Otology & Neurotology 35:1801Y1808 Ó 2014, Otology & Neurotology, Inc.
Cholesteatoma Recidivism: Comparison of Three Different Surgical Techniques Marcus Neudert, Susen Lailach, Nikoloz Lasurashvili, Max Kemper, Thomas Beleites, and Thomas Zahnert Department of Otorhinolaryngology, Head and Neck Surgery, Medizinische Fakulta¨t Carl Gustav Carus, Technische Universita¨t Dresden, Dresden, Saxony, Germany
Objective: To compare cholesteatoma recidivism rates after exclusive transcanal technique (ETC), combined transcanal and mastoidal technique (TCM, both subsets of intact canal wall technique, ICW), and canal wall down surgery (CWD). Study Design: Retrospective case review and clinical case study Setting: Tertiary referral center. Patients: 406 cholesteatoma surgeries (2007Y2009), 116 ears in clinical re-examination at least 1 year postoperatively. Intervention: Sequential cholesteatoma surgery with ETC, TCM, or CWD. Main Outcome Measures: Cholesteatoma recidivism, residual and recurrent disease, localization of recidivism, validity of clinical findings. Results: Out of 406 patients, ETC was performed in 227 (56%), TCM in 122 (30%), and CWD in 57 (14%) cases. Recidivism rates after ICW (15%) and CWD (16%) were almost similar. Recidivism was more frequent after ETC (11%) than after TCM (25%). Residuals were observed in 2% after ETC, 6.5% after TCM, and 7% after CWD. Incidence of recurrent disease was
9% for ETC, 18% for TCM, and 9% for CWD. Preferred localization of recidivism was the tympanic cavity after ETC (92%) and CWD (56%) and the mastoid cavity after TCM (53%). The clinical re-examination showed no further recidivistic disease. Conclusions: Sequential surgery is an effective and successful strategy in cholesteatoma eradication, providing a similar recidivism rate compared to following cholesteatoma retrograde and resection of the posterior canal wall. Lower recidivism after ETC was observed as a consequence of limited disease and the postoperative middle ear status determined the higher rate of recurrence after TCM. Therefore, the restricted visualization of the middle ear during ICW surgery does not increase the rate of recidivism, compared with CWD, as described in other studies. Cholesteatoma recidivism is mainly attributed to the surgeon’s experience that outweighs the chosen strategy. Key Words: Canal wall downVCholesteatomaVRecidivismV Recurrent diseaseVSurgical techniqueVTranscanal technique. Otol Neurotol 35:1801Y1808, 2014.
Since the end of the 19th century, several attempts have been made to optimize surgical techniques in cholesteatoma surgery and to lower the rate of cholesteatoma recidivism significantly. Most clinical studies focused on the impact of resection (canal wall down surgery, CWD) or preservation (intact canal wall, ICW) of the posterior canal wall on recidivistic cholesteatoma.
Today, it is widely accepted that cholesteatoma surgery should be individually adapted to extent, localization, pathogenesis, and complications of cholesteatoma (1Y5). Nevertheless, several surgical philosophies result in considerable differences in the various strategies in cholesteatoma management. The cholesteatoma can be followed to its extent in a retrograde way with resection (‘‘inside out’’) and with reconstruction of the lateral attic wall (3,6Y8) or it can be managed step by step with a primary transcanal and mastoidal technique (TCM, also known as combined approach) and posterior tympanotomy (9) if cholesteatoma extension requires mastoidectomy. The TCM offers the benefits of an intact posterior canal wall and an improved visualization by a simultaneous mastoidectomy. Resection of the posterior canal wall is only the final step in eradication of cholesteatoma during a sequential surgery. This study estimates cholesteatoma recidivism in a sequential cholesteatoma surgery. Differences in residual
Address correspondence and reprint requests to Marcus Neudert, M.D., Department of Otorhinolaryngology, Head and Neck Surgery, Medizinische Fakulta¨t Carl Gustav Carus, Technische Universita¨t Dresden, Fetscher Strasse 74, 01307 Dresden, Saxony, Germany; E-mail: [email protected] The work was done in the aforementioned institute. M.N. and S.L. contributed equally to this work and should therefore be considered first authors of this article. This work was presented in part at the 82nd annual meeting of the ‘‘Deutsche Gesellschaft fu¨r HNO-Heilkunde, Kopf- und Hals-Chirurgie,’’ June 5, 2011, Freiburg, Germany The authors disclose no conflicts of interest.
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and recurrent disease after three surgical techniques (exclusive transcanal technique [ETC], TCM, and CWD with obliteration) were evaluated. MATERIALS AND METHODS Surgical Techniques and Surgical Strategy In the Department of Otorhinolaryngology, Head and Neck Surgery Dresden, a sequential cholesteatoma surgery is preferred. Exclusive transcanal technique (ETC): After a most obligatory retroauricular incision, an ETC is primarily used. This includes the spare resection of the lateral attic wall as well as an atticotomy if necessary. Combined transcanal and mastoid (TCM) technique: In cases of extensive pathology, which would lead to a delicate defect of the posterior canal wall, a TCM with an additional access by mastoidectomy (antrotomy and/or posterior tympanotomy) is performed. Canal wall down (CWD) technique: Resection of the posterior auditory canal wall leading to an open mastoid cavity is only used in poorly visible middle ear conditions, revision surgery with extensive recidivistic disease, or an already existing wide erosion of the posterior canal wall. Open mastoid cavities are obliterated with autologous bone pate and sliced concha cartilage plates in the same surgical session. Eradication of cholesteatoma matrix and hearing restoration by an ossiculoplasty are performed in the same surgical stage. The tympanic membrane is usually reconstructed with cartilage slices with a thickness of 250 to 500 Km combined with perichondrium in a ‘‘tuliplike’’ underlay technique (10). Ossiculoplasty was performed using autologous incus interposition or, when involved or destroyed in the cholesteatoma, with titanium partial
or total ossicular replacement prostheses (Kurz Company, Dusslingen, Germany). In cases of uncertainty of complete removal of cholesteatoma matrix, extensive or ‘‘open-type’’ cholesteatoma, a staged second-look operation was considered advisable 6 to 12 months after primary surgery. All operations were performed by experienced otosurgeons. Focusing on the intraoperative visualization, intact canal wall techniques (ICW) were determined by keeping the posterior canal wall intact during surgery. Therefore, ETC and TCM were assigned to ICW. In keeping with this definition, obliterated mastoid cavities were allocated to CWD, although the postoperative status in the clinical examination is consistent with a ‘‘closed technique’’ (Fig. 1).
Residual and Recurrent Cholesteatoma Recidivistic disease was determined by detecting cholesteatoma matrix during a planned second-look operation or an unplanned revision surgery after an initial cholesteatoma operation. In our department, a special consultation hour was established to follow up all patients during the wound healing period. Afterwards, all patients were assessed by practicing otorhinolaryngologists. Patients with regular postoperative progress were examined in a yearly routinely control visit in our department. In cases of suspicious otoscopic findings or symptoms, patients were sent to our outpatient department. Depending on otoscopic and/or endoscopic findings, recidivistic cholesteatomas were detected or excluded by diffusion-weighted magnetic resonance imaging and/or a surgical re-exploration. Recurrent and residual cholesteatoma were discriminated as follows: residuals were associated with postoperative remaining cholesteatoma matrix in the middle ear or mastoid cavity and simultaneous non-pathological otoscopic findings, such as an
FIG. 1. Classification of surgical techniques in cholesteatoma surgery considering the intraoperative exposure (otoscopic findings in clinical re-examination were not taken into consideration, * classification according to Hildmann [1]). Otology & Neurotology, Vol. 35, No. 10, 2014
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CHOLESTEATOMA RECIDIVISM intact closure of the tympanic cavity without retractions or perforations. In contrast, patients with recurrent disease showed clinical findings like poorly visualized retraction pockets, perforations of the tympanic membrane, and/or destructions of the lateral attic or posterior canal wall upon preoperative microscopic examination. Additionally, the total recidivism rate was calculated as the sum of residual and recurrent cholesteatoma and in the following addressed by the term ‘‘cholesteatoma recidivism.’’
Chart Review and Patient Selection Criteria A retrospective chart review of all 430 patients, who had undergone primary or revision cholesteatoma surgery within 2007 and 2009 in our department, was performed. Because 60 patients showed bilateral disease, a total number of 713 middle ear operations were carried out on 490 ears. As revision surgeries for recurrent cholesteatoma were also included when the first operation was performed before 2007, the observed time period ranged from 1994 until November 2010. Surgical approach and technique (ETC, TCM, and CWD), preoperative otoscopic findings, revision or planned secondlook operations, and occurrence and localization of recidivistic disease were categorized. We excluded 78 patients who were initially operated in a different clinic to reduce biasing factors caused by inter-clinical differences in cholesteatoma surgery. Preoperative examination of all patients included ear microscopy and endoscopy, pure-tone audiometry, tympanometry, imaging by x-ray (Schuller’s view) or computed tomography as well as caloric vestibular stimulation. Ear microscopy, endoscopy, pure-tone audiometry, and tympanometry were performed in the routine postoperative follow-up visit. In cases of suspicious otoscopic findings and symptoms, clinical examination was completed by diffusionweighted magnetic resonance imaging or temporal bone computed tomography.
