- Email: [email protected]
One-stage reconstruction in management of extensive cholesteatoma
International Congress Series 1240 (2003) 121 – 131
One-stage reconstruction in management of $ extensive cholesteatoma Ramadan Hashem Sayed * ENT Department, Sohag Faculty of Medicine, Sohag, Egypt
Abstract One-stage reconstruction utilizing mainly autogenous materials was done to assess feasibility, safety, and functional outcome. The study included 31 patients with extensive cholesteatoma. Wide exposure through canal wall-down (CWD) procedure, eradication of the pathology, and establishment of Eustachian tube patency were the principal goals leaving an area free of residual disease suitable for one-stage reconstruction. Autogenous conchal cartilage was utilized for reconstruction of the bony meatal wall. Plasti-Pore TORP prosthesis was used for ossicular reconstruction in cases with absent stapes (seven cases), otherwise, temprofascial flap/graft was applied directly over the stapes head as a columella. Intact, rigid, fully epithelialized canal wall was achieved in 100% of cases within 8 weeks. Graft failure with persistent middle ear infection occurred in one case (3.2%). Recurrent cholesteatoma occurred in one case that could be managed in the office, and now, it is free of disease. Hearing improvement occurred in 26:31 (83.9%) of cases with no significant difference between cases with columella type and those with TORP prosthesis reconstruction. We concluded that one-stage reconstruction is a safe procedure in management of extensive cholesteatoma. Autogenous conchal cartilage is a suitable material for canal wall reconstruction. Columella-type tympanoplasty, when stapes is intact, gives good anatomic and functional results without the need for alloplastic materials. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Cholesteatoma; One-stage; Autogenous
1. Introduction There is a wide controversy regarding management of cholesteatoma. Many authors recommend closed technique for anatomic preservation and better functional results. $ This paper was accepted for oral presentation at the XVII World Congress of the IFOS held on 28 September – 3 October 2002 with ref.: 1617O-0. * Tel.: +20-93-325850; fax: +20-93-602963. E-mail address: [email protected] (R.H. Sayed).
0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00837-9
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R.H. Sayed / International Congress Series 1240 (2003) 121–131
However, the failure rate is enormous and unacceptable to the public and to the profession [1]. Others recommend the canal wall-down (CWD) technique for proper exposure and eradication of cholesteatoma to overcome the drawbacks of the canal wall-up (CWU) technique [1– 4], however, with poor anatomic [5,6] and functional results. In two-stage procedures reconstruction is done in the second stage when it is sure that the ear is free of residual or recurrent disease [7,8] and with no trace of infection [9]. The author combined both approaches together in cases with extensive cholesteatoma, using mainly autogenous materials, in a one-stage procedure to assess feasibility, safety, and functional results.
2. Patients and methods The series included 36 patients with extensive cholesteatoma (Fig. 1), proved on exploration, operated upon in the ENT Department, Sohag University Hospital in the period from January 1, 1996 to June 1, 2000. Out of these cases, 5 patients were lost to follow-up and thus excluded. Table 1 shows age and sex distribution and type of operation at presentation in the remaining 31 cases. The patients were subjected to full clinical examination, ENT examination, preoperative audiologic evaluation, and conventional radiographic examination of the mastoids with Schu¨ller’s lateral projection. CT scanning of the temporal bone was done in revision cases. Table 2 shows the preoperative otoscopic findings in these cases. Atticoantral cholesteatoma with extension into the posterior mesotympanum, and in nine cases into the whole mesotympanum, was evident on exploration in all cases.
Fig. 1. Extensive cholesteatoma (ch) filling the mastoid and eroding the posterior bony meatal wall appeared after removal of mastoid cortex.
