central mastoid tract
can be removed at this
time

Canal wall removal

Meatoplasty:
•Local anaesthestic
infiltration
•Removal of cartilage
•Suturing
•Various techniques

Techniques of meatoplasty
Korner’s meatoplasty Fisch meatoplasty

Techniques of meatoplasty
Stacke’s meatoplasty
•Similar to korner’s but inferiorly based
Portman’s technique
•3 flaps-lateral, superior and inferior

Post-operative mastoid cavity
•Well saucerized cavity
•Smooth cavity
•Adequately lowered facial ridge
•Adequate meatoplasty

Problems encountered during surgery
•Disease over dehiscent facial nerve
Disease left over dehiscent area- 2nd stage surgery
needed
•Disease over labyrinthine fistula
Fistula <2mm- matrix can be removed
Fistula >2mm or in only hearing ear or fistula over
promontary should not be removed
Removal of matrix with fascial grafting (Kobayasi et
al 1995)

Problems encountered during surgery
•Disease over dehiscent dura
•Disease over dehiscent sinus plate
•Disease over stapes area

Post-operative period
•Vertigo, Nausea vomiting
•Nystagmus
•Facial palsy
•Weber test
•Bandage soakage
•Wound

Complications
•Early complications
•Facial nerve injury
•Sensorineural hearing loss
•Dysequilibrium
•Corda tympani nerve injury
•Injury to dura- CSF leak
•Vascular injury- sigmoid sinus, jugular bulb,
carotid artery
•Wound infection, perichondritis

Complications
•Late complications
•Recurrent cholesteatoma
•Graft failure
•Persistent otorrhoea
•Cavity problem
•External auditory canal stenosis
•Brain fungus

Facial nerve injury
•Incidence- 0.6%-3.6%, revision surgery-
4%-10%
•Due to disease- horizontal portion or 2nd genu
•Due to surgery- vertical segment
•prevention of injury-
•Identification of landmarks
•Surgical techniques

Facial nerve injury
•Treatment
•If nerve sheath intact- decompression (3mm)
•Disruption of nerve fiber- nerve grafting
•If partial loss- steroid
•Progressive severe loss- exploration & nerve
grafting
•Total paralysis- immediate exploration

Dural injury
•Simple dural exposure- no treatment
•Dural injury with CSF leak-
•Small leak- close spontaneous
•Large leak- repair with facial graft, repair
•Bed rest, prophylactic antibiotics
•If CSF leak persist- lumbar drain

Vascular injury
•Sigmoid sinus
•Minor injury- adrenaline soaked cotton
•Laceration- exta or intraluminal packing
•Severe haemorrhage- sinus obliteration,
haemoclips
•Jugular bulb
•Small opening- bone wax
•If severe- jugular vein ligation

Vascular injury
•Carotid artery injury
•1% case dehiscent
•Small laceration- repair
•Larger laceration- balloon occlusion, resection
& grafting

Labyrinthine fistula
•Incidence- 4%-15%
•3 sites commonly involved-
•Lateral semicircular canal
•Promontary
•Oval window

Labyrinthine fistula
• Size: <2 mm, >2 mm
•Depth (Dornhoffer and Milewski):
1-Bone erosion but intact endosteum
2a-Endosteum breached but perilymphatic space
preserved
2b-Perilymph violated
3-Membranous labyrinth and endolymph disrupted

Labyrinthine fistula repair
•At the end of surgery; protection of the area till
then
•Intravenous steroid on detection
•1, 2a- repair- remove cholesteatoma and matrix
•2b & 3- leave matrix intact-2nd stage
•Covered with bone plate or fascia, augmented
with tympanic graft; biological glue to seal
•Primary repair-10% SNHL, staged- 4%

Hearing loss
•SNHL results from
•cholesteatoma, iatrogenic fistula,
manipulation of ossicles
•Contact of drill with incus
•Excessive mobilization of stapes

Outcome of CWD
•Kos et al. 2004, n=259, F/U 2yrs
•Dry ear- 95%
•Recurrence- 6.1%
•TM perforation- 7.3%
•Otorrhea- 5%
•Hearing improved- 30%, deteriorate- 28%
•SNHL- 1 patient
•Facial palsy- 1 patient
•Vertigo- 4 patient
•Milan Stankovic 2007, n=758, F/U 4 yrs
•Recurrence – 19% in children, 9.4% in adult