Clinical Re-Examination In addition to the retrospective chart review, 99 of the aforementioned patients, who had undergone a cholesteatoma surgery in our department until 2009, were enrolled for evaluation of the long-term follow-up. An evaluation period of 6 months (June 2010 to November 2010) was determined. Patients with a regular postoperative process as well as patients, who were referred to our department by practicing otorhinolaryngologist because of persistent ear symptoms (unsatisfactory hearing function, recurrent otorrhea, and vertigo), were assessed for the long-term outcome. Because of a missing randomization, a selection bias should be considered for this analysis. Within this subpopulation, an equal distribution (one-third) of each surgical technique (ETC, TCM, and CWD) was indented. All patients were examined within a yearly clinical routine follow-up visit, including otoscopy, tympanometry, and pure-tone audiometry. Even though the hearing outcome assessed by pre- and postoperative pure-tone audiometry and calculation of the airbone gap was determined for all patients, these parameters were not considered in this analysis.
Statistical Analysis Statistical analyses were performed using PASW Statistics 18.0 (SPSS Inc., Chicago, IL) and Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA). One-way analysis of variance was used to compare mean values of patients’ demographic data between the three different surgical techniques. Data were shown as mean T standard deviation. Categorical
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variables were expressed as percentages and compared using W2 tests and Fisher exact test for 3 2 contingency tables. A p value less than 0.05 was considered statistically significant.
RESULTS Chart Review Patients’ Demographic Data A total number of 406 cholesteatoma surgeries matched our including criteria. Sex ratio (200 female and 206 male) and side distribution (189 left and 217 right) were nearly balanced. Mean age at surgery was 42.2 T 21.3 years (range 3.1Y89.8 yr) without any significant difference between the three investigated surgical techniques. Total Recidivism Rate of Cholesteatoma Out of 406 patients, ETC was performed in 227 (56%) cases, TCM in 122 (30%) cases, and primary CWD in 57 (14%) cases. Revision surgery was carried out after 33% (133/406) of all cholesteatoma surgeries and residual or recurrent diseases were detected during 47% (63/ 133) of these surgical re-explorations. Consequently, the overall incidence of cholesteatoma recidivism was 16% (63/406). Stratified for the surgical technique in the initial operation, recidivistic cholesteatomas were more frequent after a TCM (25%, 30/122) than after ETC (11%, 24/227) and after CWD (16%, 9/57). In 349 cases with an ICW (equals ETC and TCM), recidivistic cholesteatoma was diagnosed in 15% (54/349) of the total ears (Table 1). Equivalent to these data, a relative risk of 0.98 (95% confidence interval 0.5Y1.9) was calculated for recidivistic cholesteatoma after ICW as compared with CWD. When comparing the TCM group (surgical access to the mastoid with intact canal wall) with the CWD group, the TCM group had a 1.56-fold higher risk of recidivistic disease than the CWD group (95% confidence interval 0.8Y3.0). Forty-four patients (11%, 44/406) underwent a planned second-look operation on an average of 251.4 T 18.3 days (8.2 T 4.1 mo) after initial surgery. Therefore, one-third (33%, 44/133) of all revisions (planned and unplanned) were considered advisable already during primary surgery. Nine out of all 63 recidivistic diseases (14%; 9/63) were detected during the planned second-look operation. They occurred in 21% (5/24) after ETC and in 13% (4/30) after TCM in the first surgery. The remaining 44 patients with recidivistic cholesteatoma (86%, 54/63) were detected by clinical examination, medical imaging (computed tomography and diffusion-weighted magnetic resonance imaging), or an unplanned surgical re-exploration. Localization of Recidivistic Cholesteatoma Within the 63 residual or recurrent cholesteatomas, 41 (65%) were located in the tympanic cavity. Eighty percent (33/41) of these patients had suspicious otoscopic findings in the preoperative examination. Cholesteatoma extended into the mastoid cavity or the pneumatized cells Otology & Neurotology, Vol. 35, No. 10, 2014
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TABLE 1.
Status after cholesteatoma surgery: revisions, recidivism, and recurrent and residual disease depending on type of surgical technique Surgical technique
Revision Total recidivism Residual cholesteatoma Tympanic cavity Mastoid Recurrent cholesteatoma Tympanic cavity Mastoid Second look Recidivism
All patients (n = 406)
ETC (n = 227)
TCM (n = 122)
CWD (n = 57)
33% (133) 16% (63) 4% (16) 2% (8) 2% (8) 12% (47) 8% (33) 3% (14) 11% (44) 20% (9/44)
27% (61) 11% (24) 2% (4) 2% (4) 0% (0) 9% (20) 8% (18) 1% (2) 11% (26) 19% (5/26)
43% (52) 25% (30) 6,5% (8) 2.5% (3) 4% (5) 18% (22) 9% (11) 9% (11) 12% (15) 27% (4/15)
35% (20) 16% (9) 7% (4) 2% (1) 5% (3) 9% (5) 7% (4) 2% (1) 5% (3) 0% (0/3)
Data shown are relative frequencies in percentages out of n, absolute frequency in parentheses; n indicates cumulative number of patients; ETC, exclusively transcanal technique; TCM, transcanal and mastoidal technique; CWD, canal wall down; total recidivism including residual and recurrent cholesteatoma.
in 22 patients (35%) with recidivistic diseases. Therefore, recidivistic disease was identifiable by ear microscopy in 64% (14/22) of these cases. Extension into mastoid cavity or pneumatized cells was more frequent after a TCM (53%) and a CWD (44%) than after ETC (8%). Only one of four residual or recurrent cholesteatomas was detectable by ear microscopy in an obliterated mastoid cavity after CWD. Respectively, 75% (47/63) of patients who had developed a recidivistic cholesteatoma presented otoscopic findings that were indicative for a cholesteatoma preoperatively. In cases with non-pathological findings in the preoperative otoscopy after TCM or CWD, recidivistic cholesteatoma was detected more commonly in the mastoid during revision surgery (Table 2). Non-pathological otoscopic findings were further analyzed as a predictor of residual cholesteatoma. Therefore, patients with an asymptomatic otoscopy were stratified for the appearance of residuals in the second-look operation. Cholesteatoma residuals were equally frequent after TCM and CWD (6.5% and 7%, respectively, Table 1). TABLE 2.
The ETC showed the lowest rate of residuals (2%) in the second look. Recurrent cholesteatoma localized in the tympanic cavity developed with equal frequency, regardless of the surgical technique (Table 1). Patients receiving TCM showed a higher incidence of recurrent cholesteatoma (9%) extending into the mastoid compared with patients after ETC (2%) or within the obliteration of the mastoidal cavity in CWD surgery (1%). Choice of Technique for Revision Surgery in Cases With Recidivistic Cholesteatoma According to the extent of recidivistic cholesteatoma, revision surgery was performed by ETC in 19 (30%), TCM in 18 (29%), and CWD in 26 (41%) cases out of all patients with recidivistic diseases (n = 63). Recidivistic cholesteatoma required conversion to CWD in 5 of 24 (20.8%) patients after an initial ETC and in 14 of 30 (46.6%) patients who underwent a primary TCM (Fig. 2).
Cholesteatoma recidivism: extensions and preoperative otoscopic examination depending on technique in primary surgery Surgical technique: recidivistic cholesteatoma
Localization Tympanic cavity Otoscopy (% of total) Mastoid Otoscopy (% of total) Otoscopy Pathological Localization (% of total) Ordinary Localization (% of total)
All patients (n = 63)
ETC (n = 24)
TCM (n = 30)
CWD (n = 9)
Total recidivism Pathological Regular Total recidivism Pathological Regular
65% (41) 80% (33) 20% (8) 35% (22) 64% (14) 36% (8)
92% (22) 82% (18) 17% (4) 8% (2) 100% (2) 0% (0)
47% (14) 79% (11) 21% (3) 53% (16) 69% (11) 31% (5)
56% (5) 80% (4) 20% (1) 44% (4) 25% (1) 75% (3)
Total recidivism Tympanic cavity Mastoid Total recidivism Tympanic cavity Mastoid
75% (47) 70% (33) 30% (14) 25% (16) 50% (8) 50% (8)
83% (20) 90% (18) 10% (2) 17% (4) 100% (4) 0% (0)
73% (22) 50% (11) 50% (11) 27% (8) 37,5% (3) 62,5% (5)
56% (5) 80% (4) 20% (1) 44% (4) 25% (1) 75% (3)
Data shown are relative frequencies in percentages out of n, absolute frequency in parentheses; n indicates cumulative frequency of recurrent and residual disease; ETC, exclusively transcanal technique; TCM, transcanal and mastoidal technique; CWD, canal wall down technique; total recidivism rates including recurrent and residual cholesteatoma. Otology & Neurotology, Vol. 35, No. 10, 2014
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CHOLESTEATOMA RECIDIVISM
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FIG. 2. Surgical technique in revision cholesteatoma surgery and localization of recidivistic cholesteatoma (data shown are relative frequencies in percentages out of n, absolute frequency in parentheses; n indicates cumulative number of patients; ETC, exclusively transcanal technique, TCM, transcanal and mastoidal technique; CWD, canal wall down).
