20
Complications of Cholesteatoma and Chronic Otitis Media with Effusion
The objectives of surgery for otitis media (OM) are to obtain a dry safe ear, to restore hearing, and to maintain anatomical integrity as much as possible. The most important of these is to eliminate disease and infection while avoiding complications such as facial paralysis, sensorineural hearing loss (SNHL), and dural injury. This chapter describes safe surgical techniques to be used during operative management of OM and its associated complications, both disease related and iatrogenic.
■ General Concepts
Patients must be made knowledgeable of the nature of OM and its complications in order to make appropriate decisions regarding treatment. We counsel patients on the anatomy and function of the normal middle ear and describe abnormal exam findings in detail, using diagrams. We personally review the audiogram and discuss conductive and sensorineural hearing loss. When a surgical procedure is proposed, we emphasize that the primary goal of surgery is to eliminate disease. The secondary goal may be to improve hearing, but in many cases it will require a staged operation. The patients are told to expect temporary taste disturbance, tinnitus, numbness of the auricle, and a sensation of fullness in the ear. Surgical complications discussed include infection, hearing loss, dizziness, facial paralysis, and hematoma of the wound. When appropriate, we discuss the risks of intratemporal and intracranial complications. Patients receive a standard pamphlet with details highlighted appropriate to their case. After a follow-up discussion on a second preoperative visit, patients sign a consent form that includes all the risks and complications. An audiogram is always performed on the day of or the day prior to surgery. Patients obtain medical clearance for surgery from their primary care doctor.
In the setting of chronic disease, mastoid and middle ear anatomy is often concealed by infection or cholesteatoma or both. In addition, erosive processes may render the facial nerve, horizontal semicircular canal, and inner ear more susceptible to injury. The surgeon must have a solid knowledge of and respect for neuro-otologic structures and should be well practiced in temporal bone dissection.
High-quality computed tomography (CT) of the temporal bones is often required for management of complicated ear problems. CT is important when signs or symptoms suggest mastoiditis or a labyrinthine fistula and in the presence of facial paralysis. In the setting of fever, headache, or other sign of intracranial complication, magnetic resonance imaging (MRI) with contrast will also be required. Additionally, we occasionally obtain a CT scan prior to revising a surgery performed at another institution, when the details of the previous surgery are obscure and surgical findings seem to be unpredictable. For the CT, axial and coronal images with 1 or 1.5 mm sections and bone windows are the minimum requirement.
We do not routinely utilize facial nerve monitoring during chronic ear surgery, but monitoring is a helpful assistant during complicated or revision cases. We do not rely on the monitor to keep us away from the facial nerve, but rather use it as an aid in safe identification of the nerve. The surgeon must be knowledgeable in regard to the equipment, the setup, and the technique of monitoring.
Quality of care can be followed by good record keeping. We record surgical findings and techniques on a standard data sheet after every case. It includes information on the type of procedure performed and specific intraoperative techniques, including type of graft and prosthesis used. The presence and location of pathology, such as discharge, perforation, cholesteatoma, tympanosclerosis, and mucosal disease are listed. We also record facial exposure, dural exposure, canal fistula, cerebrospinal fluid (CSF) leak, and ossicular status. This record is kept in the patient’s chart and provides both a quick review of surgery and a method of reviewing outcomes.
■ Complications and Management Principles
Both the disease process itself and the surgical procedures to manage these processes can result in significant sequelae. Table 20–1 discusses the pitfalls associated with chronic ear disease as well as the complications or difficulties associated with surgical management of this condition.
Conductive Hearing Loss
Conductive hearing loss is found in almost every case of chronic OM. It may be caused by middle ear effusion, retraction or perforation of the tympanic membrane, ossicular erosion, cholesteatoma, or tympanosclerosis.
Tympanosclerosis, a common sequela of OM, deserves special mention. Tympanosclerotic plaques may fix the ossicular chain at the oval window, epitympanum, tensor tympani, or anterior mallear ligament. It can be managed nonsurgically with amplification, but in our experience, good hearing results can be achieved with surgical removal. A sharp Rosen needle or laser under high-power magnification is used to lift tympanosclerotic plaques from the oval window niche, freeing the stapes (Fig. 20 If the stapes is fixed at the level of the footplate, careful removal of plaques may allow mobilization. The annular ligament is not usually involved. The stapes should not be rocked or manipulated too aggressively because hydraulic cochlear damage and SNHL may result. If the stapes footplate cannot be freed, a stapedectomy is performed. A stapedectomy should not be performed in the presence of active disease or a perforation. Opening the inner ear in an infected field could result in a bacterial labyrinthitis, and in this situation, a staged procedure is required. If the lateral chain is fixed, we prefer to remove the incus and place a partial ossicular replacement prosthesis (PORP) to the mobile stapes. In a review of our surgical results, 66.2% of patients with ossicular chain fixation due to tympanosclerosis achieved a postoperative air–bone gap of 20 dB.1
Problem | Prevention/Treatment |
|---|---|
Conductive hearing loss | |
Middle ear effusion | Ventilation of the middle ear/mastoid |
Tympanosclerosis | Removal of tympanosclerotic plaques |
Ossicular discontinuity | Ossicular reconstruction |
Sensorineural hearing loss | Minimize trauma to stapes |
Identify and prepare for a labyrinthine fistula | |
Maintain cholesteatoma matrix over fistula and perform a canal wall down mastoidectomy | |
Maintain cholesteatoma matrix over fistula and perform a canal wall up mastoidectomy with a planned staged second look | |
Remove cholesteatoma matrix with prompt replacement with fascia | |
Recurrent/residual cholesteatoma | Attempt to remove cholesteatoma matrix intact |
Avoid reimplantation of squamous debris by continuous wipedown of instrumentation | |
Copious irrigation of surgical field prior to reconstruction and closing | |
A planned second-stage procedure for canal wall up mastoidectomy and close follow-up for those who received a canal wall down mastoidectomy | |
Repair of scutal defects using cartilage grafts or bone pate | |
Facial paralysis | |
Acute otitis media | Computed tomography to rule out coalescent mastoiditis |
Myringotomy with ventilation tube placement | |
Intravenous antibiotics | |
Mastoidectomy with decompression if there is complete facial paralysis with electrical signs of complete neural degeneration | |
Chronic otitis media | Immediate mastoidectomy with identification of the segment involved |
Sharp dissection of disease from facial nerve | |
Decompression proximally and distally from the affected facial nerve segment | |
Meningitis | Lumbar puncture to assist in diagnosis of organism |
High-dose steroids to reduce incidence of sensorineural hearing loss | |
Mastoidectomy and myringotomy | |
Dural venous thrombosis | Decompress lateral and sigmoid sinus |
Assess patency or frank intraluminal abscess formation with a needle puncture | |
If patent, seal puncture site with Gelfoam | |
If purulent drainage or no flow detected, evacuate and seal sinus | |
Dural injury/cerebrospinal fluid leak |
