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Incidence and Localization in Canal Wall Down Tympanoplasty With Soft-Wall Reconstruction
Shin-Ichi Haginomori, MD; Atsuko Takamaki, MD; Ryuzaburo Nonaka, MD; Hiroshi Takenaka, MD
Objective: To compare the incidence and localization of residual cholesteatomas in canal wall down tympanoplasty with soft-wall reconstruction with results with the canal wall down and open tympanoplasty or canal wall up tympanoplasty. Design: Retrospective case-series study. Setting: Tertiary care university hospital. Patients: Eighty-five patients (85 ears) with fresh extensive cholesteatomas who underwent canal wall down tympanoplasty with soft-wall reconstruction as first-stage surgery and a second operation after 1 year to confirm residual cholesteatomas and perform ossiculoplasty. Main Outcome Measures: The incidence and localization of residual cholesteatomas in the middle ear were compared between surgery using the canal wall down and open tympanoplasty and canal wall up tympanoplasty. Possible technical causes of the residua were reviewed in a retrospective videotape analysis of the first-stage operations. Results: Of the 85 ears operated on, 18 had residual cho-
facial canal (6%), and 1 just under the skin of the external auditory canal (6%). The retrospective videotape analysis revealed that the main cause of residual cholesteatomas in the epitympanum and sinus tympani was incomplete removal of the matrix under an indirect surgical view because of insufficient drilling. Residual matrix in a bony defect in the middle cranial fossa or facial canal was the cause of residual cholesteatomas in the antrum or facial canal. Inappropriate keratinizing epithelium rolling during tympanic membrane or external auditory canal reconstruction was the cause of residual cholesteatomas in the tympanic membrane or external auditory canal.
Conclusions: The incidence of residual cholesteatomas in patients who underwent canal wall down tympanoplasty with soft-wall reconstruction was similar to that in patients who underwent surgery involving the canal wall down and open tympanoplasty or canal wall up tympanoplasty. In terms of localization, with canal wall down tympanoplasty with soft-wall reconstruction, there is the possibility of residua not only in the tympanic cavity but also in the antrum or mastoid cavity, as with the canal wall up method. Results of this study suggest that in patients with extensive cholesteatoma, canal wall down tympanoplasty with soft-wall reconstruction should be followed by a second procedure to detect any residual cholesteatomas in the tympanic cavity, antrum, or mastoid cavity.
lesteatomas, for an overall incidence of 21%, with 1 residuum per ear. Six cholesteatomas were located in the epitympanum (33%), 3 in the sinus tympani (17%), 3 in the antrum (17%), 2 on the stapes (11%), 2 on the tympanic membrane (11%), 1 on the tympanic portion of the
Arch Otolaryngol Head Neck Surg. 2008;134(6):652-657 tilation of the middle ear. A residual cholesteatoma develops from matrix that was not removed at tympanoplasty and depends on the surgical maneuvers performed by the otologist.1,2 Residual matrix is frequently observed at the sinus tympani, oval window, middle cranial fossa, and bone dehiscence of the facial canal. Surgeons always attempt to decrease the incidence of residual cholesteatomas, for example, by using a small mirror or endoscope to observe the middle ear. The 2 primary procedures used to treat cholesteatoma are the canal wall down (CWD; open-cavity) and the canal wall up
Author Affiliations: Department of Otolaryngology, Osaka Medical College, Osaka, Japan.