After revision surgery, the total recidivism rate was 21% (4/19) after ETC, 28% (5/18) after TCM, and 8% (2/26) after CWD. Clinical Re-Examination Patients’ Demographic Data Ninety-nine patients (45 female and 54 male) were followed up by clinical examination. Because 17 patients showed bilateral disease, a total number of 116 ears were analyzed. The mean follow-up period was 1044.3 T 759.7 days (34.8 T 5.3 mo) after the last surgery and the mean age was 53.1 T 17.0 years (range 9.6Y82.7 yr). Both parameters showed no significant difference between the three surgical techniques. The side distribution (62 left and 54 right) was nearly equal. Forty-three (37%) of all surgical procedures were performed by ETC, 42 (36%) by TCM, and 31 (27%) by CWD. A total number of 40 (34%) patients (ETC n = 11, TCM n = 13, CWD n = 16) had undergone revision surgery. Underlying reasons for revision surgery were a recurrent or residual cholesteatoma in 19 (48%) patients, planned second look in 10 (25%) patients (without recidivistic disease in the second look), secretory mastoid cavity in 4 (10%) patients, hearing restoration by second-stage prostheses insertion in 6 (15%) patients, and tympanic membrane perforation in 1 (2%) patient. Patients’ Otoscopic Results At the last follow-up, no further recidivistic cholesteatoma was detected in all 116 ears. In two cases after TCM, a second-look operation was initiated in the clinical follow-up visit and performed to exclude residual disease because of suspect otoscopic findings. Fixed and
controllable retractions of the tympanic membrane were found in 15% (17/116) of the ears (Table 3). The tendency of a higher frequency after TCM was not proven to be statistically significant (p = 0.08). Perforation of tympanic membrane was found in five cases (5%) without any significant difference between the three surgical techniques (p = 0.77). Otoscopic follow-up showed a dry and healthy mastoid cavity in 26 of 31 CWD ears (84%). Persistent secretory of mastoid cavity was found in the remaining five ears (16%), requiring a short time intervention of conservative treatment. DISCUSSION Discussion of Definitions and Terms Data assessment depends on definition and classification of the surgical technique. Previous reviews reported cholesteatoma recidivism after two major surgical procedures: canal wall down (‘‘open’’) and canal wall up TABLE 3. Postoperative otoscopic findings in clinical examination depending on surgical technique Postoperative otoscopic findings Recidivistic cholesteatoma TM retraction TM perforation All patients (n = 116) ETC (n = 43) TCM (n = 42) CWD (n = 31)
0% (0) 0% (0) 0% (0) 0% (0) p 9 0,05
15% (17) 7% (3) 24% (10) 13% (4) p 9 0,05
5% (5) 7% (3) 5% (2) 3% (1) p 9 0,05
Data shown are relative frequencies in percentages out of n, absolute frequency in parentheses; TM indicates tympanic membrane; ETC, exclusively transcanal technique; TCM, transcanal and mastoidal technique; CWD, canal wall down; n, total number of patients. Otology & Neurotology, Vol. 35, No. 10, 2014
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(‘‘intact canal wall’’ or ‘‘closed’’) technique. In practice, the term ‘‘CWD’’ is used synonymously for partially or completely obliterated as well as classical open mastoid cavities. The term ‘‘canal wall up’’ includes ETC, TCM, and secondary reconstruction of the removed posterior canal wall after primary CWD. Additionally, Hildmann preferred an appropriation of partially or completely obliterated mastoid cavities with reconstruction of the posterior canal wall and aerated antrum to the ‘‘closed techniques’’ (1). This classification does not determine the status of the posterior canal wall with the resultant intraoperative visualization and the middle ear conditions postoperatively. Although the intraoperative visualization directly affects the risk for residual cholesteatoma, cholesteatoma recurrence is mainly determined by the stability of the tympanic membrane, lateral attic and posterior wall reconstruction, and the postoperative middle ear conditions. Our classification of ETC, TCM, and CWD with obliteration considers the status of the posterior canal wall intra- and postoperatively. A categorization of ETC and TCM observes the postoperative presence of a visually closed mastoid cavity behind the posterior canal wall (Fig. 1). Cholesteatoma Recidivism: ICW Versus CWD Preoperative randomization was ethically and practically not possible because the choice of the technique depended on numerous factors: the assessment of extent and localization of cholesteatoma, middle ear destruction, coexisting pathological factors during the surgical procedure, and other patient-related aspects. In our department and therefore in the study, the preservation of the posterior canal wall was always preferred. Hence, only 14% of all patients received a primary CWD surgery. As in other clinical studies (11,12), a systematical selection bias resulting from the simultaneous use of three surgical techniques and the retrospective study design must be considered. Differences in cholesteatoma recidivism between CWD and ICW are widely discussed. Depending on cholesteatoma extent, former reviews reported recidivism after CWD ranged from 13 to 20% (5,11,13Y15) in cases of extensive disease and from 7.7 to 10.5% (12,16Y18) including patients with limited cholesteatoma. Reports comparing CWD and ICW showed a higher incidence of cholesteatoma recidivism after ICW compared with CWD (11,13,15Y19). Only Stankovic described higher cholesteatoma recidivism after CWD (20%) than after ICW (12%), but without discriminating between ETC and TCM. In our study, frequency of recidivistic cholesteatoma after ICW (15%, including ETC and TCM) and CWD (16%) was approximately similar. Preserving the posterior canal wall, authors noted recidivism rates ranged from 10 to 70% (11,13,15Y19). In our patients, cholesteatoma recidivism was observed more frequently after TCM (25%) than after a purely transcanal technique (11%). A differentiation of ETC and TCM was not commonly accepted in further reviews. Other authors published recidivism rates from 9 to 70% for patients who underwent TCM (11,13,14,17,19). After ETC with
reconstruction of the lateral attic wall, recidivism rates of 2 to 17% were demonstrated in previous studies (20Y22). A recent meta-analysis demonstrated a significantly increased incidence of cholesteatoma recidivism with a relative risk of 2.87 (95% confidence interval ranged from 2.45 to 3.37) for patients undergoing ICW compared with CWD (23). In our study, ICW and CWD achieved similar results for cholesteatoma recidivism confirmed by the relative risk of 0.98 (95% confidence interval ranged from 0.5 to 1.9) in our data. The lower recidivism rate after ETC must be mainly attributed to the limited disease. In case of complete removal of cholesteatoma under direct vision, surgery was performed exclusively by a transcanal technique. If necessary, the lateral attic wall and/or the posterior canal wall were partially resected and areas poorly visualized by microscopic surgery were endoscopically examined. To prevent large defects of the bony auditory canal and the resulting loss of stability, an additional access through mastoidectomy and posterior tympanotomy (combined approach) was used. Consequently, a low rate of residuals (2%) was obtained. Out of 20 patients with recurrent cholesteatomas in the ETC group, mainly based on deep retraction pockets, the recurrence was restricted to tympanic cavity in 18 of 20 patients. This is also reflected by the low conversion rate to CWD (20.8%) in revision surgery. Residual and Recurrent Cholesteatoma: ICW Versus CWD Inadequate visualization is said to be responsible for the higher rate of recidivistic cholesteatoma after TCM. Therefore, cholesteatoma matrix in the middle ear and especially behind an intact posterior canal wall would tend to remain and to progress unnoticeably during the postoperative period (24,25). According to some authors, who detected recidivistic cholesteatoma after ICW most commonly (45Y78%) in mastoid or epitympanum (15,24), the most common location for recidivistic cholesteatoma was the mastoid cavity (53%) after TCM. Nevertheless, 69% of these recidivistic cholesteatomas showed some pathologic indicators by conventional ear microscopy. To analyze the reason for a higher recidivism rate after TCM, a stratification for recurrent and residual cholesteatoma was indispensable. In our study, residual cholesteatoma occurred equally after TCM (7%) and CWD (7%). In contrast, recurrent cholesteatoma after TCM (18%) were twice as much seen than after CWD (9%) and ETC (9%). Whereas the incidence of recurrent cholesteatoma in the tympanic cavity was nearly equal after all surgical techniques, TCM showed a higher incidence of recurrent cholesteatoma extended into the mastoid of 9%, with ETC 1% and CWD 2%. Consistently, recurrent cholesteatoma (7Y52%) was observed more frequently than residual cholesteatoma (0Y12%) after ICW by other authors (5,11,26). Charachon and Sanna found higher frequencies of residual cholesteatoma (13 to 24%) during consecutive performances of second-look operations (14,27). However, a detailed evaluation of these data is limited as
