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Efficacy of surgical treatment of chronic otitis media
Efficacy of surgical treatment of chronic otitis media OSWALDO LAE´RCIO M. CRUZ,
MD,
CRISTIANE A. KASSE,
MD,
This article presents our results of surgical treatment of chronic otitis media (COM) and discusses its efficacy regarding the control of disease and hearing results. A retrospective chart review of 84 ears was performed. Forty-one ears with noncholesteatomatous COM underwent tympanomastoidectomy, 43 ears with cholesteatoma were managed according to the extension of the disease, closed mastoidectomy was indicated in 19 cases, and open mastoidectomy was performed in 24 ears. In the group without cholesteatoma, a stable ear with closed tympanic membrane was obtained in 85% of cases after the first procedure. The speech response threshold before and after surgery was 38 and 26 dB. In patients with cholesteatoma, a dry ear was achieved in 79% of cases on both techniques after the first intervention. The recurrence rate of cholesteatoma was 10% for the closed technique and 4% for the open technique. The mean preoperative and postoperative SRTs for the closed technique were 30 and 29 dB and for the open technique were 50 and 54 dB. The surgical treatment for COM can be a rewarding procedure if a correct technique is indicated. The surgery should be tailored regarding the clinical stage and intraoperative findings in each case. (Otolaryngol Head Neck Surg 2003;128: 263-6.)
T his study was designed to evaluate the efficacy of the treatment of active forms of chronic otitis media (COM) for which a mastoidectomy is the treatment of choice. We classify COM in 3 main forms: COM with effusion, noncholesteatomatous From the Disciplina de Otorrinolaringologia Pedia´trica (Dr Cruz) and Disciplina de Otorrinolaringologia (Drs Kasse and Leonhart), Universidade Federal de Sa˜o Paulo, Escola Paulista de Medicina. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Denver, CO, September 9-12, 2001. Reprint requests: Oswaldo Lae´rcio M. Cruz, MD, Universidade Federal de Sa˜o Paulo, Rua Mato Grosso 128/74, Cep 01239-040, Sa˜o Paulo, Brasil; e-mail, olacruz@uol. com.br. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1067/mhn.2003.86
and FERNANDO D. LEONHART,
MD,
Sa˜o Paulo, Brazil
COM (NCCOM), and COM with cholesteatoma (COMC). This classification takes into account the main histopathologic characteristics and clinical expressions for each form. COM with effusion has initial histoarchitectural alterations and is potentially reversible with clinical treatment or ventilation tube. The other forms have irreversible alterations that impose surgical correction followed by repair of the anatomic defects and assurance of middle ear cleft ventilation. Mastoidectomy associated with tympanoplasty is the most common form of therapy for NCCOM. Only sporadic articles show good long-terms results with only tympanoplasty to treat active COM. Controversy still exists in the literature regarding the choice of closed or open mastoidectomy for the treatment of COMC. Surgeon experience and local medical assistance conditions should influence the indication of each technique. In this article, we present our results of surgical treatment of NCCOM and COMC and discuss its efficacy regarding the control of disease and hearing results. We will also comment on some technical details that could contribute to improved results. MATERIAL AND METHODS Data from 84 ears (78 patients) that underwent surgical procedures by the same surgeon were available for clinical and audiometric studies, with a minimum follow-up period of 24 months. Fortyone ears (49%; 41/84) were diagnosed with NCCOM. Twenty-two patients were female, and 19 were male, with mean age of 21.3 years (range, 4 to 62 years). The diagnosis of NCCOM was made on the basis of: (1) history (episodes of recurrent ear discharge or presence of otorrhea in the last 6 months); (2) otoscopy; or (3) CT scan findings when necessary. All of these patients underwent mastoidectomy associated with tympanoplasty with the following technical steps: a complete mastoidectomy, including tip and retro facial air cell resection when present; widening of the aditus, with a osseous egg shell left protecting 263
Otolaryngology– Head and Neck Surgery February 2003
264 CRUZ et al
Table 1. Clinical results after tympanomastoidectomy in patients with NCCOM (n ⫽ 41) Results