HE GOALS OF CHOLESTEAtoma surgery are to prevent residual or recurrent cholesteatomas and to restore hearing. A recurrent
CME available online at www.jamaarchivescme.com and questions on page 579
cholesteatoma arises from a new postoperative retraction pocket with a crust1,2 that requires frequent cleaning or cannot be cleaned sufficiently because of poor ven-
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO. 6), JUNE 2008 652
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6 Smith et al7 first reported CWD tympanoplasty with soft-wall reconstruction in 1986.). 3 (2 of the pars flaccida type and 1 congenital) were in the antrum (17%). In this method. All rights reserved.9 We examined the incidence and localization of residual cholesteatomas in planned revision tympanoplasty in patients in whom cholesteatomas had been removed at previous CWD tympanoplasty with soft-wall reconstruction and compared them with the reported incidence in the CWU and CWD and open tympanoplasties. the 2 surgeons (S-I. as described by Smith et al.4 EAC bone. hypotympanum. The most reasonable procedure for overcoming the disadvantages of CWD and open tympanoplasty or CWU tympanoplasty is CWD tympanoplasty with reconstruction of the posterior wall of the EAC. 1 of the pars tensa type was on the tympanic portion of the facial canal (6%).T. No residual cholesteatomas were observed in the mastoid cavity. After removing the polymeric silicone sheet. All patients underwent tympanoplasty twice. Ikegami Tsushinki Co. 5-81 years]).10 However. 6 had residual cholesteatomas (25%). all patients underwent revision tympanoplasty with ossiculoplasty. . performed by 2 of us (S. This “cavity problem” in the open cavity is caused by bacterial or fungal infection and disturbed external auditory canal (EAC) skin migration. and tympanic cavity. In this second-stage operation. as much of the posterior EAC wall skin as possible is preserved.) reviewed the videotapes of the firststage tympanoplasty of the patients with residua using a monitor screen (TM2150M. RESULTS Of 85 ears operated on in 85 patients (50 male and 35 female. Although another 6 of the 85 ears (7%) had a deep. Ltd.3. which enables quick postoperative wound healing but involves a restricted surgical view and a higher rate of cholesteatoma recurrence compared with CWD tympanoplasty. 47 years [age range. 2010 ©2008 American Medical Association. we reviewed videotapes of the first operations in the patients with residua to determine which surgical maneuvers might have caused the residual cholesteatomas. the defects in the TM and EAC skin were lined with a piece of deep temporal fascia.ARCHOTO. A 0. 18 had residual cholesteatomas (10 of the pars flaccida type. including the antrum.-I. 34 were of the pars tensa type. Tokyo. for residual cholesteatoma. 2005. There was 1 residuum per ear. wide retraction pocket without a crust in the attic and did not WWW. Ikegami Tsushinki Co.5 or bone paste.7-9 This method differs from the conventional CWD tympanoplasty and open procedure. All 85 patients had fresh cholesteatomas and no history of ipsilateral ear surgery.9. and use of this method has spread as a modified tympanoplasty. In the first-stage operation. METHODS Between January 1. Our ultimate goals were to determine the technical pitfalls of this surgery and to make the best use of our experience to decrease the incidence of residual cholesteatomas after CWD tympanoplasty with softwall reconstruction. and 1 congenital). 6). 46 cholesteatomas were of the pars flaccida type. and early postoperative wound healing.H. Conversely. the incidence and localization of residual cholesteatomas with this procedure have not been well described. The surgery was recorded throughout on minidigital videotape using a 3-CCD video camera (MKC305. 