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CHOLESTEATOMA RECIDIVISM ‘‘ICW’’ was not further defined. These data lead us to conclude that the higher rate of cholesteatoma recidivism after TCM is not only determined by a poorer exposure during surgery. In fact, postoperative middle ear conditions should be considered responsible for recurrent cholesteatoma. An exenterated mastoid cavity behind an intact posterior canal wall was estimated to be a precondition for cholesteatoma recurrence (28Y31). Poor ventilation of mastoid cavity in cases of an impaired function of the auditory tube results in negative pressure in the mastoid cavity leading to retraction pockets growing via the antrum into the mastoid (29,31). The clinical reexamination showed retractions of the tympanic membrane in 24% of our patients who underwent TCM. Additionally, this process is supported by mastoidal fibrous tissue and adhesions between the tympanic membrane and the facial ridge decreasing the mastoid ventilation (28,30). Methods to prevent negative pressure in the mastoid by obliteration (29,31), to reduce the adhesion processes by insertion of bioresorbable membranes (28), and to improve mastoid ventilation by insertion of a retroauricular mastoid ventilation tube (32) were not proven to lower the rate of recurrence significantly. Defects of the lateral canal and the posterior-superior canal wall contribute to the development of recurrent cholesteatoma into the mastoid. We preferred reconstruction of bony defects using cartilage because of its biocompatibility, availability, and the possibility of an uncomplicated re-exploration of the epitympanon during second-look operations. Reconstruction prevents further adhesions between tympanic membrane and the posterior part of tympanic cavity leading to a narrowed tympanum. Nevertheless, in a randomized, blinded study in temporal bones, Hulka found that intact canal wall procedures afford poorer visualization of the sinus tympani, posterior crus of the stapes, and lateral epitympanum, which is consistent with our findings (33). Only the posterior crus of stapes was visualized by simultaneous transcanal technique. A conversion rate to CWD of 46.6% caused likely by a large mastoidal extension confirms the possibility of residual increase behind the posterior canal wall. Exclusive endoscopic surgery and endoscopic-assisted microsurgery were established to provide an improved exposure of structures such as sinus tympani, anterior epitympanum, facial recess, and the auditory tube. Significant reduction of residual disease was not observed in previous trials because of frequently small case numbers and missing long-term results (34Y37). Therefore, second-look operations should be performed to exclude residual cholesteatoma reliably. In our series, only 14% of all recidivistic cholesteatomas were detected during a planned second-look operation. This rate is unsatisfactory referring to other authors showing results of 40% (16) and 67% (12). In good keeping with the literature, these data highlight the importance of a second look in all cases of uncertainty of complete cholesteatoma removal, especially after TCM, and in children cholesteatoma surgery. The higher rates of recidivistic cholesteatoma in children are widely discussed (5,11,14). ETC, because of an efficient otoscopic detection of recidivistic
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cholesteatoma, and CWD, according to the low recidivism rate, do not require second look stringently. CWD offers an excellent exposure to the middle ear (25,33,38,39). However, obliteration of the mastoid cavity constricted an otoscopic detection of recidivistic cholesteatoma. Fortyfour percent (4/9) of recidivistic cholesteatomas were localized in the mastoid. Only one was detectable by ear microscopy. Residual cholesteatoma behind obliteration tissue remains still an unsolved problem in CWD surgery with simultaneous obliteration (17,26). Sequential Cholesteatoma Surgery Versus Retrograde (‘‘Inside Out’’) Cholesteatoma Surgery A detailed description of the preferred surgical strategy is crucial for the evaluation of cholesteatoma recidivism and often a problem when comparing data in the literature. In addition to the sequential strategy performed at our institution, retrograde following of cholesteatoma to its extent with resection and reconstruction of the posterior canal wall is widely practiced and published (3,6Y8,40). Despite resection of the posterior canal wall and an improved intraoperative exposure, the strategy of following cholesteatoma retrograde showed an incidence of recidivism (5Y24%) similar to our analyzed sequential operative strategy (16%) for cholesteatoma eradication. Gehrking observed residuals in 7 to 13% (6) and Hatano in 20% (40) of the analyzed patients. However, frequency of retraction pockets, potentially leading to recurrent cholesteatoma, was rather high in all studies (6Y8). Represented results confirm the importance of postoperative middle ear status contributing to cholesteatoma recidivism as well as the intraoperative exposure. A further increase of cholesteatoma recidivism should be considered possible in the continuing follow-up. Nevertheless, our clinical reexamination did not show any recidivistic cholesteatoma. A long-term follow-up of all patients in a tertiary referral center poses many practical and methodological challenges. Therefore, our concept of involving practicing otorhinolaryngologists in the aftertreatment process provides an effective follow-up care. In the background of the long-lasting discussion on the advantages and disadvantages of TCM and CWD surgery, it is the surgeon’s experience that outweighs the strategy. It is unlikely that a superior strategy alone would lead to better results in the hands of a novice. Therefore, besides numerous factors, the disease itself and the patient’s comorbidity, a well-trained and experienced otosurgeon accounts for the greatest difference in the postoperative outcome. CONCLUSION This study shows that sequential cholesteatoma surgery is a reliable, effective, and successful strategy in cholesteatoma eradication. Intraoperative exposure and postoperative middle ear conditions are factors determining residual and recurrent disease. Cholesteatoma surgery should be adapted to the individual pathology and Otology & Neurotology, Vol. 35, No. 10, 2014
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coexisting factors. An exclusively transcanal technique should be preferred in cases of limited disease because of a low risk for cholesteatoma recidivism. A combined transcanal-mastoidal technique, here showing the highest rate of recidivism, requires consecutive follow-up to exclude recidivistic cholesteatoma. Furthermore, a secondlook operation should be generously indicated. In addition to our findings, in terms of a potentially favorable surgical technique, good results in cholesteatoma surgery are more a question of the surgeon’s training and experience than the strategy itself. A standardized classification and a detailed (preferably consistent) description and terminology of the surgical techniques and strategies are essential factors for comparing results of different studies. REFERENCES 1. Hildmann H, Sudhoff H, Jahnke K. [Basic principles of cholesteatoma surgery]. Laryngorhinootologie 2000;79:73Y94. 2. Tos M, Lau T. Attic cholesteatoma. Recurrence rate related to observation time. Am J Otol 1988;9:456Y64. 3. Roth TN, Haeusler R. Inside-out technique cholesteatoma surgery: a retrospective long-term analysis of 604 operated ears between 1992 and 2006. Otol Neurotol 2009;30:59Y63. 4. Nikolopoulos TP, Gerbesiotis P. Surgical management of cholesteatoma: the two main options and the third wayVatticotomy/limited mastoidectomy. Int J Pediatr Otorhinolaryngol 2009;73:1222Y7. 5. Stankovic M. Follow-up of cholesteatoma surgery: open versus closed tympanoplasty. ORL J Otorhinolaryngol Relat Spec 2007; 69:299Y305. 6. Gehrking E. Osteoplastic atticoantrotomy with autologous bone chips and a bony attic strut in cholesteatoma surgery. Eur Arch Otorhinolaryngol 2010;267:1055Y66. 7. Dornhoffer JL. Retrograde mastoidectomy with canal wall reconstruction: a follow-up report. Otol Neurotol 2004;25:653Y60. 8. Uyar Y, Ozturk K, Keles B, Arbag H, Ulku CH. Anterior atticoantrostomy for cholesteatoma surgery. Ann Otol Rhinol Laryngol 2006;115:150Y5. 9. Jansen C. The combined approach for tympanoplasty (report on 10 years’ experience). J Laryngol Otol 1968;82:779Y93. 10. Mu¨rbe D, Zahnert T, Bornitz M, Hu¨ttenbrink KB. Acoustic properties of different cartilage reconstruction techniques of the tympanic membrane. Laryngoscope 2002;112:1769Y76. 11. Nyrop M, Bonding P. Extensive cholesteatoma: long-term results of three surgical techniques. J Laryngol Otol 1997;111:521Y6. 12. Maassen MM, Plinkert PK, Diedrichs H, Ludtke R, Zenner HP. [Functional long-term results after open cholesteatoma surgery and ossiculoplasty with allogenic ossicles in adulthood]. Laryngorhinootologie 1998;77:74Y81. 13. Brown JS. A ten year statistical follow-up of 1142 consecutive cases of cholesteatoma: the closed vs. the open technique. Laryngoscope 1982;92:390Y6. 14. Charachon R, Gratacap B, Tixier C. Closed versus obliteration technique in cholesteatoma surgery. Am J Otol 1988;9:286Y92. 15. Jahnke K, Khatib M, Rau U. [Long-term results following cholesteatoma surgery]. Laryngol Rhinol Otol (Stuttg) 1985;64:238Y42. 16. Kempf HG, Mockel C, Jahnke K. [Hearing ability after cholesteatoma surgery]. Laryngorhinootologie 1990;69:625Y30. 17. Vartiainen E, Nuutinen J. Long-term results of surgical treatment in different cholesteatoma types. Am J Otol 1993;14:507Y11.