First intervention
Second intervention
Stable ear Dry tympanic membrane perforation Persistent disease Tympanic membrane retraction Total
35 (85.3%) 4 (9.7%) 1 (2.4%) 1 (2.4%) 41
41 (100%)
the dura and a thin but safe (without erosion) wall at the external auditory canal; resection of all irreversible pathologic mucous membrane tissue and osteitis; and reconstruction of the ossicular chain and the tympanic membrane as necessary. Forty-three ears (51%; 43/84) had COMC and were managed according to the extension of the disease. A closed mastoidectomy associated with tympanoplasty, with the same principles as described previously, was indicated in 19 cases (44%; 19/43) of cholesteatoma restricted to the tympanic cavity (exception to anterior attic) or aditus. An open mastoidectomy (canal wall down) with reconstruction of the sound conduction system was performed in 24 ears (56%; 24/43) of cholesteatoma extending to the mastoid antrum or anterior attic, associated with extensive granulation tissue or eustachian tube insufficiency. The open technique observed the same principles of complete resection of mastoid air cells and irreversible tissue lesions, with special attention to the cholesteatoma itself and dysplasic areas. The reconstruction of ossicular chain and tympanic membrane was conducted wherever a cochlear function existed with the modified radical mastoidectomy model, when possible, or with the tympanic graft over the reconstructed ossicular chain supported by the lateral semicircular canal and facial wall posteriorly. With both techniques, we used remodeled autologous bone obtained from spared malleus, incus, or mastoid cortical to reconstruct the ossicular system. RESULTS In the NCCOM group (n ⫽ 41) treated with tympanomastoidectomy, a stable ear with closed tympanic membrane was obtained in 85% of the cases (n ⫽ 35) after the first procedure. Six patients (15%; 6/41) needed a second intervention: 4 patients underwent tympanoplasty for a residual
41
dry tympanic membrane perforation, 1 tympanomastoidectomy was indicated for persistent NCCOM, and a ventilation tube procedure for tympanic membrane retraction with effusion was performed in 1 case. A clinically stable ear was obtained in all those patients after the second procedure. Three patients (7%) with moderated tympanic membrane retraction underwent conservative management (Table 1). Improvement of speech response threshold (SRT) was achieved in 37 ears (90%), with preoperative and postoperative SRT means of 38 and 26 dB, respectively. A reduction of the air bone gap was obtained in 35 patients (85%), with mean preoperative gaps of 26 and 15 dB in the postoperative evaluation (Table 2). In the COMC group (n ⫽ 43), a dry ear was achieved in 79% of both groups in the first intervention: 15 of 19 patients for closed technique and 19 of 24 for open technique. The recurrence rate of cholesteatoma was 10% (2/19) for the intact canal wall procedure (closed technique) and 4% (1/24) for the canal wall down procedure (open technique; Table 3). Two patients who underwent the closed technique (10%; 2/19) had cholesteatoma recurrence and underwent open technique. An important observation was that time of recurrence varied from 1.5 to 9 years. Two patients (10%; 2/19) of the closed technique group needed a second intervention for persistent disease without cholesteatoma (granulation tissue). One patient had a dry tympanic perforation develop and needed a tympanoplasty (Table 3). In the open technique group, 1 patient (4%; 1/24) underwent revision surgery for cholesteatoma recurrence and 2 patients (8%; 2/24) needed a second surgery to remove foreign body granuloma from hydroxyapatite implanted to reduce the
Otolaryngology– Head and Neck Surgery Volume 128 Number 2
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265
Table 2. SRT mean and air bone gap in NCCOM and COMC groups before and after surgery Preoperative SRT (dB)
NCCOM Tympanomastoidectomy COMC Close technique COMC Open technique
Postoperative SRT (dB)
Preoperative gap (dB)
Postoperative gap (dB)
38
26
26
15
30.5 50
29 54
17.72 28
17.5 25
Table 3. Clinical results after surgery for COMC group (n ⫽ 43) Results
Closed technique
Open technique
Stable ear in first intervention Reccurence of cholesteatoma Granulation tissue Dry tympanic perforation Granuloma with hydroxyapatite Total
15 (79%) 2 (11%) 2 (11%) 1 (5%) 0 19 (100%)
19 (79%) 1 (4%) 2 (8%) 0 2 (8%) 24 (100%)