3 of the pars tensa type were in the sinus tympani (17%). The recorded videotapes were stored in the video library in our department.COM (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO.9 During surgery. Six cholesteatomas (5 of the pars flaccida type and 1 of the pars tensa type) were in the epitympanum (33%). the CWU procedure maintains the shape of the EAC with normal skin migration. and A. an incompletely cleaned cavity leads to wet granulation tissue covered by debris and otorrhea. including cartilage. Midland. the cholesteatoma was removed using the CWD procedure and reconstruction with soft tissues (soft-wall reconstruction) such as free deep temporal fascia. Michigan) sheet was placed between the tympanic cavity and the antrum or mastoid cavity. Corning Dow Corporation. protympanum.archoto. the posterior half of the bony EAC wall was drilled down and as much as possible of the intact TM and EAC wall skin was preserved. the tympanic cavity was approached through the mastoid cavity with the soft wall of the EAC and the TM was lifted. the recovery of tympanomastoid aeration when the middle ear mucosa is preserved during surgery. The posterior EAC wall was not reinforced or reconstructed using hard tissue or material (eg. and after the cholesteatoma is removed. Japan) attached to a surgical microscope and a digital videocassette recorder (WVDR9.7 Hosoi and Murata. and December 31. and is thought to result in a low rate of recurrence of cholesteatoma. cortical bone or EAC bone) in any ears. The CWD procedure provides sufficient approach to the facial recess and tympanic sinus. In addition. mean age. Tokyo). which opens the mastoid cavity to the EAC. and 5 were congenital.7-10 Several advantages of this method have been documented. After the cholesteatoma was removed. One year later.N. Several materials for reconstruction have been reported. insofar as postoperative separation of the mastoid cavity from the EAC. its location in the middle ear was recorded and the incidence of residual cholesteatomas after CWD tympanoplasty with soft-wall reconstruction was calculated. JUNE 2008 653 Downloaded from www. 2 (1 of the pars flaccida type and 1 of the pars tensa type) were in the TM (11%). and there was no correlation between the residual cholesteatoma and posterior EAC retraction. However. In terms of postoperative EAC retraction. the defect in the tympanic membrane (TM) and posterior EAC wall is reconstructed using free soft tissue such as the deep temporal fascia. with an adequate surgical view.H. Ltd) and analyzed the maneuvers performed in the first surgery that might have caused the residual cholesteatomas. mastoid cavity. including the little additional time required during surgery. and R. or tympanic orifice of the eustachian tube (Figure 1).8 and Takahashi et al. When a residual cholesteatoma was found. and 1 of the pars flaccida type was just under the skin of the EAC (6%). Of these 24 ears. 2 (1 of the pars flaccida type and 1 of the pars tensa type) were on the stapes (11%). 2000. 7 of the pars tensa type. 85 patients (85 ears) in our hospital underwent planned 2-stage CWD tympanoplasty with soft-wall reconstruction because of extensive cholesteatomas in which there was suspicion of residua after the first-stage operation.com on August 18.5-mm-thick polymeric silicone (Silastic. In addition. The incus and head of the malleus were removed. for an overall incidence of 21%. closed-cavity) procedures. we meticulously checked the entire middle ear. As evaluated at microscopy and computed tomography. 24 of 85 ears operated on (28%) had posterior EAC wall retraction at the second-stage operation.(CWU. Sony Corp.
F. no recurrent cholesteatomas were observed in 85 ears at the second-stage operation.ARCHOTO. external auditory canal. A indicates antrum.15 As a result. stapes. Sheehy et al1 and Sheehy and Robinson2 also performed CWU tympanoplasty and reported that the middle ear. All rights reserved.6% in the aditus or mastoid cavity.13 In other articles that included both CWU and CWD tympanoplasties. the residual cholesteatomas observed in the epitympanum were thought to be caused by an insufficient surgical view resulting from incomplete opening of the attic. We used the CWD procedure with soft-wall reconstruction rather than using the bony EAC wall. where not much attention is paid to residua in ears operated on using the CWD and open tympanoplasty. epitympanum.5% in the mesotympanum. S. a planned 2-stage tympanoplasty should be considered in patients with extensive cholesteatomas removed at CWD with soft-wall reconstruction to ensure ears that are absolutely free of cholesteatomas after the second-stage tympanoplasty. as follows: 47. Syms and Luxford13 reported similar incidence.2. Therefore.11 although others hold the opposite opinion.archoto. residual cholesteatomas are found not only in locations in which residua are expected but also where they are unexpected. the problem still remains in the mesotympanum. epitympanum. However. the necessity of secondstage tympanoplasty is a relative disadvantage of CWD tympanoplasty with soft-wall reconstruction compared with the CWD and open tympanoplasty insofar as operating time and medical economy. 