•Suzanne et al 2002- causes of failure in 50 ears
1. Incomplete lowering of facial ridge- 94%
2. Persistent sinodural angle- 92%
3. Persistent tegmen air cells- 88%
4. Recurrent or persistent cholesteatoma- 66%
5. Persistent mastoid tip air cell- 62%
6. Small meatus- 60%
7. Persistent hypotympanic air cells- 56%

Radical mastoidectomy
•A canal wall down mastoidectomy
•Eradicate disease from middle ear cleft
•Mastoid cavity, tympanum and EAC are
converted into a common cavity
•Exteriorised through the EAC
•Structures of tympanic cavity (remnants of the
incus and malleus, and the drum remnant) are
removed.

Indications for radical mastoidectomy
1. Unresectable cholesteatoma extending down
the Eustachian tube or into the petrous apex
2. Promontory cochlear fistula caused by
Cholesteatoma
3. Chronic perilabyrinthine osteitis or
cholesteatoma that cannot be removed and
must be cleaned or inspected periodically
4. Resection of temporal bone neoplasms with
periodic monitoring

Revision mastoid surgery
•Indications
•Inadequate ventilation
•Persistence of infection in residual cell tract
•Recurrence of cholesteatoma
•Inadequately opened cell tract in
epitympanum or behind high facial ridge
•Recurrent contamination due to defect in TM

Males scale of mastoid misery

Revision mastoid surgery contd…
•Difficulties
•Risky
•Loss of landmarks
•Exposed facial nerve, dura, sinus, labyrinth
•Performed by same surgeon
•Previous operative notes available

Revision mastoid surgery contd…
•Meatoplasty
•Lowering of facial ridge
•Exenterating all mastoid air cells
•Excising all diseased lining
•Tympanomastoid reareation with long graft
•Autologous epithelium- buccal epithelium
(Premchandra et al. 1991)

Mastoid obliteration
•Autologous bone chips or allogenic femoral
cortical bone chips (Shea 1972)
•Hydroxyapatite ceramic powder
•Muscle obliteration
•Local muscle periosteal transposition &
rotational flap of sternocleidomastoid
•Temporalis muscle (Rambo 1958)
•Postauricular muscle periosteal flap based on
sternocleidomastoid (Higler 1963)

•Anteriorly based postauricular muscle
periosteal transposition together with bone
pate (Palva 1963)
•Temporoparietal fascia flap (Byrd 1980)
•Temporalis fascia flap- Hong Kong flap (Van
Hasselt 1994)

Posterior canal wall reconstruction
•Cartilage grafts
•Allogenic EAC bone
•Autologous mastoid bone
•Mastoid bone pate
•Canal prosthesis

Laser in mastoid surgery
•Carbondioxide laser is used to vaporize
abnormal soft tissue
•Coagulation
•Vaporization and coagulation of granulation
tissue over foot plate, round window or facial
areas

KTP laser
•To vaporise disease from the ossicles without
touching them
•The laser can be passed down extremely fine
fibroptic fibres.
•Laser can't be used on cholesteatoma directly on
the facial nerve

Endoscope in mastoid surgery
•To detect residual disease in hidden areas- wide
field of view, better resolution, all nooks and
corners
•Used in primary dissection of cholesteatoma
•Eliminate the need of mastoidectomy
•Used in 2nd look operation using 30 degree
endoscope for recurrence
•Disadvantage: Only one hand free for surgery,
depth perception, encroachment of space, heat
injury, learning curve

References
• Scott-Brown’s Otolaryngology, Head and Neck Surgery, 7th edition. 2008.
• Glasscock-Shambaugh Surgery of the Ear, 6th edition.2012
• Rob & Smith’s operative surgery, 4th edition, 1983
• Cummings Otolaryngology–Head and Neck Surgery, 6th edition.2010
• Ballenger’s Otorhinolaryngology Head and Neck Surgery, 17th Edition.2009
• Bailey's Head and Neck Surgery- Otolaryngology, 5th edition, 2014.
• Ear Surgery, W.B. Saunders Co., Philadelphia, 2000.
• http://emedicine.medscape.com/
• http://www.uptodate.com
• https://en.wikipedia.org/wiki

Chloesteatoma surgery mukace

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