mastoid cavity. Three patients (12.5%; 3/24) needed several ambulatory aspiration sessions followed by granuloma cauterization to obtain a healed cavity (Table 3). Regarding the functional results, with the closed technique, the mean preoperative and postoperative SRTs were 30.5 and 29 dB, respectively. The mean air bone gap was 17.72 dB before and 17.5 dB after surgery. For the open technique, the mean SRTs before and after surgery were 50 and 54 dB, respectively. The air bone gap was 28 dB in the preoperative period and 25 dB after surgery (Table 2). DISCUSSION With COM, consideration of clinical and histopathologic aspects of this particular disease for an adequate therapeutic choice is of utmost importance. The main objective of surgery is to reestablish autocleaning and a well-aerated cavity. Whenever possible, function restoration should be considered. With the option of a closed technique, a good result depends on a reconstitution of a near normal mucous membrane, a sufficient ventilation of the tympanic and mastoid cavities, and clearance of residual mucous secretion production. When an open cavity is conducted, the main result is a well-skin-folded cavity that, ideally, should be autocleaning and aerate with a proportionally
larger external auditory canal created with meatoplasty. The eustachian tube function is necessary only for the aeration of a reduced tympanic cavity, assuring some air pressure under the tympanic membrane to contribute to sound energy transmission. On the basis of those principles, we believe that there is no perfect surgery for COM but rather an adequate choice of surgical technique tailored for each case. In the cases of NCCOM treated with tympanomastoidectomy, 85% disease control after the first procedure was considered a good result and comparable with the literature.1-7 If we consider 4 patients who needed a second surgery to close a dry tympanic perforation as having the inflammatory disease under control, this number was raised to 94%. Regarding the functional results, our data were also considered good. We obtained improvement of SRT in 90%, with 70% ⱕ30 dB, and the air bone gap was ⬍30 dB in 90% of patients, with 50% having an air bone gap of ⱕ10 dB in the postoperative control. In our opinion, these good results are first related to an adequate therapeutic option. Few disagreements exist that mastoidectomy associated to tympanoplasty is the better procedure to treat NCCOM. Tympanoplasty, in our experience, is indicated only for the sequelae of COM without active inflammatory process within the confines of
Otolaryngology– Head and Neck Surgery February 2003
266 CRUZ et al
the middle ear cleft. Some forms of NCCOM may have a silent clinical expression and impose a careful preoperative evaluation, including image study, for its perfect characterization. When one performs a tympanoplasty and unintentionally leaves granulation tissue or cholesterol granuloma at middle ear cleft, even at hidden regions, longterm results can be compromised. That fact brings us to the second aspect that assures a good result: a careful technical procedure. In our view, it is of fundamental importance to perform a complete mastoidectomy, opening even the retro facial cells when present in more pneumatized mastoids, to obtain an inflammatory free middle ear and mastoid. An efficient control of disease and a more accurate functional reconstruction could be expected in these circumstances. Regarding COMC, we had a good control of the disease in 90% of patients with the closed technique and in 95% of patients with the open technique. The functional results were considered reasonable, with maintenance of preoperative SRT and air bone gap in the postoperative period in both techniques groups. With consideration that 58% of all patients with COMC had air bone gaps of ⱕ30 dB in the postoperative audiometric control, these functional results should be considered satisfactory.1-3,8 Compared with the literature,1-3,8-12 our overall results in COMC could be considered good, and again we credit this to a correct surgical option and technical execution. Regarding our local conditions and personal experience, the closed technique can be performed in cases of acquired cholesteatoma limited to the tympanic cavity and aditus. When located in the tympanic cavity, the exception is the presence of cholesteatoma in the anterior attic. In our later revision cases, it was the most important area of recurrence and now is an indicator for open technique along with cholesteatomas that reach regions beyond the aditus limits.13 With those precise criteria of indication and technical execution for the closed and open techniques, we could obtain interesting results compared with the worldwide literature. During the follow-up period, our patients who undergo closed technique are monitored with clinical and image evaluation, and a second surgery is indicated only when recurrence is suspected. It is