6). or residual matrix on a bony defect of the middle cranial fossa. JUNE 2008 654 Downloaded from www.12 and slightly higher than the 14. Some of our patients had bony defects in the middle cranial fossa. our experience supports the opinion that CWD has no advantages over CWU insofar as reducing the possibility of residual cholesteatomas.E:6 A:3 F:1 S:2 TM:2 ST:3 EAC:1 Figure 1. such as the antrum and epitympanum. A residual cholesteatoma on the facial canal was thought to arise from insufficient removal of the matrix from the bony dehiscence of the facial canal.12 Hence.1 Sheehy and Robinson. On the basis of findings at retrospective videotape analysis.12. However. Sanna et al12 performed CWU tympanoplasty at the first-stage operation and reported the incidence of residua by location. Sanna et al12 reported a similar opinion.15 the incidence of residua ranged from 26% to 31%. which is similar to that reported by Sanna et al. and mastoid cavity. It is still unclear whether CWU or CWD is better for decreasing the incidence of residua. Sheehy et al1 and Sheehy and Robinson2 recommended planned 2-stage tympanoplasty in patients with cholesteatomas who underwent CWU tympanoplasty. . grade of cholesteatoma expansion. similar to results with the CWU procedure. slightly higher than reported herein.COM (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO. which is one of the causes of residual cholesteatomas. CWD tympanoplasty does not demonstrate great advantage over CWU tympanoplasty insofar as the incidence of residual cholesteatoma. incomplete cleaning around the head and neck of the malleus. ST. and individual surgeon skills.16 To prevent residual cholesteatomas and to improve hearing. tympanic membrane. The residual cholesteatomas in the antrum resulted from residual matrix on the bony defect of the middle cranial fossa (Figure 3) and incomplete opening of the cells of the antrum. contained residual cholesteatomas more frequently than did the epitympanum or mastoid cavity. which is a great advantage of CWD and open tympanoplasty. The cause of the residual cholesteatomas observed in the sinus tympani was insufficient removal of the matrix under indirect surgical view attributable to insufficient drilling into the facial ridge (Figure 2).12 because the sinus tympani in the mesotympanum is hidden from surgical view under the microscope even if the CWD is performed. and 11.12 The difference between the results of Sheehy et al. The differences among these rates might arise from variations in the surgical procedures.2 and the present study could be attributed to the grade of cholesteatoma expansion to the middle cranial fossa.7-10 Although we performed CWD before posterior wall reconstruction. the CWD and open tympanoplasty prevents residual cholesteatomas in the antrum. We found that the incidence of residua in the mesotympanum was the same as that in other regions involving the antrum and epitympanum. On the basis of our experience with second-stage tympanoplasty performed 1 year after the first-stage CWD tympanoplasty with soft-wall reconstruction. EAC.15 In theory. require cleaning.6% incidence with the CWD and open tympanoplasty. and TM. E. facial canal.11. which includes the mesotympanum and protympanum. Most otologists think that CWD tympanoplasty is more effective.2. The cholesteatomas remaining on the stapes resulted from incomplete removal of the matrix owing to maneuvers performed under indirect surgical view. 41% in the epitympanum.14. Location and number of residual cholesteatomas observed in 18 ears at second-stage tympanoplasty.com on August 18. The residual cholesteatomas observed in the TM and EAC resulted from unsuitable keratinizing epithelium rolling during TM and EAC skin reconstruction (Figure 4). the incidence of residua was similar to that with CWU. and revision surgery is not necessary in most cases. 2010 ©2008 American Medical Association. sinus tympani. where the probability of residual cholesteatomas is high1. This is similar to the 20% to 25% incidence with CWU tympanoplasty2. CWD tympanoplasty with soft-wall reconstruction did WWW. According to these results.2. COMMENT The incidence of residua found at planned second-stage operations was 21%.
