CHOLESTEATOMA SURGERY

A. H. MARIN
 Cholesteatoma - definition
The central element of the dangerous,
bone-invading type of chronic suppurative
otitis media is cholesteatoma

Cholesteatoma is defined as the presence

of keratinizing squamous epithelium
within the middle ear or in other
pneumatized areas of the temporal bone
Cholesteatoma - Pathogenesis
Congenital Cholesteatoma is a
developmental defect arising from an
epithelial rest of embryonal origin,
occurring in the temporal bone
Acquired Cholesteatoma occurs after
birth and is caused by invasion of
keratinizing squamous epithelium,
originating from the EAC or from the
tympanic membrane, into the middle ear
 Cholesteatoma - Pathogenesis
Secondary acquired cholesteatoma - develops
because of the ingrowth of the squamous epithelium
from the meatus into the middle ear, mostly through a
marginal perforation of the tympanic membrane.
Primary acquired cholesteatoma (attic retraction
cholesteatoma) – 4 theories of development:
1.invagination of the pars flaccida due to negative
pressure into the attic, causing the development of a
retraction pocket
2.epithelial invasion of the epitympanum following a
marginal perforation of Shrapnells membrane
3.papillary proliferation of the basal layer in the
epidermis of Shrapnells membrane induced by
prolonged inflamation
4.metaplasia of the attical mucosa into squamous
epithelium
 CONGENITAL SECONDARY PRIMARY
CHOLESTEATOMA ACQUREAD ACQUREAD
CHOLESTEATOMA CHOLESTEATOMA
 Surgical treatment of
cholesteatoma
Aims (Fisch):
Eradication of disease
Prevention of recurrent and retention
cholesteatomas
Formation of a dry and self-cleasing cavity
Restoration of tympanic aeration
Reconstruction of a sound-transformer
mechanism
 Surgical treatment of
cholesteatoma
Surgical concepts:
Closed techniques – intact canal wall
Open techniques – canal wall down
“Open – closed” techniques – temporary
resection of the canal wall; reconstruction
of the canal wall using bone, cartilage,
hidroxyapatite, titanium.
 Surgical treatment of
cholesteatoma
Choice of approach (Fisch)
Depends on:
Function of the eustachian tube
Extent of the disease
Criteria for the the choice of the approach:
1. Limited disease with good pneumatisation –
closed technique
2. Sclerotic mastoid with extensive disease – open
technique
3. Disease cannot be radically removed - open
technique
 Open (canal wall down)
techniques
Classic radical mastoidectomy (without
tympanoplasty)
Conservative radical mastoidectomy; modified
radical mastoidectomy (with preservation of the
ossicles and tympanic membrane) – Jansen,
Bondy, Sourdille
Modified radical mastoidectomy with
tympanoplasty; complete mastoidectomy with
tympanoplasty; open mastoidoepitympanectomy
with tympanolplasty (Fisch)
 Open (canal wall down)
techniques
Principle – to create a large, self-cleasing
cavity in which no retention of keratinizing
epithelium is possible. This is done by
removing the superior and posterior canal
wall, taking down the bridge and lowering
the facial ridge.
 Open (canal wall down)
techniques
Indications for the classic radical
mastoidectomy (rarely performed today)
Cholesteatoma associated with an intracranial
complication
Unresectable cholesteatoma extending down the
eustachian tube
Promontory cochlear fistula due to colesteatoma
Chronic perilabyrinthine osteitis or cholesteatoma that
cannot be removed and must be cleaned and
inspected periodically
Patients in whom restoration of auditory function and
middle ear space is not posible
Radical mastoidectomy for giant
cholesteatoma
Radical mastoidectomy for giant
cholesteatoma
Radical mastoidectomy for giant
cholesteatoma
 Classic radical mastoidectomy
-drawbacks
The drawback of classic radical
mastoidectomy without tympanoplasty is the
recurrent infection of the open middle ear
cavity resulting in repeating episodes of
otorrhea.
Poor functional result.
Necessity of water avoidance and periodic
aftercare of the classic radical cavities and
also of the Bondy type cavities
Modified radical mastoidectomy
with tympanoplasty
Is the operation in which the principles of
the radical, canal wall down mastoidectomy
apply, but the ossicular and tympanic
membrane remnants are not removed and
the middle ear space is closed by means of
a tympanoplasty.
Ossicular reconstruction can be done within
the same surgical intervention or staged,
after a period of time.
 Modified radical mastoidectomy with
tympanoplasty