important to remember that the follow-up period for patients with cholesteatoma should always be long term. This is in concordance with the literature and is supported by our case with a recurrence 9 years after the first surgery. CONCLUSION The surgical treatment for COM can be a rewarding procedure if a correct technique is indicated and conducted with extreme technical care. To achieve this ideal condition, we need to tailor the procedure regarding the clinical stage and intraoperative findings in each case. REFERENCES
1. Ruhl CM, Pensak ML. Role of aerating mastoidectomy in noncholesteatomatous chronic otitis media. Laryngoscope 1999;109:1924-7. 2. Sheehy JL, Robinson JV. Cholesteatoma surgery at the Otologic Medical Group. Residual and recurrent disease. A report on 307 revision operations. Am J Otol 1982;3: 209-15. 3. Murphy TP, Wallis DL. Hearing results in pediatric patients after canal-wall-up and canal-wall-down mastoid surgery. Otolaryngol Head Neck Surg 1998;119:439-43. 4. Fisch U. Tympanoplasty, mastoidectomy and stapes surgery. New York: Thieme Medical Publishers; 1994. 5. Vartiainen E, Nuutinen J. Long term hearing results of one stage tympanoplasty for chronic otitis media. Eur Arch Otorhinolaryngol 1992;753-6. 6. Chiossone E. Long term results in intact wall tympanoplasty. In: Tos M, Thomsen J, Peitersen E, editors. Cholesteatoma and mastoid surgery. Amsterdam: Kugler Publications; 1989. p. 663-5. 7. Cruz OLM, Caldas SR, Takeushi M, et al. Clinical and surgical aspects of cholestatoma in children. Ear Nose Throat J 1990:69:530-6. 8. Veldman JE, Braunius WW. Revision surgery for chronic otitis media: a learning experience. Report on 389 cases with a long-term follow-up. Ann Otol Rhinol Laryngol 1998;107:486-91. 9. Nyrop M, Bonding P. Achievement of stable ears in cholesteatoma surgery. Long-term results of three surgical techniques. In: Nakano Y. Cholesteatoma and mastoid surgery. Amsterdam: Kugler Publications; 1992. p. 753-6. 10. Vartiainen E. Ten-year results of canal wall down mastoidectomy for acquired cholesteatoma. Auris Nasus Larynx 2000;27:227-9. 11. Roden D, Honrubia VF, Wiet R. Outcome of residual cholesteatoma and hearing in mastoid surgery. J Otolaryngol 1996;25:178-81. 12. Harkness P, Brown P, Fowler S, et al. Mastoidectomy audit: results of the Royal College of Surgeons of England comparative audit of ENT surgery. Clin Otolaryngol 1995;20:89-94. 13. Costa SS, Hueb MM, Ruschel C, et al. Otite media croˆ nica colesteatomatosa. In: Cruz OLM, Costa SS, editors. Otologia Clinica e Ciru´ rgica. Rio de Janeiro: Revinter; 2000. p. 197-216.
MD,
CRISTIANE A. KASSE,
MD,
This article presents our results of surgical treatment of chronic otitis media (COM) and discusses its efficacy regarding the control of disease and hearing results. A retrospective chart review of 84 ears was performed. Forty-one ears with noncholesteatomatous COM underwent tympanomastoidectomy, 43 ears with cholesteatoma were managed according to the extension of the disease, closed mastoidectomy was indicated in 19 cases, and open mastoidectomy was performed in 24 ears. In the group without cholesteatoma, a stable ear with closed tympanic membrane was obtained in 85% of cases after the first procedure. The speech response threshold before and after surgery was 38 and 26 dB. In patients with cholesteatoma, a dry ear was achieved in 79% of cases on both techniques after the first intervention. The recurrence rate of cholesteatoma was 10% for the closed technique and 4% for the open technique. The mean preoperative and postoperative SRTs for the closed technique were 30 and 29 dB and for the open technique were 50 and 54 dB. The surgical treatment for COM can be a rewarding procedure if a correct technique is indicated. The surgery should be tailored regarding the clinical stage and intraoperative findings in each case. (Otolaryngol Head Neck Surg 2003;128: 263-6.)