2.ARCHOTO.archoto.COM (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO. CWU tympanoplasty. the incidence of recurrent cholesteatoma has decreased to 0% to 5%.15 was thought to have a high associated incidence of recurrent cholesteatoma. In our study of 85 ears treated using CWD tympanoplasty with soft-wall reconstruction. A. JUNE 2008 655 Downloaded from www.17 Before 1970. Retrospective videotape analysis of the first-stage surgery. Retrospective videotape analysis of the first-stage tympanoplasty indicated that the matrix of the cholesteatoma (M) remained at the bony defect of the middle cranial fossa (asterisk).18 which has the potential for development of a recurrent cholesteatoma. A.8 similar to results with the CWD and open procedures.16 The results of our retrospective videotape analyWWW. Right ear. not reduce the incidence of residua compared with CWU tympanoplasty. The tip of the duckbill elevator (E) was hidden behind the facial ridge (F ). it seems likely that CWD tympanoplasty with soft-wall reconstruction results in a low incidence of recurrent cholesteatoma and deep retraction pocket. Residual cholesteatoma (arrow) was observed on the middle cranial fossa at second-stage tympanoplasty. All rights reserved.com on August 18. 6). in ears operated on with the CWU procedure.18 However. Although long-term observation of the ears is necessary.A B M F E Figure 2. With the combined use of a surgical microscope and endoscopes. The matrix of the cholesteatoma (M and arrow) was removed from the sinus tympani without a direct view. With the adoption of planned 2-stage tympanoplasty and placement of a polymeric silicone or plastic sheet in the tympanic cavity to facilitate aeration of the middle ear in the first-stage operation. Sheehy et al1 and Yanagihara et al18 reported recurrence rates of 10% to 20% and 41%. B. Nyrop and Bonding 17 reported that approximately 55% of ears treated using the CWU procedure from 1979 to 1981 developed a recurrent cholesteatoma in the 10 to 13 years of postoperative followup. Residual cholesteatoma (asterisk) was found in the sinus tympani at second-stage tympanoplasty. 2010 ©2008 American Medical Association. no recurrent cholesteatoma was observed and the incidence of a deep retraction pocket (7%) was lower than in ears treated with CWU tympanoplasty. The reason the incidence of residua in our patients’ ears was not lower than that with CWU tympanoplasty might be that the sinus tympani is still hidden from surgical view under the microscope after the CWD procedure. Left ear. only 4% of ears treated using the CWD procedure in the same period developed recurrent cholesteatoma.12.1. . In general. B. which is an ideal surgical procedure for maintaining the shape of the normal EAC with skin migration and results in slightly better hearing compared with CWD tympanoplasty. A B M M Figure 3. In contrast. which led to the residual cholesteatoma. respectively. there is no longer thought to be an obvious difference between CWD and CWU tympanoplasties insofar as the incidence of residual cholesteatoma. Yanagihara et al18 also reported that 23% of ears treated using the CWU procedure still developed a deep retraction pocket.
. further analysis of the postoperative hearing outcome is needed. sis of the first-stage operation suggest that greater effort must be made to avert leaving residual cholesteatoma matrix in the sinus tympani assisted with endoscopic observation. whereas a retracted posterior EAC wall. The existence of residual cholesteatomas. Retrospective videotape analysis was extremely useful in determining the technical faults that led to residual cholesteatomas. 2010 ©2008 American Medical Association. In such cases. 