18. Park KT, Song JJ, Moon SJ, Lee JH, Chang SO, Oh SH. Choice of approach for revision surgery in cases with recurring chronic otitis media with cholesteatoma after the canal wall up procedure. Auris Nasus Larynx 2011;38:190Y5. 19. Moss R, Lucente FE. Results in resident cholesteatoma surgery: a review of 85 cases. Laryngoscope 1987;97:212Y4. 20. Donald PJ, Baker SR. Hearing results following atticotomy. Laryngoscope 1979;89(2 Pt 1):195Y203. 21. Duckert LG, Makielski KH, Helms J. Management of anterior epitympanic cholesteatoma: expectations after epitympanic approach and canal wall reconstruction. Otol Neurotol 2002;23:8Y13. 22. East DM. Atticotomy with reconstruction for limited cholesteatoma. Clin Otolaryngol Allied Sci 1998;23:248Y52. 23. Tomlin J, Chang D, McCutcheon B, Harris J. Surgical technique and recurrence in cholesteatoma: a meta-analysis. Audiol Neurootol 2013;18:135Y42. 24. Strauss P. [Surgical treatment of middle ear cholesteatoma. Open versus closed technique (author’s transl)]. Laryngol Rhinol Otol (Stuttg) 1982;61:20Y5. 25. Plester D. Chirurgie des Cholesteatoms. Eur Arch Otorhinolaryngol 1979;223:380Y90. 26. Cody DT, McDonald TJ. Mastoidectomy for acquired cholesteatoma: follow-up to 20 years. Laryngoscope 1984;94:1027Y30. 27. Sanna M, Zini C, Scandellari R, Jemmi G. Residual and recurrent cholesteatoma in closed tympanoplasty. Am J Otol 1984;5:277Y82. 28. Caylan R, Bektas D. Preservation of the mastoid aeration and prevention of mastoid dimpling in chronic otitis media with cholesteatoma surgery using hyaluronate-based bioresorbable membrane (Seprafilm). Eur Arch Otorhinolaryngol 2007;264:377Y80. 29. Meuser W. The exenterated mastoid: a problem of ear surgery. Am J Otol 1985;6:323Y5. 30. Kapur TR. Causes of failure of combined approach tympanoplasty in the treatment of acquired cholesteatomas of the middle ear and the mastoid. J Laryngol Otol 1995;109:710Y2. 31. Minoda R, Hayashida M, Masuda M, Yumoto E. Preliminary experience with beta-tricalcium phosphate for use in mastoid cavity obliteration after mastoidectomy. Otol Neurotol 2007;28:1018Y21. 32. Yung MW, Bowdler D, Swan IR. The Yung percutaneous mastoid vent: results of a multicenter trial. Otol Neurotol 2004;25:885Y90. 33. Hulka GF, McElveen JT Jr. A randomized, blinded study of canal wall up versus canal wall down mastoidectomy determining the differences in viewing middle ear anatomy and pathology. Am J Otol 1998;19:574Y8. 34. Migirov L, Shapira Y, Horowitz Z, Wolf M. Exclusive endoscopic ear surgery for acquired cholesteatoma: preliminary results. Otol Neurotol 2011;32:433Y6. 35. Tarabichi M. Transcanal endoscopic management of cholesteatoma. Otol Neurotol 2010;31:580Y8. 36. Ayache S, Tramier B, Strunski V. Otoendoscopy in cholesteatoma surgery of the middle ear: what benefits can be expected? Otol Neurotol 2008;29:1085Y90. 37. Badr-el-Dine M. Value of ear endoscopy in cholesteatoma surgery. Otol Neurotol 2002;23:631Y5. 38. Beutner D, Stumpf R, Zahnert T, Hu¨ttenbrink KB. [Longterm results following mastoid obliteration in canal wall down tympanomastoidectomy]. Laryngorhinootologie 2007;86:861Y6. 39. Palva T. Surgical treatment of chronic middle ear disease. II. Canal wall up and canal wall down procedures. Acta Otolaryngol 1987; 104:487Y94. 40. Hatano M, Ito M, Yoshizaki T. Retrograde mastoidectomy on demand with soft-wall reconstruction in pediatric cholesteatoma. Acta Otolaryngol 2010;130:1113Y8.
Otology & Neurotology, Vol. 35, No. 10, 2014
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Cholesteatoma Recidivism: Comparison of Three Different Surgical Techniques Marcus Neudert, Susen Lailach, Nikoloz Lasurashvili, Max Kemper, Thomas Beleites, and Thomas Zahnert Department of Otorhinolaryngology, Head and Neck Surgery, Medizinische Fakulta¨t Carl Gustav Carus, Technische Universita¨t Dresden, Dresden, Saxony, Germany
Objective: To compare cholesteatoma recidivism rates after exclusive transcanal technique (ETC), combined transcanal and mastoidal technique (TCM, both subsets of intact canal wall technique, ICW), and canal wall down surgery (CWD). Study Design: Retrospective case review and clinical case study Setting: Tertiary referral center. Patients: 406 cholesteatoma surgeries (2007Y2009), 116 ears in clinical re-examination at least 1 year postoperatively. Intervention: Sequential cholesteatoma surgery with ETC, TCM, or CWD. Main Outcome Measures: Cholesteatoma recidivism, residual and recurrent disease, localization of recidivism, validity of clinical findings. Results: Out of 406 patients, ETC was performed in 227 (56%), TCM in 122 (30%), and CWD in 57 (14%) cases. Recidivism rates after ICW (15%) and CWD (16%) were almost similar. Recidivism was more frequent after ETC (11%) than after TCM (25%). Residuals were observed in 2% after ETC, 6.5% after TCM, and 7% after CWD. Incidence of recurrent disease was
9% for ETC, 18% for TCM, and 9% for CWD. Preferred localization of recidivism was the tympanic cavity after ETC (92%) and CWD (56%) and the mastoid cavity after TCM (53%). The clinical re-examination showed no further recidivistic disease. Conclusions: Sequential surgery is an effective and successful strategy in cholesteatoma eradication, providing a similar recidivism rate compared to following cholesteatoma retrograde and resection of the posterior canal wall. Lower recidivism after ETC was observed as a consequence of limited disease and the postoperative middle ear status determined the higher rate of recurrence after TCM. Therefore, the restricted visualization of the middle ear during ICW surgery does not increase the rate of recidivism, compared with CWD, as described in other studies. Cholesteatoma recidivism is mainly attributed to the surgeon’s experience that outweighs the chosen strategy. Key Words: Canal wall downVCholesteatomaVRecidivismV Recurrent diseaseVSurgical techniqueVTranscanal technique. Otol Neurotol 35:1801Y1808, 2014.
Since the end of the 19th century, several attempts have been made to optimize surgical techniques in cholesteatoma surgery and to lower the rate of cholesteatoma recidivism significantly. Most clinical studies focused on the impact of resection (canal wall down surgery, CWD) or preservation (intact canal wall, ICW) of the posterior canal wall on recidivistic cholesteatoma.
Today, it is widely accepted that cholesteatoma surgery should be individually adapted to extent, localization, pathogenesis, and complications of cholesteatoma (1Y5). Nevertheless, several surgical philosophies result in considerable differences in the various strategies in cholesteatoma management. The cholesteatoma can be followed to its extent in a retrograde way with resection (‘‘inside out’’) and with reconstruction of the lateral attic wall (3,6Y8) or it can be managed step by step with a primary transcanal and mastoidal technique (TCM, also known as combined approach) and posterior tympanotomy (9) if cholesteatoma extension requires mastoidectomy. The TCM offers the benefits of an intact posterior canal wall and an improved visualization by a simultaneous mastoidectomy. Resection of the posterior canal wall is only the final step in eradication of cholesteatoma during a sequential surgery. This study estimates cholesteatoma recidivism in a sequential cholesteatoma surgery. Differences in residual
Address correspondence and reprint requests to Marcus Neudert, M.D., Department of Otorhinolaryngology, Head and Neck Surgery, Medizinische Fakulta¨t Carl Gustav Carus, Technische Universita¨t Dresden, Fetscher Strasse 74, 01307 Dresden, Saxony, Germany; E-mail: [email protected] The work was done in the aforementioned institute. M.N. and S.L. contributed equally to this work and should therefore be considered first authors of this article. This work was presented in part at the 82nd annual meeting of the ‘‘Deutsche Gesellschaft fu¨r HNO-Heilkunde, Kopf- und Hals-Chirurgie,’’ June 5, 2011, Freiburg, Germany The authors disclose no conflicts of interest.
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and recurrent disease after three surgical techniques (exclusive transcanal technique [ETC], TCM, and CWD with obliteration) were evaluated. MATERIALS AND METHODS Surgical Techniques and Surgical Strategy In the Department of Otorhinolaryngology, Head and Neck Surgery Dresden, a sequential cholesteatoma surgery is preferred. Exclusive transcanal technique (ETC): After a most obligatory retroauricular incision, an ETC is primarily used. This includes the spare resection of the lateral attic wall as well as an atticotomy if necessary. Combined transcanal and mastoid (TCM) technique: In cases of extensive pathology, which would lead to a delicate defect of the posterior canal wall, a TCM with an additional access by mastoidectomy (antrotomy and/or posterior tympanotomy) is performed. Canal wall down (CWD) technique: Resection of the posterior auditory canal wall leading to an open mastoid cavity is only used in poorly visible middle ear conditions, revision surgery with extensive recidivistic disease, or an already existing wide erosion of the posterior canal wall. Open mastoid cavities are obliterated with autologous bone pate and sliced concha cartilage plates in the same surgical session. Eradication of cholesteatoma matrix and hearing restoration by an ossiculoplasty are performed in the same surgical stage. The tympanic membrane is usually reconstructed with cartilage slices with a thickness of 250 to 500 Km combined with perichondrium in a ‘‘tuliplike’’ underlay technique (10). Ossiculoplasty was performed using autologous incus interposition or, when involved or destroyed in the cholesteatoma, with titanium partial
or total ossicular replacement prostheses (Kurz Company, Dusslingen, Germany). In cases of uncertainty of complete removal of cholesteatoma matrix, extensive or ‘‘open-type’’ cholesteatoma, a staged second-look operation was considered advisable 6 to 12 months after primary surgery. All operations were performed by experienced otosurgeons. Focusing on the intraoperative visualization, intact canal wall techniques (ICW) were determined by keeping the posterior canal wall intact during surgery. Therefore, ETC and TCM were assigned to ICW. In keeping with this definition, obliterated mastoid cavities were allocated to CWD, although the postoperative status in the clinical examination is consistent with a ‘‘closed technique’’ (Fig. 1).
Residual and Recurrent Cholesteatoma Recidivistic disease was determined by detecting cholesteatoma matrix during a planned second-look operation or an unplanned revision surgery after an initial cholesteatoma operation. In our department, a special consultation hour was established to follow up all patients during the wound healing period. Afterwards, all patients were assessed by practicing otorhinolaryngologists. Patients with regular postoperative progress were examined in a yearly routinely control visit in our department. In cases of suspicious otoscopic findings or symptoms, patients were sent to our outpatient department. Depending on otoscopic and/or endoscopic findings, recidivistic cholesteatomas were detected or excluded by diffusion-weighted magnetic resonance imaging and/or a surgical re-exploration. Recurrent and residual cholesteatoma were discriminated as follows: residuals were associated with postoperative remaining cholesteatoma matrix in the middle ear or mastoid cavity and simultaneous non-pathological otoscopic findings, such as an
FIG. 1. Classification of surgical techniques in cholesteatoma surgery considering the intraoperative exposure (otoscopic findings in clinical re-examination were not taken into consideration, * classification according to Hildmann [1]). Otology & Neurotology, Vol. 35, No. 10, 2014
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CHOLESTEATOMA RECIDIVISM intact closure of the tympanic cavity without retractions or perforations. In contrast, patients with recurrent disease showed clinical findings like poorly visualized retraction pockets, perforations of the tympanic membrane, and/or destructions of the lateral attic or posterior canal wall upon preoperative microscopic examination. Additionally, the total recidivism rate was calculated as the sum of residual and recurrent cholesteatoma and in the following addressed by the term ‘‘cholesteatoma recidivism.’’