T his study was designed to evaluate the efficacy of the treatment of active forms of chronic otitis media (COM) for which a mastoidectomy is the treatment of choice. We classify COM in 3 main forms: COM with effusion, noncholesteatomatous From the Disciplina de Otorrinolaringologia Pedia´trica (Dr Cruz) and Disciplina de Otorrinolaringologia (Drs Kasse and Leonhart), Universidade Federal de Sa˜o Paulo, Escola Paulista de Medicina. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Denver, CO, September 9-12, 2001. Reprint requests: Oswaldo Lae´rcio M. Cruz, MD, Universidade Federal de Sa˜o Paulo, Rua Mato Grosso 128/74, Cep 01239-040, Sa˜o Paulo, Brasil; e-mail, olacruz@uol. com.br. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1067/mhn.2003.86
and FERNANDO D. LEONHART,
MD,
Sa˜o Paulo, Brazil
COM (NCCOM), and COM with cholesteatoma (COMC). This classification takes into account the main histopathologic characteristics and clinical expressions for each form. COM with effusion has initial histoarchitectural alterations and is potentially reversible with clinical treatment or ventilation tube. The other forms have irreversible alterations that impose surgical correction followed by repair of the anatomic defects and assurance of middle ear cleft ventilation. Mastoidectomy associated with tympanoplasty is the most common form of therapy for NCCOM. Only sporadic articles show good long-terms results with only tympanoplasty to treat active COM. Controversy still exists in the literature regarding the choice of closed or open mastoidectomy for the treatment of COMC. Surgeon experience and local medical assistance conditions should influence the indication of each technique. In this article, we present our results of surgical treatment of NCCOM and COMC and discuss its efficacy regarding the control of disease and hearing results. We will also comment on some technical details that could contribute to improved results. MATERIAL AND METHODS Data from 84 ears (78 patients) that underwent surgical procedures by the same surgeon were available for clinical and audiometric studies, with a minimum follow-up period of 24 months. Fortyone ears (49%; 41/84) were diagnosed with NCCOM. Twenty-two patients were female, and 19 were male, with mean age of 21.3 years (range, 4 to 62 years). The diagnosis of NCCOM was made on the basis of: (1) history (episodes of recurrent ear discharge or presence of otorrhea in the last 6 months); (2) otoscopy; or (3) CT scan findings when necessary. All of these patients underwent mastoidectomy associated with tympanoplasty with the following technical steps: a complete mastoidectomy, including tip and retro facial air cell resection when present; widening of the aditus, with a osseous egg shell left protecting 263
Otolaryngology– Head and Neck Surgery February 2003
264 CRUZ et al
Table 1. Clinical results after tympanomastoidectomy in patients with NCCOM (n ⫽ 41) Results
First intervention
Second intervention
Stable ear Dry tympanic membrane perforation Persistent disease Tympanic membrane retraction Total
35 (85.3%) 4 (9.7%) 1 (2.4%) 1 (2.4%) 41
41 (100%)
the dura and a thin but safe (without erosion) wall at the external auditory canal; resection of all irreversible pathologic mucous membrane tissue and osteitis; and reconstruction of the ossicular chain and the tympanic membrane as necessary. Forty-three ears (51%; 43/84) had COMC and were managed according to the extension of the disease. A closed mastoidectomy associated with tympanoplasty, with the same principles as described previously, was indicated in 19 cases (44%; 19/43) of cholesteatoma restricted to the tympanic cavity (exception to anterior attic) or aditus. An open mastoidectomy (canal wall down) with reconstruction of the sound conduction system was performed in 24 ears (56%; 24/43) of cholesteatoma extending to the mastoid antrum or anterior attic, associated with extensive granulation tissue or eustachian tube insufficiency. The open technique observed the same principles of complete resection of mastoid air cells and irreversible tissue lesions, with special attention to the cholesteatoma itself and dysplasic areas. The reconstruction of ossicular chain and tympanic membrane was conducted wherever a cochlear function existed with the modified radical mastoidectomy model, when possible, or with the tympanic graft over the reconstructed ossicular chain supported by the lateral semicircular canal and facial wall posteriorly. With both techniques, we used remodeled autologous bone obtained from spared malleus, incus, or mastoid cortical to reconstruct the ossicular system. RESULTS In the NCCOM group (n ⫽ 41) treated with tympanomastoidectomy, a stable ear with closed tympanic membrane was obtained in 85% of the cases (n ⫽ 35) after the first procedure. Six patients (15%; 6/41) needed a second intervention: 4 patients underwent tympanoplasty for a residual
41