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Table 1 Age and sex distribution and type of operation at presentation (31 cases) Age
Sex
Type of operation
6 to < 15 years
15 – 54 years
male
female
first time
revision
13 (41.9%)
18 (58.1%)
17 (54.8%)
14 (45.2%)
21 (67.7%)
10 (32.3%)
CWD mastoidectomy with one-stage reconstruction was done in all cases with the following broad points on the technique: – The pathology in the mastoid bowl was eradicated until the confining bony plates were reached and the three semicircular canals were skeletonized, even in cases with sclerotic mastoid (Figs. 2 and 3). – CWD procedure was performed with skeletonization of the vertical part of the facial nerve canal (Fig. 4). – Eradication of cholesteatoma, granulation tissue, granulating mucosa with adequate safety margin of surrounding mucosa down to bare bone was done. – Patency of tympanic orifice of Eustachian tube was achieved by removing any granulations, fibrosis, and cholesteatoma in the region of protympanum, widening of the tympanic orifice, if needed, by careful drilling of overhanging anterior bony lip, and injecting sterile saline, using the sterile cannula of Abbocath-T vein catheter number 22G introduced through the tympanic orifice, to clear tubal lumen of any inspissated discharge. – At this point, one-stage reconstruction could be done with attic obliteration and building up the posterior bony meatal wall utilizing conchal cartilage with its covering perichondrium. If stapes or stapes superstructures were missing, Plasti-Pore TORP prosthesis was applied to the oval window, with intervening perichondrial or vein graft, or to the footplate. TORP prostheses were used in seven cases, three cases were operated upon for the first time, and four cases with revision mastoidectomy. Temprofascial flap or free temprofascial graft was placed beneath the tympanic membrane remnant and Table 2 Preoperative otoscopic findings Otoscopic findings
Number of cases
Posterosuperior pathology (retraction, perforation, granulations, polyp, cholesteatoma) Attic pathology (retraction, crust, perforation, granulations, polyp, cholesteatoma, cavity, erosion) Aural polyp filling the external auditory canal Mesotympanic pathology other than posterosuperior quadrant pathology (perforation, granulations, retraction, cholesteatoma) Meatomastoid fistula with overlying granulations and flakes of cholesteatoma Sagging of the posterosuperior bony meatal wall with tenderness over the mastoid Postauricular mastoid abscess
13
N.B. some patients presented with more than one finding.
9 6 6 2 2 1
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Fig. 2. Cortical mastoidectomy with skeletonization of tegmental plate (TP), sinus plate (SP), semicircular canals (scc).
draped over the head of stapes or prosthesis, with an intervening thin piece of cartilage, and then over the canal wall side of the reconstructing cartilage. Meatoconchoplasty and closure of post-auricular soft tissues and skin were done. Aural pack was removed 2 weeks postoperatively. Serial follow-up was scheduled, at first weekly for 8 weeks, then monthly for 3 months, and every 3– 6 months thereafter to evaluate the size of the meatus, the reconstructed external auditory canal (EAC), state of the tympanic membrane graft, state of middle ear cavity, development of retraction pocket,
Fig. 3. Cortical mastoidectomy with deep tip (T) and retrosigmoid (rs) air cells, removed.
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Fig. 4. Rt. CWD mastoidectomy with lowering the facial ridge down to the level of the facial nerve canal.
and residual or recurrent cholesteatoma. Functional results were assessed at the 12th week and 6th month postoperatively to record:
Functional success: closure of air – bone gap, using the preoperative bone conduction level and the postoperative air conduction level, to less than 20 dB at the hearing frequencies 500, 1000, and 2000 Hz Closure of air – bone gap by 10 dB or more No change in the preoperative hearing level Deterioration of hearing Follow-up period was ranged between 2.2 and 6.7 years with an average of 3.8 years.