Chart Review and Patient Selection Criteria A retrospective chart review of all 430 patients, who had undergone primary or revision cholesteatoma surgery within 2007 and 2009 in our department, was performed. Because 60 patients showed bilateral disease, a total number of 713 middle ear operations were carried out on 490 ears. As revision surgeries for recurrent cholesteatoma were also included when the first operation was performed before 2007, the observed time period ranged from 1994 until November 2010. Surgical approach and technique (ETC, TCM, and CWD), preoperative otoscopic findings, revision or planned secondlook operations, and occurrence and localization of recidivistic disease were categorized. We excluded 78 patients who were initially operated in a different clinic to reduce biasing factors caused by inter-clinical differences in cholesteatoma surgery. Preoperative examination of all patients included ear microscopy and endoscopy, pure-tone audiometry, tympanometry, imaging by x-ray (Schuller’s view) or computed tomography as well as caloric vestibular stimulation. Ear microscopy, endoscopy, pure-tone audiometry, and tympanometry were performed in the routine postoperative follow-up visit. In cases of suspicious otoscopic findings and symptoms, clinical examination was completed by diffusionweighted magnetic resonance imaging or temporal bone computed tomography.
Clinical Re-Examination In addition to the retrospective chart review, 99 of the aforementioned patients, who had undergone a cholesteatoma surgery in our department until 2009, were enrolled for evaluation of the long-term follow-up. An evaluation period of 6 months (June 2010 to November 2010) was determined. Patients with a regular postoperative process as well as patients, who were referred to our department by practicing otorhinolaryngologist because of persistent ear symptoms (unsatisfactory hearing function, recurrent otorrhea, and vertigo), were assessed for the long-term outcome. Because of a missing randomization, a selection bias should be considered for this analysis. Within this subpopulation, an equal distribution (one-third) of each surgical technique (ETC, TCM, and CWD) was indented. All patients were examined within a yearly clinical routine follow-up visit, including otoscopy, tympanometry, and pure-tone audiometry. Even though the hearing outcome assessed by pre- and postoperative pure-tone audiometry and calculation of the airbone gap was determined for all patients, these parameters were not considered in this analysis.
Statistical Analysis Statistical analyses were performed using PASW Statistics 18.0 (SPSS Inc., Chicago, IL) and Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA). One-way analysis of variance was used to compare mean values of patients’ demographic data between the three different surgical techniques. Data were shown as mean T standard deviation. Categorical
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variables were expressed as percentages and compared using W2 tests and Fisher exact test for 3 2 contingency tables. A p value less than 0.05 was considered statistically significant.
RESULTS Chart Review Patients’ Demographic Data A total number of 406 cholesteatoma surgeries matched our including criteria. Sex ratio (200 female and 206 male) and side distribution (189 left and 217 right) were nearly balanced. Mean age at surgery was 42.2 T 21.3 years (range 3.1Y89.8 yr) without any significant difference between the three investigated surgical techniques. Total Recidivism Rate of Cholesteatoma Out of 406 patients, ETC was performed in 227 (56%) cases, TCM in 122 (30%) cases, and primary CWD in 57 (14%) cases. Revision surgery was carried out after 33% (133/406) of all cholesteatoma surgeries and residual or recurrent diseases were detected during 47% (63/ 133) of these surgical re-explorations. Consequently, the overall incidence of cholesteatoma recidivism was 16% (63/406). Stratified for the surgical technique in the initial operation, recidivistic cholesteatomas were more frequent after a TCM (25%, 30/122) than after ETC (11%, 24/227) and after CWD (16%, 9/57). In 349 cases with an ICW (equals ETC and TCM), recidivistic cholesteatoma was diagnosed in 15% (54/349) of the total ears (Table 1). Equivalent to these data, a relative risk of 0.98 (95% confidence interval 0.5Y1.9) was calculated for recidivistic cholesteatoma after ICW as compared with CWD. When comparing the TCM group (surgical access to the mastoid with intact canal wall) with the CWD group, the TCM group had a 1.56-fold higher risk of recidivistic disease than the CWD group (95% confidence interval 0.8Y3.0). Forty-four patients (11%, 44/406) underwent a planned second-look operation on an average of 251.4 T 18.3 days (8.2 T 4.1 mo) after initial surgery. Therefore, one-third (33%, 44/133) of all revisions (planned and unplanned) were considered advisable already during primary surgery. Nine out of all 63 recidivistic diseases (14%; 9/63) were detected during the planned second-look operation. They occurred in 21% (5/24) after ETC and in 13% (4/30) after TCM in the first surgery. The remaining 44 patients with recidivistic cholesteatoma (86%, 54/63) were detected by clinical examination, medical imaging (computed tomography and diffusion-weighted magnetic resonance imaging), or an unplanned surgical re-exploration. Localization of Recidivistic Cholesteatoma Within the 63 residual or recurrent cholesteatomas, 41 (65%) were located in the tympanic cavity. Eighty percent (33/41) of these patients had suspicious otoscopic findings in the preoperative examination. Cholesteatoma extended into the mastoid cavity or the pneumatized cells Otology & Neurotology, Vol. 35, No. 10, 2014
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TABLE 1.
Status after cholesteatoma surgery: revisions, recidivism, and recurrent and residual disease depending on type of surgical technique Surgical technique
Revision Total recidivism Residual cholesteatoma Tympanic cavity Mastoid Recurrent cholesteatoma Tympanic cavity Mastoid Second look Recidivism
All patients (n = 406)
ETC (n = 227)
TCM (n = 122)
CWD (n = 57)
33% (133) 16% (63) 4% (16) 2% (8) 2% (8) 12% (47) 8% (33) 3% (14) 11% (44) 20% (9/44)
27% (61) 11% (24) 2% (4) 2% (4) 0% (0) 9% (20) 8% (18) 1% (2) 11% (26) 19% (5/26)
43% (52) 25% (30) 6,5% (8) 2.5% (3) 4% (5) 18% (22) 9% (11) 9% (11) 12% (15) 27% (4/15)
35% (20) 16% (9) 7% (4) 2% (1) 5% (3) 9% (5) 7% (4) 2% (1) 5% (3) 0% (0/3)
Data shown are relative frequencies in percentages out of n, absolute frequency in parentheses; n indicates cumulative number of patients; ETC, exclusively transcanal technique; TCM, transcanal and mastoidal technique; CWD, canal wall down; total recidivism including residual and recurrent cholesteatoma.
in 22 patients (35%) with recidivistic diseases. Therefore, recidivistic disease was identifiable by ear microscopy in 64% (14/22) of these cases. Extension into mastoid cavity or pneumatized cells was more frequent after a TCM (53%) and a CWD (44%) than after ETC (8%). Only one of four residual or recurrent cholesteatomas was detectable by ear microscopy in an obliterated mastoid cavity after CWD. Respectively, 75% (47/63) of patients who had developed a recidivistic cholesteatoma presented otoscopic findings that were indicative for a cholesteatoma preoperatively. In cases with non-pathological findings in the preoperative otoscopy after TCM or CWD, recidivistic cholesteatoma was detected more commonly in the mastoid during revision surgery (Table 2). Non-pathological otoscopic findings were further analyzed as a predictor of residual cholesteatoma. Therefore, patients with an asymptomatic otoscopy were stratified for the appearance of residuals in the second-look operation. Cholesteatoma residuals were equally frequent after TCM and CWD (6.5% and 7%, respectively, Table 1). TABLE 2.
The ETC showed the lowest rate of residuals (2%) in the second look. Recurrent cholesteatoma localized in the tympanic cavity developed with equal frequency, regardless of the surgical technique (Table 1). Patients receiving TCM showed a higher incidence of recurrent cholesteatoma (9%) extending into the mastoid compared with patients after ETC (2%) or within the obliteration of the mastoidal cavity in CWD surgery (1%). Choice of Technique for Revision Surgery in Cases With Recidivistic Cholesteatoma According to the extent of recidivistic cholesteatoma, revision surgery was performed by ETC in 19 (30%), TCM in 18 (29%), and CWD in 26 (41%) cases out of all patients with recidivistic diseases (n = 63). Recidivistic cholesteatoma required conversion to CWD in 5 of 24 (20.8%) patients after an initial ETC and in 14 of 30 (46.6%) patients who underwent a primary TCM (Fig. 2).