dry tympanic membrane perforation, 1 tympanomastoidectomy was indicated for persistent NCCOM, and a ventilation tube procedure for tympanic membrane retraction with effusion was performed in 1 case. A clinically stable ear was obtained in all those patients after the second procedure. Three patients (7%) with moderated tympanic membrane retraction underwent conservative management (Table 1). Improvement of speech response threshold (SRT) was achieved in 37 ears (90%), with preoperative and postoperative SRT means of 38 and 26 dB, respectively. A reduction of the air bone gap was obtained in 35 patients (85%), with mean preoperative gaps of 26 and 15 dB in the postoperative evaluation (Table 2). In the COMC group (n ⫽ 43), a dry ear was achieved in 79% of both groups in the first intervention: 15 of 19 patients for closed technique and 19 of 24 for open technique. The recurrence rate of cholesteatoma was 10% (2/19) for the intact canal wall procedure (closed technique) and 4% (1/24) for the canal wall down procedure (open technique; Table 3). Two patients who underwent the closed technique (10%; 2/19) had cholesteatoma recurrence and underwent open technique. An important observation was that time of recurrence varied from 1.5 to 9 years. Two patients (10%; 2/19) of the closed technique group needed a second intervention for persistent disease without cholesteatoma (granulation tissue). One patient had a dry tympanic perforation develop and needed a tympanoplasty (Table 3). In the open technique group, 1 patient (4%; 1/24) underwent revision surgery for cholesteatoma recurrence and 2 patients (8%; 2/24) needed a second surgery to remove foreign body granuloma from hydroxyapatite implanted to reduce the
Otolaryngology– Head and Neck Surgery Volume 128 Number 2
CRUZ et al
265
Table 2. SRT mean and air bone gap in NCCOM and COMC groups before and after surgery Preoperative SRT (dB)
NCCOM Tympanomastoidectomy COMC Close technique COMC Open technique
Postoperative SRT (dB)
Preoperative gap (dB)
Postoperative gap (dB)
38
26
26
15
30.5 50
29 54
17.72 28
17.5 25
Table 3. Clinical results after surgery for COMC group (n ⫽ 43) Results
Closed technique
Open technique
Stable ear in first intervention Reccurence of cholesteatoma Granulation tissue Dry tympanic perforation Granuloma with hydroxyapatite Total
15 (79%) 2 (11%) 2 (11%) 1 (5%) 0 19 (100%)
19 (79%) 1 (4%) 2 (8%) 0 2 (8%) 24 (100%)
mastoid cavity. Three patients (12.5%; 3/24) needed several ambulatory aspiration sessions followed by granuloma cauterization to obtain a healed cavity (Table 3). Regarding the functional results, with the closed technique, the mean preoperative and postoperative SRTs were 30.5 and 29 dB, respectively. The mean air bone gap was 17.72 dB before and 17.5 dB after surgery. For the open technique, the mean SRTs before and after surgery were 50 and 54 dB, respectively. The air bone gap was 28 dB in the preoperative period and 25 dB after surgery (Table 2). DISCUSSION With COM, consideration of clinical and histopathologic aspects of this particular disease for an adequate therapeutic choice is of utmost importance. The main objective of surgery is to reestablish autocleaning and a well-aerated cavity. Whenever possible, function restoration should be considered. With the option of a closed technique, a good result depends on a reconstitution of a near normal mucous membrane, a sufficient ventilation of the tympanic and mastoid cavities, and clearance of residual mucous secretion production. When an open cavity is conducted, the main result is a well-skin-folded cavity that, ideally, should be autocleaning and aerate with a proportionally
larger external auditory canal created with meatoplasty. The eustachian tube function is necessary only for the aeration of a reduced tympanic cavity, assuring some air pressure under the tympanic membrane to contribute to sound energy transmission. On the basis of those principles, we believe that there is no perfect surgery for COM but rather an adequate choice of surgical technique tailored for each case. In the cases of NCCOM treated with tympanomastoidectomy, 85% disease control after the first procedure was considered a good result and comparable with the literature.1-7 If we consider 4 patients who needed a second surgery to close a dry tympanic perforation as having the inflammatory disease under control, this number was raised to 94%. Regarding the functional results, our data were also considered good. We obtained improvement of SRT in 90%, with 70% ⱕ30 dB, and the air bone gap was ⬍30 dB in 90% of patients, with 50% having an air bone gap of ⱕ10 dB in the postoperative control. In our opinion, these good results are first related to an adequate therapeutic option. Few disagreements exist that mastoidectomy associated to tympanoplasty is the better procedure to treat NCCOM. Tympanoplasty, in our experience, is indicated only for the sequelae of COM without active inflammatory process within the confines of
