Endoscopic Management of Attic Cholesteatoma




At present, the main application of endoscopic surgery is in the surgical treatment of middle ear cholesteatoma; however, for definitive validation and acceptance by scientific community, results are needed regarding recurrent and residual rates of the condition. This article analyzes the single-institution experience from results of surgical treatment of attic cholesteatoma.


Key points








  • Most spaces considered to be difficult to access with the microscopic technique could be easily visualized by endoscope-assisted surgery.



  • The surgical approach should be tailored to the anatomic and physiologic concepts behind the genesis of the attic cholesteatoma, respecting as much as possible the physiology and anatomy of the middle ear.



  • Middle ear folds may play an important role in the blockage of ventilation routes, possibly provoking sectorial epitympanic dysventilation.



  • When isthmus blockage occurs, ventilation of the epitympanum may be impaired, and the only gas exchange would come from the mucosa of mastoid cells, excluding air provision from the Eustachian tube.






Introduction


Surgical management of cholesteatoma remains a controversial issue. Classical concepts are based on microscopic surgical management, as is the traditional classification of open tympanoplasties (canal wall down [CWD]) and closed tympanoplasties (canal wall up [CWU]), depending on the preservation of the posterior ear canal wall. The choice between these 2 techniques is based on several factors, although in most cases, the main factors influencing surgeons’ ultimate attitude toward surgical management of cholesteatoma are their experience, personal beliefs, and confidence with each technique.


Endoscopic instrumentation, techniques, and knowledge have really improved during the past few years, and we believe that, in the future, endoscopic surgical techniques will gain increasing importance in otologic surgery. From our 7-year experience in endoscopic ear surgery, we believe that most of the spaces considered to be difficult to access with the microscopic technique could be easily visualized by endoscope-assisted surgery and we feel that new anatomic concepts should be introduced in preparation for this. From this perspective, classical concepts of CWU and CWD tympanoplasty could be completely changed in clinical practice.


When a new technique is introduced, acceptable results are essential to have it accepted by the scientific community. Because endoscopic ear surgery is a relatively “just-born” technique, only few articles reporting results are present in the literature. This article illustrates the principles and results at our institution regarding endoscopic treatment of attic cholesteatoma.




Introduction


Surgical management of cholesteatoma remains a controversial issue. Classical concepts are based on microscopic surgical management, as is the traditional classification of open tympanoplasties (canal wall down [CWD]) and closed tympanoplasties (canal wall up [CWU]), depending on the preservation of the posterior ear canal wall. The choice between these 2 techniques is based on several factors, although in most cases, the main factors influencing surgeons’ ultimate attitude toward surgical management of cholesteatoma are their experience, personal beliefs, and confidence with each technique.


Endoscopic instrumentation, techniques, and knowledge have really improved during the past few years, and we believe that, in the future, endoscopic surgical techniques will gain increasing importance in otologic surgery. From our 7-year experience in endoscopic ear surgery, we believe that most of the spaces considered to be difficult to access with the microscopic technique could be easily visualized by endoscope-assisted surgery and we feel that new anatomic concepts should be introduced in preparation for this. From this perspective, classical concepts of CWU and CWD tympanoplasty could be completely changed in clinical practice.


When a new technique is introduced, acceptable results are essential to have it accepted by the scientific community. Because endoscopic ear surgery is a relatively “just-born” technique, only few articles reporting results are present in the literature. This article illustrates the principles and results at our institution regarding endoscopic treatment of attic cholesteatoma.




Material and methods


In January 2006, a database was created by the authors D.V. and D.M., in which all patients operated for middle ear surgery were included and followed up at our clinic by regular visits at appropriate timing (generally, after 1, 3, 6, and 12 months from the operation, then annually). At follow-up, patients were evaluated by endoscopic office examination. Noted in the database were recurrences (defined as non–self cleaning re-retraction of the attic requiring surgery) and residuals (defined as insufficient primary resection of the epidermal matrix, presenting in absence of re-retraction of the tympanic membrane). Residuals were also defined by computed tomographic evaluations, performed most frequently at 1-year follow-up. In May 2012, the database was reviewed and 321 endoscopic procedures for middle ear pathologic condition were analyzed. Of these, 253 were middle ear cholesteatomas. For the present study, only attic cholesteatomas treated endoscopically (exclusively or combined) with at least 1.5 years of follow-up were included for further analyses. Patients who had prior middle ear operations at clinical history were excluded from the analyses.




Statistical analysis


Pearson correlation coefficient was used to evaluate the correlation between the absence or presence of disease (residual or recurrence) and age of patients (less than or greater than age 18 years) or type of matrix (infiltrative or sac matrix), the correlation between the absence or the residual disease and the extent of disease (cholesteatoma limited to the attic, mesotympanum extension, antral extension, mastoid extension), and the correlation between the absence or the recurrence of disease and the kind of reconstruction (cartilage, bone or fascia). The software, SPSS Statistics, version 17.0 was used for statistical analyses.




Results


The final study group included 146 ears (from 146 patients). The mean follow-up was 31.2 months (DS ± 15.8). Of the 146 patients, 135 (92.5%) were free from disease at their last follow-up visit, 4 (2.7%) patients were diagnosed with recurrence, and 7 (4.8%) patients had residual disease ( Fig. 1 ).




Fig. 1


Circular diagram showing the follow-up results.


Of the 146 patients, 120 (82.2%) underwent exclusive endoscopic approach and 26 (17.8%) underwent an endoscopic approach combined with mastoidectomy ( Fig. 2 ). Of 146 patients, 34 (23.3%) underwent a cholesteatoma limited exclusively to the attic, while 56 patients (38.4%) also had a mesotympanic extension of the disease, 32 (21.9%) had antral extension, and 24 (16.4%) had mastoid extension.




Fig. 2


Chart showing the surgical approaches.


Of the 146 patients, 14 (9.6%) ( Fig. 3 ) were younger than 18 years, whereas 132 (90.4%) were adults.




Fig. 3


Circular diagram showing the site of cholesteatoma; blue, limited to the attic; dark green, attic and mesotympanum; red, violet, attic and antrum; red, attic and mastoid.


The cholesteatoma matrix was infiltrative in 117 of 146 patients (80.1%); 29 of 146 (19.9%) patients had a sac matrix. In 39 patients (26.7%), it was possible to avoid ossicular removal, whereas in 107 patients (73.3%), ossicular removal and reconstruction was necessary (in these cases, an ossicular chain erosion or an infiltrative matrix of the medial aspect of the ossicles was found). A total of 77 patients had a cartilage reconstruction of scutum (52.7%); in 21 patients, the reconstruction was performed by bone (14.4%) and in 48 (32.9%), by temporalis fascia ( Figs. 4–6 ).


Apr 1, 2017 | Posted by in OTOLARYNGOLOGY | Comments Off on Endoscopic Management of Attic Cholesteatoma
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