6). This technique is characterized by almost complete preservation of the shape of the EAC in ears with positive mastoid cavity aeration after surgery. like a radical mastoid cavity.com on August 18. and epithelialization of the mastoid cavity and EAC occurs separately. sufficient opening of the attic is needed. CONCLUSIONS Canal wall down tympanoplasty with soft-wall reconstruction has no advantage in terms of the incidence of recurrent cholesteatoma compared with CWU tympaWWW. The combination of the CWD procedure and softwall reconstruction is useful. After soft-wall reconstruction. For example. S. should be explored at a second-stage tympanoplasty. As advantages of this method. JUNE 2008 656 Downloaded from www. Insofar as other factors that may increase the risk of residua.A B EAC TM TM FAS S Figure 4. is observed in ears without gas exchange function in the mastoid cavity. which is similar to findings with the CWU procedure and different from findings with the CWD and open procedures. or ears in which the mucosa had become polypoidal had a greater chance of residual disease compared with ears in which the mucosa was normal. Moreover. no residual cholesteatomas have been found in the mastoid cavity owing to sufficient mastoidectomy performed in ears with suspected residua in the mastoid cavity. the mastoid cavity itself determines whether the posterior EAC wall is retracted after surgery. the mastoid cavity is separate from the EAC. bony defects of the middle cranial fossa or facial canal can hide unexpected residual cholesteatomas. Additional opening of the EAC wall and endoscopic observation are necessary when the cholesteatoma extends into the sinus tympani. FAS indicates deep temporal fascia. we recommend a planned 2-stage tympanoplasty in patients with extensive cholesteatomas who undergo CWD tympanoplasty with soft-wall reconstruction in the first-stage operation. Gristwood and Venables11 reported that ears with infiltration of the matrix to the pneumatized mastoid cavity. Accordingly. technical ease. The videotapes of the first-stage operations identified the manipulations that must be performed with great care to decrease cholesteatoma residua. Another reason for a planned 2-stage tympanoplasty with CWD and soft-wall reconstruction is that the length of the columella might be easier to determine at a second-stage than a first-stage tympanoplasty because the shape of the EAC or the distance between the TM and the stapes are fixed by 1 year after the first-stage operation using CWD tympanoplasty with soft-wall reconstruction. Hosoi and Murata8 mentioned the low incidence of retraction pockets and recurrent cholesteatoma after surgery using this method. from this perspective. More conscientious maneuvering and observation are essential to eliminate such lesions. Smith et al7 listed early postoperative wound healing. However. Videotape analysis of the first-stage operation indicated that unsuitable keratinizing epithelium rolling (arrow) occurred during tympanic membrane (TM) reconstruction.7 Takahashi et al9 stated that with the soft-wall reconstruction method.9 Regarding this point. according to its residual gas exchange function. In our experience. as with CWU tympanoplasty. Residual cholesteatoma (asterisk) was found just under the tympanic membrane (TM) at the second-stage tympanoplasty.archoto. EAC represents external auditory canal skin. the matrix should be removed completely in the first-stage operation and a secondstage tympanoplasty should be considered. In addition. Left ear. silicone sheet. A. not only in the antrum and tympanic cavity but also in the mastoid cavity.COM (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO. the soft-wall reconstruction method is associated with the possibility of residual cholesteatomas in the mastoid cavity. B. ears in which the middle ear mucosa was replaced by matrix.ARCHOTO. and little additional operating time compared with the CWD and open procedures. All rights reserved. The mastoid cavity determines whether the posterior EAC wall is retracted after surgery according to its residual gas exchange function. Whether other cases demonstrate a lower rate of residua must be determined by further surgical analysis in the near future. when removing the matrix from the bony wall of the epitympanum.