Cholesteatoma recidivism: extensions and preoperative otoscopic examination depending on technique in primary surgery Surgical technique: recidivistic cholesteatoma
Localization Tympanic cavity Otoscopy (% of total) Mastoid Otoscopy (% of total) Otoscopy Pathological Localization (% of total) Ordinary Localization (% of total)
All patients (n = 63)
ETC (n = 24)
TCM (n = 30)
CWD (n = 9)
Total recidivism Pathological Regular Total recidivism Pathological Regular
65% (41) 80% (33) 20% (8) 35% (22) 64% (14) 36% (8)
92% (22) 82% (18) 17% (4) 8% (2) 100% (2) 0% (0)
47% (14) 79% (11) 21% (3) 53% (16) 69% (11) 31% (5)
56% (5) 80% (4) 20% (1) 44% (4) 25% (1) 75% (3)
Total recidivism Tympanic cavity Mastoid Total recidivism Tympanic cavity Mastoid
75% (47) 70% (33) 30% (14) 25% (16) 50% (8) 50% (8)
83% (20) 90% (18) 10% (2) 17% (4) 100% (4) 0% (0)
73% (22) 50% (11) 50% (11) 27% (8) 37,5% (3) 62,5% (5)
56% (5) 80% (4) 20% (1) 44% (4) 25% (1) 75% (3)
Data shown are relative frequencies in percentages out of n, absolute frequency in parentheses; n indicates cumulative frequency of recurrent and residual disease; ETC, exclusively transcanal technique; TCM, transcanal and mastoidal technique; CWD, canal wall down technique; total recidivism rates including recurrent and residual cholesteatoma. Otology & Neurotology, Vol. 35, No. 10, 2014
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FIG. 2. Surgical technique in revision cholesteatoma surgery and localization of recidivistic cholesteatoma (data shown are relative frequencies in percentages out of n, absolute frequency in parentheses; n indicates cumulative number of patients; ETC, exclusively transcanal technique, TCM, transcanal and mastoidal technique; CWD, canal wall down).
After revision surgery, the total recidivism rate was 21% (4/19) after ETC, 28% (5/18) after TCM, and 8% (2/26) after CWD. Clinical Re-Examination Patients’ Demographic Data Ninety-nine patients (45 female and 54 male) were followed up by clinical examination. Because 17 patients showed bilateral disease, a total number of 116 ears were analyzed. The mean follow-up period was 1044.3 T 759.7 days (34.8 T 5.3 mo) after the last surgery and the mean age was 53.1 T 17.0 years (range 9.6Y82.7 yr). Both parameters showed no significant difference between the three surgical techniques. The side distribution (62 left and 54 right) was nearly equal. Forty-three (37%) of all surgical procedures were performed by ETC, 42 (36%) by TCM, and 31 (27%) by CWD. A total number of 40 (34%) patients (ETC n = 11, TCM n = 13, CWD n = 16) had undergone revision surgery. Underlying reasons for revision surgery were a recurrent or residual cholesteatoma in 19 (48%) patients, planned second look in 10 (25%) patients (without recidivistic disease in the second look), secretory mastoid cavity in 4 (10%) patients, hearing restoration by second-stage prostheses insertion in 6 (15%) patients, and tympanic membrane perforation in 1 (2%) patient. Patients’ Otoscopic Results At the last follow-up, no further recidivistic cholesteatoma was detected in all 116 ears. In two cases after TCM, a second-look operation was initiated in the clinical follow-up visit and performed to exclude residual disease because of suspect otoscopic findings. Fixed and
controllable retractions of the tympanic membrane were found in 15% (17/116) of the ears (Table 3). The tendency of a higher frequency after TCM was not proven to be statistically significant (p = 0.08). Perforation of tympanic membrane was found in five cases (5%) without any significant difference between the three surgical techniques (p = 0.77). Otoscopic follow-up showed a dry and healthy mastoid cavity in 26 of 31 CWD ears (84%). Persistent secretory of mastoid cavity was found in the remaining five ears (16%), requiring a short time intervention of conservative treatment. DISCUSSION Discussion of Definitions and Terms Data assessment depends on definition and classification of the surgical technique. Previous reviews reported cholesteatoma recidivism after two major surgical procedures: canal wall down (‘‘open’’) and canal wall up TABLE 3. Postoperative otoscopic findings in clinical examination depending on surgical technique Postoperative otoscopic findings Recidivistic cholesteatoma TM retraction TM perforation All patients (n = 116) ETC (n = 43) TCM (n = 42) CWD (n = 31)
0% (0) 0% (0) 0% (0) 0% (0) p 9 0,05
15% (17) 7% (3) 24% (10) 13% (4) p 9 0,05
5% (5) 7% (3) 5% (2) 3% (1) p 9 0,05
Data shown are relative frequencies in percentages out of n, absolute frequency in parentheses; TM indicates tympanic membrane; ETC, exclusively transcanal technique; TCM, transcanal and mastoidal technique; CWD, canal wall down; n, total number of patients. Otology & Neurotology, Vol. 35, No. 10, 2014
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(‘‘intact canal wall’’ or ‘‘closed’’) technique. In practice, the term ‘‘CWD’’ is used synonymously for partially or completely obliterated as well as classical open mastoid cavities. The term ‘‘canal wall up’’ includes ETC, TCM, and secondary reconstruction of the removed posterior canal wall after primary CWD. Additionally, Hildmann preferred an appropriation of partially or completely obliterated mastoid cavities with reconstruction of the posterior canal wall and aerated antrum to the ‘‘closed techniques’’ (1). This classification does not determine the status of the posterior canal wall with the resultant intraoperative visualization and the middle ear conditions postoperatively. Although the intraoperative visualization directly affects the risk for residual cholesteatoma, cholesteatoma recurrence is mainly determined by the stability of the tympanic membrane, lateral attic and posterior wall reconstruction, and the postoperative middle ear conditions. Our classification of ETC, TCM, and CWD with obliteration considers the status of the posterior canal wall intra- and postoperatively. A categorization of ETC and TCM observes the postoperative presence of a visually closed mastoid cavity behind the posterior canal wall (Fig. 1). Cholesteatoma Recidivism: ICW Versus CWD Preoperative randomization was ethically and practically not possible because the choice of the technique depended on numerous factors: the assessment of extent and localization of cholesteatoma, middle ear destruction, coexisting pathological factors during the surgical procedure, and other patient-related aspects. In our department and therefore in the study, the preservation of the posterior canal wall was always preferred. Hence, only 14% of all patients received a primary CWD surgery. As in other clinical studies (11,12), a systematical selection bias resulting from the simultaneous use of three surgical techniques and the retrospective study design must be considered. Differences in cholesteatoma recidivism between CWD and ICW are widely discussed. Depending on cholesteatoma extent, former reviews reported recidivism after CWD ranged from 13 to 20% (5,11,13Y15) in cases of extensive disease and from 7.7 to 10.5% (12,16Y18) including patients with limited cholesteatoma. Reports comparing CWD and ICW showed a higher incidence of cholesteatoma recidivism after ICW compared with CWD (11,13,15Y19). Only Stankovic described higher cholesteatoma recidivism after CWD (20%) than after ICW (12%), but without discriminating between ETC and TCM. In our study, frequency of recidivistic cholesteatoma after ICW (15%, including ETC and TCM) and CWD (16%) was approximately similar. Preserving the posterior canal wall, authors noted recidivism rates ranged from 10 to 70% (11,13,15Y19). In our patients, cholesteatoma recidivism was observed more frequently after TCM (25%) than after a purely transcanal technique (11%). A differentiation of ETC and TCM was not commonly accepted in further reviews. Other authors published recidivism rates from 9 to 70% for patients who underwent TCM (11,13,14,17,19). After ETC with
reconstruction of the lateral attic wall, recidivism rates of 2 to 17% were demonstrated in previous studies (20Y22). A recent meta-analysis demonstrated a significantly increased incidence of cholesteatoma recidivism with a relative risk of 2.87 (95% confidence interval ranged from 2.45 to 3.37) for patients undergoing ICW compared with CWD (23). In our study, ICW and CWD achieved similar results for cholesteatoma recidivism confirmed by the relative risk of 0.98 (95% confidence interval ranged from 0.5 to 1.9) in our data. The lower recidivism rate after ETC must be mainly attributed to the limited disease. In case of complete removal of cholesteatoma under direct vision, surgery was performed exclusively by a transcanal technique. If necessary, the lateral attic wall and/or the posterior canal wall were partially resected and areas poorly visualized by microscopic surgery were endoscopically examined. To prevent large defects of the bony auditory canal and the resulting loss of stability, an additional access through mastoidectomy and posterior tympanotomy (combined approach) was used. Consequently, a low rate of residuals (2%) was obtained. Out of 20 patients with recurrent cholesteatomas in the ETC group, mainly based on deep retraction pockets, the recurrence was restricted to tympanic cavity in 18 of 20 patients. This is also reflected by the low conversion rate to CWD (20.8%) in revision surgery. Residual and Recurrent Cholesteatoma: ICW Versus CWD Inadequate visualization is said to be responsible for the higher rate of recidivistic cholesteatoma after TCM. Therefore, cholesteatoma matrix in the middle ear and especially behind an intact posterior canal wall would tend to remain and to progress unnoticeably during the postoperative period (24,25). According to some authors, who detected recidivistic cholesteatoma after ICW most commonly (45Y78%) in mastoid or epitympanum (15,24), the most common location for recidivistic cholesteatoma was the mastoid cavity (53%) after TCM. Nevertheless, 69% of these recidivistic cholesteatomas showed some pathologic indicators by conventional ear microscopy. To analyze the reason for a higher recidivism rate after TCM, a stratification for recurrent and residual cholesteatoma was indispensable. In our study, residual cholesteatoma occurred equally after TCM (7%) and CWD (7%). In contrast, recurrent cholesteatoma after TCM (18%) were twice as much seen than after CWD (9%) and ETC (9%). Whereas the incidence of recurrent cholesteatoma in the tympanic cavity was nearly equal after all surgical techniques, TCM showed a higher incidence of recurrent cholesteatoma extended into the mastoid of 9%, with ETC 1% and CWD 2%. Consistently, recurrent cholesteatoma (7Y52%) was observed more frequently than residual cholesteatoma (0Y12%) after ICW by other authors (5,11,26). Charachon and Sanna found higher frequencies of residual cholesteatoma (13 to 24%) during consecutive performances of second-look operations (14,27). However, a detailed evaluation of these data is limited as
