Abstract
Purpose
The study was designed to assess correlations between intraoperative findings in revision tympanomastoidectomy as predictors of cholesteatoma recurrence.
Materials and methods
A retrospective single-institution cohort of 101 patients who underwent surgical treatment for recurrent chronic otitis media in a tertiary referral otology centre.
Results
Out of 101 patients, 65 had canal wall up and 36 canal wall down revision surgery. There were 35 cholesteatoma recurrences. Sites most commonly associated with recurrent disease were residual facial ridge cells in 46 (45.5%), ossicular chain sites in 46 (45.5%) patients, posterior external auditory canal wall erosions in 38 (37.6%) patients and mastoid apex recurrence in 35 (34.7%) patients. Ossicular and posterior external auditory canal wall erosion and incomplete removal of mastoid apex cells correlate well with cholesteatoma recurrence accompanied by canal wall up surgery ( p = 0.009). Residual mastoid apex cells, posterior external auditory canal wall erosion and presence of residual facial ridge cells were identified as the strongest positive predictors of cholesteatoma recurrence, identifying high risk patients associated with canal wall down procedures ( p = 0.0036).
Conclusions
Correlations between intraoperative findings and cholesteatoma recurrence could improve preoperative and intraoperative planning and reduce the rates of postoperative failures1 due to mismanagement of high risk areas.
1
Introduction
Chronic otitis media with cholesteatoma remains one of the most commonly surgically treated disorders in otology. Areas of recurrence after initial surgery can encompass disease limited to the tympanic cavity, but can also lead to extensive erosion of surrounding structures and temporal bone involvement. The main goals of revision surgery are to eliminate mucosal and bone disease while choosing the optimal surgical procedure plan . Numerous published papers deal with two major surgical procedures that are used in achieving disease control: canal wall down (CWD) and canal wall up (CWU) procedures. Several factors have been described to contribute to postoperative failure after CWD surgery; small meatus, high facial ridge, dependent mastoid tip, granulation and poor cavity design . Identifying and correcting residual disease factors converts discharging ears into dry, safe ears in most cases. However, few authors have investigated connections between intraoperative findings in revision surgery as predictors of cholesteatoma recurrence. Little literature is available in guiding the clinical decision making process in planning revision surgery. Improving preoperative and intraoperative understanding of recurrence patterns enables adequate control of the disease. The aim of this paper is to examine the intraoperative details of revision tympanomastoidectomy and analyze the patterns of cholesteatoma recurrence in the mastoid and tympanic cavity. It is our hypothesis that clinically useful patterns of cholesteatoma recurrence can be identified and that these patterns can help in deciding on the type of revision surgery.
2
Materials and methods
This retrospective longitudinal cohort study and its protocol included 123 patients diagnosed with recurrent chronic otitis media and was approved by the University Hospital Centre Bioethical Board adhering to the Helsinki Declaration Revision of 1989. All patients who underwent canal wall up (CWU) or canal wall down (CWD) revision tympanomastoidectomy from January 1st, 2010 to December 31st, 2015 in our National Referral Centre for Otology were eligible for inclusion. The procedures were performed by an otologic team of 3 surgeons, with complete intraoperative notes obtained and analyzed. The patients were included consecutively, with demographic information, time and type of previous surgery, intraoperative anatomical and procedural details noted. All of the patients signed informed consent forms after evaluation by an otologist. Strict study protocol criteria excluded 22 patients due to incomplete documentation. Data for 12 sites of chronic otitis media with possible cholesteatoma recurrence were identified during revision surgery, documented by the same team of otologists. The large percentage of patients (80.3%) that had previous surgery at other institutions did not influence the quality of data obtained during the preparation of this manuscript. All of the patient’s previous records were available, and the data were collected from uniform sources and intraoperative notes from our institution, created through a uniform manner of writing. Statistical analysis was performed using MedCalc software (Version 11.2.1© 1993–2010. MedCalc Software bvba Software, Broekstraat 52, 9030 Mariakerke, Belgium), using standard descriptive statistics and frequency tabulation as indicated. Associations between variables were assessed using the Kruskal-Wallis test, chi-squared test and logistic regression with odds ratios (OR) with confidence intervals (CI) to test statistically significant correlations. All tests of statistical significance were performed using a two-sided 5% type I error rate.