Tympanoplasty with reconstruction of soft posterior meatal wall in ears with cholesteatoma. Laryngoscope. on the basis of our retrospective videotape analysis of surgical procedures with residual cholesteatomas. Bonding P. Funabiki K. Shelton C. Laryngoscope. 4.99(2. accepted October 14. Hosoi H. Am J Otol.14(1):82-87. and material support: Haginomori. Naito Y. and Nonaka. Takamaki. JUNE 2008 657 WWW. Smyth GD. McCleve DE. Soft-wall reconstruction of the posterior external ear canal wall. Robinson JV. 1970. Crabtree JA. (2) search carefully for residua when the matrix is being removed from the cranial fossa or facial canal with bony defects. Correspondence: Shin-Ichi Haginomori.jp). Residual and recurrent cholesteatoma in closed tympanoplasty.83(10):1594-1621. Otolaryngol Head Neck Surg.com on August 18. 1998. Further prospective studies are required to confirm these instructive results on reducing cholesteatoma residua and to confirm whether the CWD and soft-wall reconstruction has an advantage over CWU and the CWD and open tympanoplasty in terms of recurrent cholesteatoma and hearing outcome. 14. Hasebe S. Surgery for epitympanic cholesteatoma: evaluation of training and experience. 8.74(6):1166-1182. Regarding their localization.102(2):145-151. 2007.21(1):28-31. 2. Management of cholesteatoma: status of the canal wall. several lessons must be seriously considered: (1) do not remove the cholesteatoma matrix under an indirect surgical view. 11. Takamaki.5(4):277-282. (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO. 1969. REFERENCES 1. 1993. Luxford WM.osaka-med. 1986. Gyo K. Brackmann DE. Han JC. Study concept and design: Haginomori and Takenaka. Dowe AC. 86(4 pt 1):451-462. Analysis and interpretation of data: Haginomori. 1971. 2000. Surgery for recurrent and residual cholesteatoma. Am J Otol. Tanabe M. Parisier SC.113(3):443-448. 1993. 2010 ©2008 American Medical Association. 10. 2007. Stroud MH. 18. Ann Otol Rhinol Laryngol. 1982. Composite reconstruction of the open mastoidectomy ear.024 cases. 6). Murata K. 5. similar to CWU tympanoplasty.111(6):521-526. 2003. Sheehy JL. J Laryngol Otol. 3. Takahashi H. 1990. Ann Otol Rhinol Laryngol. Graham MD. Osaka 569-8686. CWD tympanoplasty with soft-wall reconstruction should be followed by later second-stage surgery so as not to miss residual cholesteatomas not only in the tympanic cavity but also in the antrum and mastoid cavity. Hinohira Y.3(3):209-215. Jemmi G. CWD tympanoplasty with soft-wall reconstruction does not prevent the possibility of residua in the antrum.81(5):786-792. Sanna M. Administrative. Critical revision of the manuscript for important intellectual content: Nonaka and Takenaka. Prevention of recurrence of cholesteatoma in intact canal wall tympanoplasty. Factors influencing the probability of residual cholesteatoma. 2-7 Daigakumachi. 1997. Sudo M. Trans Am Acad Ophthalmol Otolaryngol. Weiss MH. or tympanic cavity. 1977. Sheehy JL. Smith MF. Sheehy JL. final revision received October 11. 12.90(3):271-274. Ramsey H. Tragal cartilage: reconstruction of the auditory canal. Scandellari R. and (3) avoid unsuitable keratinizing epithelium rolling during TM and EAC skin reconstruction with soft tissue or soft-wall reconstruction. Cholesteatoma surgery: residual and recurrent disease: a review of 1. 1992. 2007. Cause of posterior canal wall reconstruction after surgery from the viewpoint of mastoid conditions. 9. Laryngoscope. Author Contributions: Dr Haginomori had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Arch Otolaryngol. Am J Otol. Tanabe M. Miura M. Sheehy JL. Hasebe S. Am J Otol.ac.archoto. Palva T. These results suggest that in patients with extensive cholesteatomas. Furthermore. Cartilage canal plasty. Honjo I. 1990. Auris Nasus Larynx. Extensive cholesteatoma: long-term results of three surgical techniques. 13. Venables WN. Tympanoplasty: review of 400 staged cases. mastoid cavity. Zini C. Edelstein DR. Smith PG. Am J Otol. Takatsuki. Laryngoscope. 16. Yanagihara N.94(3):355-359.21(2):69-74. 1994.ARCHOTO. Cholesteatoma surgery at the otologic medical group: residual and recurrent disease. Financial Disclosure: None reported. 1984. Laryngoscope. Sasaki Y. Syms MJ. 7. Nyrop M. Acquisition of data: Haginomori. Goebel JA. Department of Otolaryngology. . All rights reserved. and Nonaka. 6.19(2):131-135.noplasty or CWD and open tympanoplasty.100(7):679-681. pt 1):120-123. Tympanoplasty: staging the operation.14(6):590-594. Osaka Medical College. and Takenaka. Am J Otol. 1973.COM Downloaded from www. Drafting of the manuscript: Haginomori and Takamaki. 15. Study supervision: Takenaka. 17. Soft-wall reconstruction for cholesteatoma surgery: reappraisal. MD. technical. Gristwood RE. Japan (hagi @poh. Takamaki. Submitted for Publication: May 7. Takahashi H.
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