There have been very few changes in the techniques of management of cholesteatoma since the mid-1970s, but controversies remain. It is not uncommon to attend a scientific meeting, listen to three presentations on a subject, and hear that each (different) technique or prosthesis is –the only way to do it.” –It gives perfect results.” –If you do it my way you will get results just like mine.” Of course, none of these statements is true. There are many ways to accomplish a desired result, but nothing works perfectly. The results you obtain will depend on your personal ability to use your hands and instruments and on your judgment. There’s an old saying that judgment comes from experience, and experience comes from bad judgment! So what any of us do, or teach, is based on having had problems and learning how to avoid them: what to do, how to do it, and what not to do: judgment! This chapter summarizes the many factors involved in making a decision on management of cholesteatoma, particularly the management of the mastoid. I leave it up to the reader to review articles mentioned in the Suggested Readings for in-depth discussion on various aspects of management. Aims and Objectives There were two aims or objectives in the management of cholesteatoma long before the introduction of tympanoplasty: to obtain a safe ear and, one hoped, a dry ear. These were accomplished by a radical or modified radical mastoidectomy. With the introduction of tympanoplasty during the mid-1950s, a third objective was added: a hearing ear. This also introduced a controversy: how hard do you try to improve the hearing? This led to much controversy unrelated to the manner of management of the mastoid. How hard should you try to improve the hearing? To stage or not to stage? The aims and objectives of surgery on the ear with cholesteatoma, then, are (1) eliminate the disease: obtain a safe, dry, ear; and (2) restore the function: obtain a good hearing ear. Type of Operation The number one aim of cholesteatoma surgery is to obtain a safe, dry ear. The classic radical mastoidectomy accomplished the safety factor. When preservation of hearing was deemed feasible, the operation used was a modified radical mastoidectomy, a procedure that involved preservation of the tympanic membrane and ossicles while exteriorizing the epitympanum and mastoid to the ear canal. (The modified radical mastoidectomy is not a tympanoplasty, contrary to the way the term is often used today by some people.) * This work was supported by funds from the House Ear Institute, affiliated with the University of Southern California. a procedure that involved preservation of the tympanic membrane and ossicles while exteriorizing the epitympanum and mastoid to the ear canal. (The modified radical mastoidectomy is not a tympanoplasty, contrary to the way the term is often used today by some people.) With the advent of tympanoplasty during the mid-1950s, it became possible, in many cases, to restore function rather than to just preserve whatever function remained. The mastoidectomy was canal wall-down (CWD), as it had been with a modified radical or radical. But a problem developed: a narrow middle ear space. And the space often collapsed, of course, blamed on the eustachian tube. There was no help for the hearing. To avoid this narrowing of the middle ear space the canal wall-up (CWU) procedure was developed, also called the intact canal wall tympanoplasty with mastoidectomy, combined approach tympanoplasty, and posterior tympanotomy approach. This was similar to a simple (or cortical) mastoidectomy, as had been done for more than 50 years for the treatment of acute mastoiditis. The middle ear space was much wider, so prostheses were needed to transfer the sound vibrations from the tympanic membrane to the inner ear. This worked fine in some cases: a dry ear, no mastoid cavity, and improved hearing. But problems developed early on, leading many otologists to decide that the CWU procedure was not wise. If the middle ear was not mucosal lined, and air containing, the tympanic membrane retracted. Any ossicular prosthesis might well extrude. More important, a postero-superior retraction pocket might develop leading to recurrence of cholesteatoma, requiring a second operation, usually a CWD procedure. Add to this the fact that bits of cholesteatoma matrix may have been left behind gave trouble, requiring further surgery to remove this residual disease in the mastoid, epitympanum, and middle ear. Was there any good reason to use the CWU rather than the CWD procedure? Many otologists felt there was not a good reason to use the CWU rather than the CWD procedure. A major reason was the need to perform the operation in two stages, at times, to avoid the problem of residual and recurrent cholesteatoma. Counseling the Patient Counseling the patient is an individual matter. It relates to the surgeon’s personal experience, the status of the ear and the patient’s ability to understand what you are saying. Let us assume this is a patient with a draining ear and cholesteatoma with a 30-dB conductive deficit. Using our chronic ear patient discussion booklet, we explain how a normal ear functions and then show a second drawing of the ear with skin growing into the ear and forming a cholesteatoma. The explanation usually proceeds in the following way, and is the same for CWU and CWD:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