Otolaryngology– Head and Neck Surgery February 2003
266 CRUZ et al
the middle ear cleft. Some forms of NCCOM may have a silent clinical expression and impose a careful preoperative evaluation, including image study, for its perfect characterization. When one performs a tympanoplasty and unintentionally leaves granulation tissue or cholesterol granuloma at middle ear cleft, even at hidden regions, longterm results can be compromised. That fact brings us to the second aspect that assures a good result: a careful technical procedure. In our view, it is of fundamental importance to perform a complete mastoidectomy, opening even the retro facial cells when present in more pneumatized mastoids, to obtain an inflammatory free middle ear and mastoid. An efficient control of disease and a more accurate functional reconstruction could be expected in these circumstances. Regarding COMC, we had a good control of the disease in 90% of patients with the closed technique and in 95% of patients with the open technique. The functional results were considered reasonable, with maintenance of preoperative SRT and air bone gap in the postoperative period in both techniques groups. With consideration that 58% of all patients with COMC had air bone gaps of ⱕ30 dB in the postoperative audiometric control, these functional results should be considered satisfactory.1-3,8 Compared with the literature,1-3,8-12 our overall results in COMC could be considered good, and again we credit this to a correct surgical option and technical execution. Regarding our local conditions and personal experience, the closed technique can be performed in cases of acquired cholesteatoma limited to the tympanic cavity and aditus. When located in the tympanic cavity, the exception is the presence of cholesteatoma in the anterior attic. In our later revision cases, it was the most important area of recurrence and now is an indicator for open technique along with cholesteatomas that reach regions beyond the aditus limits.13 With those precise criteria of indication and technical execution for the closed and open techniques, we could obtain interesting results compared with the worldwide literature. During the follow-up period, our patients who undergo closed technique are monitored with clinical and image evaluation, and a second surgery is indicated only when recurrence is suspected. It is
important to remember that the follow-up period for patients with cholesteatoma should always be long term. This is in concordance with the literature and is supported by our case with a recurrence 9 years after the first surgery. CONCLUSION The surgical treatment for COM can be a rewarding procedure if a correct technique is indicated and conducted with extreme technical care. To achieve this ideal condition, we need to tailor the procedure regarding the clinical stage and intraoperative findings in each case. REFERENCES
1. Ruhl CM, Pensak ML. Role of aerating mastoidectomy in noncholesteatomatous chronic otitis media. Laryngoscope 1999;109:1924-7. 2. Sheehy JL, Robinson JV. Cholesteatoma surgery at the Otologic Medical Group. Residual and recurrent disease. A report on 307 revision operations. Am J Otol 1982;3: 209-15. 3. Murphy TP, Wallis DL. Hearing results in pediatric patients after canal-wall-up and canal-wall-down mastoid surgery. Otolaryngol Head Neck Surg 1998;119:439-43. 4. Fisch U. Tympanoplasty, mastoidectomy and stapes surgery. New York: Thieme Medical Publishers; 1994. 5. Vartiainen E, Nuutinen J. Long term hearing results of one stage tympanoplasty for chronic otitis media. Eur Arch Otorhinolaryngol 1992;753-6. 6. Chiossone E. Long term results in intact wall tympanoplasty. In: Tos M, Thomsen J, Peitersen E, editors. Cholesteatoma and mastoid surgery. Amsterdam: Kugler Publications; 1989. p. 663-5. 7. Cruz OLM, Caldas SR, Takeushi M, et al. Clinical and surgical aspects of cholestatoma in children. Ear Nose Throat J 1990:69:530-6. 8. Veldman JE, Braunius WW. Revision surgery for chronic otitis media: a learning experience. Report on 389 cases with a long-term follow-up. Ann Otol Rhinol Laryngol 1998;107:486-91. 9. Nyrop M, Bonding P. Achievement of stable ears in cholesteatoma surgery. Long-term results of three surgical techniques. In: Nakano Y. Cholesteatoma and mastoid surgery. Amsterdam: Kugler Publications; 1992. p. 753-6. 10. Vartiainen E. Ten-year results of canal wall down mastoidectomy for acquired cholesteatoma. Auris Nasus Larynx 2000;27:227-9. 11. Roden D, Honrubia VF, Wiet R. Outcome of residual cholesteatoma and hearing in mastoid surgery. J Otolaryngol 1996;25:178-81. 12. Harkness P, Brown P, Fowler S, et al. Mastoidectomy audit: results of the Royal College of Surgeons of England comparative audit of ENT surgery. Clin Otolaryngol 1995;20:89-94. 13. Costa SS, Hueb MM, Ruschel C, et al. Otite media croˆ nica colesteatomatosa. In: Cruz OLM, Costa SS, editors. Otologia Clinica e Ciru´ rgica. Rio de Janeiro: Revinter; 2000. p. 197-216.