Otology & Neurotology, Vol. 35, No. 10, 2014
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CHOLESTEATOMA RECIDIVISM ‘‘ICW’’ was not further defined. These data lead us to conclude that the higher rate of cholesteatoma recidivism after TCM is not only determined by a poorer exposure during surgery. In fact, postoperative middle ear conditions should be considered responsible for recurrent cholesteatoma. An exenterated mastoid cavity behind an intact posterior canal wall was estimated to be a precondition for cholesteatoma recurrence (28Y31). Poor ventilation of mastoid cavity in cases of an impaired function of the auditory tube results in negative pressure in the mastoid cavity leading to retraction pockets growing via the antrum into the mastoid (29,31). The clinical reexamination showed retractions of the tympanic membrane in 24% of our patients who underwent TCM. Additionally, this process is supported by mastoidal fibrous tissue and adhesions between the tympanic membrane and the facial ridge decreasing the mastoid ventilation (28,30). Methods to prevent negative pressure in the mastoid by obliteration (29,31), to reduce the adhesion processes by insertion of bioresorbable membranes (28), and to improve mastoid ventilation by insertion of a retroauricular mastoid ventilation tube (32) were not proven to lower the rate of recurrence significantly. Defects of the lateral canal and the posterior-superior canal wall contribute to the development of recurrent cholesteatoma into the mastoid. We preferred reconstruction of bony defects using cartilage because of its biocompatibility, availability, and the possibility of an uncomplicated re-exploration of the epitympanon during second-look operations. Reconstruction prevents further adhesions between tympanic membrane and the posterior part of tympanic cavity leading to a narrowed tympanum. Nevertheless, in a randomized, blinded study in temporal bones, Hulka found that intact canal wall procedures afford poorer visualization of the sinus tympani, posterior crus of the stapes, and lateral epitympanum, which is consistent with our findings (33). Only the posterior crus of stapes was visualized by simultaneous transcanal technique. A conversion rate to CWD of 46.6% caused likely by a large mastoidal extension confirms the possibility of residual increase behind the posterior canal wall. Exclusive endoscopic surgery and endoscopic-assisted microsurgery were established to provide an improved exposure of structures such as sinus tympani, anterior epitympanum, facial recess, and the auditory tube. Significant reduction of residual disease was not observed in previous trials because of frequently small case numbers and missing long-term results (34Y37). Therefore, second-look operations should be performed to exclude residual cholesteatoma reliably. In our series, only 14% of all recidivistic cholesteatomas were detected during a planned second-look operation. This rate is unsatisfactory referring to other authors showing results of 40% (16) and 67% (12). In good keeping with the literature, these data highlight the importance of a second look in all cases of uncertainty of complete cholesteatoma removal, especially after TCM, and in children cholesteatoma surgery. The higher rates of recidivistic cholesteatoma in children are widely discussed (5,11,14). ETC, because of an efficient otoscopic detection of recidivistic
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cholesteatoma, and CWD, according to the low recidivism rate, do not require second look stringently. CWD offers an excellent exposure to the middle ear (25,33,38,39). However, obliteration of the mastoid cavity constricted an otoscopic detection of recidivistic cholesteatoma. Fortyfour percent (4/9) of recidivistic cholesteatomas were localized in the mastoid. Only one was detectable by ear microscopy. Residual cholesteatoma behind obliteration tissue remains still an unsolved problem in CWD surgery with simultaneous obliteration (17,26). Sequential Cholesteatoma Surgery Versus Retrograde (‘‘Inside Out’’) Cholesteatoma Surgery A detailed description of the preferred surgical strategy is crucial for the evaluation of cholesteatoma recidivism and often a problem when comparing data in the literature. In addition to the sequential strategy performed at our institution, retrograde following of cholesteatoma to its extent with resection and reconstruction of the posterior canal wall is widely practiced and published (3,6Y8,40). Despite resection of the posterior canal wall and an improved intraoperative exposure, the strategy of following cholesteatoma retrograde showed an incidence of recidivism (5Y24%) similar to our analyzed sequential operative strategy (16%) for cholesteatoma eradication. Gehrking observed residuals in 7 to 13% (6) and Hatano in 20% (40) of the analyzed patients. However, frequency of retraction pockets, potentially leading to recurrent cholesteatoma, was rather high in all studies (6Y8). Represented results confirm the importance of postoperative middle ear status contributing to cholesteatoma recidivism as well as the intraoperative exposure. A further increase of cholesteatoma recidivism should be considered possible in the continuing follow-up. Nevertheless, our clinical reexamination did not show any recidivistic cholesteatoma. A long-term follow-up of all patients in a tertiary referral center poses many practical and methodological challenges. Therefore, our concept of involving practicing otorhinolaryngologists in the aftertreatment process provides an effective follow-up care. In the background of the long-lasting discussion on the advantages and disadvantages of TCM and CWD surgery, it is the surgeon’s experience that outweighs the strategy. It is unlikely that a superior strategy alone would lead to better results in the hands of a novice. Therefore, besides numerous factors, the disease itself and the patient’s comorbidity, a well-trained and experienced otosurgeon accounts for the greatest difference in the postoperative outcome. CONCLUSION This study shows that sequential cholesteatoma surgery is a reliable, effective, and successful strategy in cholesteatoma eradication. Intraoperative exposure and postoperative middle ear conditions are factors determining residual and recurrent disease. Cholesteatoma surgery should be adapted to the individual pathology and Otology & Neurotology, Vol. 35, No. 10, 2014
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coexisting factors. An exclusively transcanal technique should be preferred in cases of limited disease because of a low risk for cholesteatoma recidivism. A combined transcanal-mastoidal technique, here showing the highest rate of recidivism, requires consecutive follow-up to exclude recidivistic cholesteatoma. Furthermore, a secondlook operation should be generously indicated. In addition to our findings, in terms of a potentially favorable surgical technique, good results in cholesteatoma surgery are more a question of the surgeon’s training and experience than the strategy itself. A standardized classification and a detailed (preferably consistent) description and terminology of the surgical techniques and strategies are essential factors for comparing results of different studies. REFERENCES 1. Hildmann H, Sudhoff H, Jahnke K. [Basic principles of cholesteatoma surgery]. Laryngorhinootologie 2000;79:73Y94. 2. Tos M, Lau T. Attic cholesteatoma. Recurrence rate related to observation time. Am J Otol 1988;9:456Y64. 3. Roth TN, Haeusler R. Inside-out technique cholesteatoma surgery: a retrospective long-term analysis of 604 operated ears between 1992 and 2006. Otol Neurotol 2009;30:59Y63. 4. Nikolopoulos TP, Gerbesiotis P. Surgical management of cholesteatoma: the two main options and the third wayVatticotomy/limited mastoidectomy. Int J Pediatr Otorhinolaryngol 2009;73:1222Y7. 5. Stankovic M. Follow-up of cholesteatoma surgery: open versus closed tympanoplasty. ORL J Otorhinolaryngol Relat Spec 2007; 69:299Y305. 6. Gehrking E. Osteoplastic atticoantrotomy with autologous bone chips and a bony attic strut in cholesteatoma surgery. Eur Arch Otorhinolaryngol 2010;267:1055Y66. 7. Dornhoffer JL. Retrograde mastoidectomy with canal wall reconstruction: a follow-up report. Otol Neurotol 2004;25:653Y60. 8. Uyar Y, Ozturk K, Keles B, Arbag H, Ulku CH. Anterior atticoantrostomy for cholesteatoma surgery. Ann Otol Rhinol Laryngol 2006;115:150Y5. 9. Jansen C. The combined approach for tympanoplasty (report on 10 years’ experience). J Laryngol Otol 1968;82:779Y93. 10. Mu¨rbe D, Zahnert T, Bornitz M, Hu¨ttenbrink KB. Acoustic properties of different cartilage reconstruction techniques of the tympanic membrane. Laryngoscope 2002;112:1769Y76. 11. Nyrop M, Bonding P. Extensive cholesteatoma: long-term results of three surgical techniques. J Laryngol Otol 1997;111:521Y6. 12. Maassen MM, Plinkert PK, Diedrichs H, Ludtke R, Zenner HP. [Functional long-term results after open cholesteatoma surgery and ossiculoplasty with allogenic ossicles in adulthood]. Laryngorhinootologie 1998;77:74Y81. 13. Brown JS. A ten year statistical follow-up of 1142 consecutive cases of cholesteatoma: the closed vs. the open technique. Laryngoscope 1982;92:390Y6. 14. Charachon R, Gratacap B, Tixier C. Closed versus obliteration technique in cholesteatoma surgery. Am J Otol 1988;9:286Y92. 15. Jahnke K, Khatib M, Rau U. [Long-term results following cholesteatoma surgery]. Laryngol Rhinol Otol (Stuttg) 1985;64:238Y42. 16. Kempf HG, Mockel C, Jahnke K. [Hearing ability after cholesteatoma surgery]. Laryngorhinootologie 1990;69:625Y30. 17. Vartiainen E, Nuutinen J. Long-term results of surgical treatment in different cholesteatoma types. Am J Otol 1993;14:507Y11.
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