2
Materials and methods
This retrospective longitudinal cohort study and its protocol included 123 patients diagnosed with recurrent chronic otitis media and was approved by the University Hospital Centre Bioethical Board adhering to the Helsinki Declaration Revision of 1989. All patients who underwent canal wall up (CWU) or canal wall down (CWD) revision tympanomastoidectomy from January 1st, 2010 to December 31st, 2015 in our National Referral Centre for Otology were eligible for inclusion. The procedures were performed by an otologic team of 3 surgeons, with complete intraoperative notes obtained and analyzed. The patients were included consecutively, with demographic information, time and type of previous surgery, intraoperative anatomical and procedural details noted. All of the patients signed informed consent forms after evaluation by an otologist. Strict study protocol criteria excluded 22 patients due to incomplete documentation. Data for 12 sites of chronic otitis media with possible cholesteatoma recurrence were identified during revision surgery, documented by the same team of otologists. The large percentage of patients (80.3%) that had previous surgery at other institutions did not influence the quality of data obtained during the preparation of this manuscript. All of the patient’s previous records were available, and the data were collected from uniform sources and intraoperative notes from our institution, created through a uniform manner of writing. Statistical analysis was performed using MedCalc software (Version 11.2.1© 1993–2010. MedCalc Software bvba Software, Broekstraat 52, 9030 Mariakerke, Belgium), using standard descriptive statistics and frequency tabulation as indicated. Associations between variables were assessed using the Kruskal-Wallis test, chi-squared test and logistic regression with odds ratios (OR) with confidence intervals (CI) to test statistically significant correlations. All tests of statistical significance were performed using a two-sided 5% type I error rate.
3
Results
Patients’ age ranged from 8 to 82 years with a mean value of 42.6 years. Of the total of 101 patients enrolled in the study, 56 (55.4%) were male and 45 (44.6%) female. There were 72 (71,3%) patients with only one previous surgery, and 29 (28.7%) patients with multiple previous surgeries, with an average of 2.5 surgeries per patient. The average time elapsed from previous surgery was 8 years. Of the 101 patients, 20 (19.8%) had been treated in our institution prior to revision surgery. The types of previous surgeries were tympanoplasties in 49 (48.5%) patients, tympanoplasties with ossicular chain reconstruction in 13 (12,9%) patients and CWU tympanomastoidectomies in 39 (38.6%) patients. The types of revision procedures were CWU tympanomastoidectomies in 65 (64.4%) patients and CWD tympanomastoidectomies in 36 (35.6%) patients. ( Table 1 ) In the CWD revision procedure group, 7 patients underwent a previous CWU tympanomastoidectomy, while in 29 patients CWD surgery was performed outright due to extensive cholesteatoma recurrence. ( Table 2 ).
| Previous procedures | |
|---|---|
| Tympanoplasty | 49 (48.5) |
| Tympanoplasty with ossicular chain reconstruction | 13 (12.9) |
| Canal wall up tympanomastoidectomy | 39 (38.6) |
| Total | 101 |
| N of patients (%) | N of cholesteatoma recurrences noted during revision surgery (%) | |
|---|---|---|
| Revision procedures | ||
| Canal wall up tympanomastoidectomy | 65 (64.4) | 6 (17.1) |
| Canal wall down tympanomastoidectomy | 36 (35.6) | 29 (82.9) |
| Total | 101 | 35 |
The most common area of recurrent disease and debris retention were the residual facial ridge cells in 46 (45.5%) of patients and the ossicular chain in 46 (45.5%) patients, followed by cholesteatoma related erosion of the posterior external auditory canal wall in 38 (37.6%) patients, mastoid apex and antrum recurrence in 35 (34.7%) and 30 (29.7%) patients, respectively. ( Table 3 ) Cholesteatoma recurrence was identified in 35 (34.7%) patients. Based on previously published areas of common recurrence, the patients were divided into 5 groups: 1. non-specific or normal finding, 2. residual facial ridge cells and ossicular chain recurrence, 3. posterior external auditory canal wall erosion, 4. mastoid recurrence, 5. tympanic cavity and mastoid recurrence. A significant correlation was shown between ossicular chain, posterior external auditory canal erosions, tympanic/mastoid cholesteatoma and CWD tympanomastoidectomy ( p = 0.02, Kruskal-Wallis test). ( Fig. 1 ) Another positive correlation was shown between ossicular, posterior external auditory canal wall erosion, incomplete removal of tympanic/mastoid cells and increasing cholesteatoma recurrence ( p = 0.009, Kruskal-Wallis test). ( Fig. 2 ) Naturally, a positive correlation was noted between recurrent cholesteatoma and an increasing propensity toward CWD procedures ( p = 0.001, chi-squared test). A positive correlation was also found between rising age and recurrence ( p = 0.028, Kruskal-Wallis test). ( Fig. 3 ).
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