Preparing the tympanomeatal flap

and entering the tympanic cavity - Before taking down the bridge
cholesteatoma into the atic
Modified radical mastoidectomy with tympanoplasty
tympanoplast

Epitympanectomy: removing of the atrophic incus eroded by

the cholesteatoma and resecting the maleus head
 Modified radical mastoidectomy with
tympanoplasty

Cleaning the cholesteatoma from the epitympanum and

mesotympanum and identification of the tympanic
segment of the facial nerv; intact and mobile stapes
Modified radical mastoidectomy with
tympanoplasty

Lowering the facial ridge

 Modified radical mastoidectomy with
tympanoplasty

Placing a PORP between the stapes superstructure and maleus handle

 Modified radical mastoidectomy with
tympanoplasty

Closing the tympanic cavity Repositioning of the

with temporalis fascia tympanomeatal flap
Modified radical mastoidectomy
with tympanoplasty - advantages
This technique has the advantages of open
mastoidectomy, permitting a wide exposure
and better access to the sinus tympani and
limiting the cases of recurrent and residual
cholesteatoma.
Closure of the tympanic cavity by means of a
tympanoplasty eliminates the possible
postoperative drainage from the middle ear
and permits the reconstruction of the sound
transmitting mechanism.
 Modified radical mastoidectomy
with tympanoplasty – disadvatages
Distortion of the normal anatomy of the
external auditory bony canal.
Concerning the postoperative cavity problems,
frequently mentioned as a disadvantage of
open cavity procedures, in a study of 301
patients who underwent surgery because of
cholestetoma Fisch did not found a statistical
difference between the rate of dry and self-
cleansing open and closed cavities: 94% vs.
92% in children and 96% vs. 95% in adults.
 Closed (intact canal wall)
techniques
The principle of the intact canal wall
Tympanomastoidectomy with
tympanoplasty is to remove the
cholesteatoma without disturbing the
anatomy of the external bony canal.
This is done through a combined aproach,
transcanal and transmastoid, through the
facial recess (posterior tympanotomy).
 Intact canal wall
tympanomastoidectomy with
tympanoplasty

Removal of delimited
epitympanic cholesteatoma,
preserving the canal wall
 Intact canal wall
tympanomastoidectomy with
tympanoplasty

Reconstruction of the
tympanoossicular system –
incus interposition and
fascia
Intact canal wall tympanomastoidectomy
with tympanoplasty
The advantage of the closed technique is
the preservation of the normal anatomy of
the external bony canal, permitting a better
reconstruction and avoiding the
postoperative open cavity problems.
The disadvantage may be the limited
visibility, mostly in the area of the sinus
tympany, where cholesteatoma may
become difficult to extirpate.
Intact canal wall tympanomastoidectomy
with tympanoplasty

In a 10-year follow-up of 301 cholesteatoma patients,

Fisch found, in children, a 25% rate of residual and a
13% rate of recurrent cholesteatoma in closed cavities
a 8% rate of residual and 8% rate of recurrent
cholesteatoma in open cavities. In adults the rates of
residual cholesteatoma were 8% for closed and 2% for
open cavities and for recurrent disease 4% for closed
and none for open cavities.
 116 cases of cholesteatoma operated at the
ENT department of Timişoara - intraoperative
extension of the lesions

Atical retraction pockets – 9 cases

Cholesteatoma limited to the epytympanum – 19 cases
Posterior extension from the epytympanum to the
mastoid – 45 cases
Extension to the mastoid and to the mesotympanum –
31 cases
Extensiv tympanomastoidean cholesteatoma invading
the perilabyrinthine cells and/or extending down the
eustachian tube -7 cases
Cholesteatoma associated with an intracranial
complication - 5 cases
 Surgical techniques employed

12 Classic Radical
Mastoidectomies (RM)
70 Modified Radical
Mastoidectomies with
Tympanoplasty (MRMT) 22% 10%
RM
MRMT
9 Conservative 8% CM

Mastoidectomies (CM) 60%

ICW

25 Closed Intact Canal

Wall Techniques (ICW)
 Conclusions
In the majority of cases the canal wall down
mastoidectomy with tympanoplasty was performed.
We used the closed intact canal wall technique only in
small delimited epitympanic cholesteatoma or in
retraction pockets.
In very few cases were the cholesteatoma could be
removed without distortion of the ossicular chain we
used the conservative mastoidectomy
The classic radical mastoidectomy is still in use, but only
in special indications (cholesteatoma invading the
perilabyrinthine cells, extending down the eustachian
tube or associated with an intracranial complication).