3. Results The meatus was sufficiently wide in 30 cases (Fig. 5). In one case, mild decrease in the vertical height of the meatus was observed. Granulation tissue was found to develop in the EAC at the incision sites in 25:31 cases after 3 weeks with minimal serosanguinous, occasionally purulent, discharge. The granulations disappeared within 2 weeks with chemical cautery using chromic acid powder. After 6 – 8 weeks, complete epithelialization of the reconstructed EAC with no areas of epithelial deficits occurred in all cases (Figs. 5 and 6). Intact, well-formed, adequately wide, rigid, and completely epithelialized EAC was achieved in all cases. Mild posterior displacement of the cartilaginous wall occurred in two cases with subsequent increase in
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Fig. 5. Postoperative photograph with adequately wide meatus and epithelialized reconstructed external auditory canal.
the width of the canal without anatomic or functional effects. Mild resorption of the cartilaginous wall was evident in one case after 6 months without anatomic or functional effects. Neomembrane formation with well-aerated middle ear cavity occurred initially in all cases with full epithelialization within 4 –6 weeks (Fig. 6). One case, in which TORP prosthesis was used for ossicular reconstruction, developed graft failure with persistent discharge after 2 months. Revision was done, after failure of conservative treatment for 3 months, and revealed extensive inflammatory reaction surrounding the prosthesis displac-
Fig. 6. Intact, epitheliaslized, well-formed EAC with luster neo-membrane formation.
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Fig. 7. TORP prosthesis (P) surrounded with marked inflammatory reaction (IR).
ing it off the oval window niche (Fig. 7). Removal of the prosthesis and exteriorization were done. In another case, necrosis of the graft occurred at the edge of the cartilaginous plate used for attic obliteration 3 years after the operation. Migration of the external canal skin occurred at the necrosed edge into the attic above the cartilaginous plate with the formation of epithelialized pocket and recurrent cholesteatoma with surrounding granulations at the edges. The mesotympanum was healthy and well formed. This could be managed in the office, and now, it is free of disease over a follow-up period of 2 years. Thus, 30:31 cases had epithelialized healthy graft with well-aerated middle ear cavity (96.8%), 1 case had graft failure with revision (3.2%), and 1 case had recurrent attic cholesteatoma (3.2%) that could be managed in the office, achieving a 100% success in eradication of cholesteatoma. Displaced TORP prosthesis occurred in one case seen through an intact graft. Table 3 shows the functional results in these cases. Deterioration by 10 dB occurred in 2:31 cases (6.4%). One case that developed graft failure with TORP prosthesis, and the second case was a 55-year-old patient with revision surgery and preoperative mixed hearing loss. No significant changes in the functional results were observed on reassessment at 6 months. Table 3 Functional results 12 weeks postoperatively Hearing improvement = 26:31 (83.9%)
First time cases, 21:31 Revision cases, 10:31 TORP reconstruction, 7:31 Columella-type, 24:31
Functional success, 18:31 (58.1%)
Gain of z 10 dB, 8:31 (25.8%)
13:21 5:10 4:7 14:24
4:21 4:10 1:7 7:24
(61.9%) (50%) (57.1%) (58.3%)
(19%) (40%) (14.3%) (29.2%)
No change, 3:31 (9.7%)
Deterioration, 2:31 (6.4%)
3:21 0 1:7 2:24
1:21 1:10 1:7 1:24
(14.3%) (0%) (14.3%) (8.3%)
(4.8%) (10%) (14.3%) (4.2%)
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4. Discussion Eradication of the pathology through an adequate approach is the principal goal in management of cholesteatoma. Variability of the extent of the pathology necessitates tailoring the surgical procedure according to the operative findings. In our locality, late presentation of cholesteatoma cases with high incidence of extensive cholesteatoma is evident. By extensive cholesteatoma, authors meant ears in which mastoidectomy was a necessary step for complete removal of cholesteatoma [3,4]. Eradication of the pathology in the mastoid, even in cases with markedly sclerotic mastoids, was done, leaving a safe mastoid bowl suitable for reconstruction. In many of these cases, deeper air cells filled with granulations were found within the hard bone of the sclerotic mastoid, which if left behind, recurrence would occur. CWD procedure was done in all cases as it provides the best direct view of important areas, namely, the epitympanum and sinus tympani with successful removal of the disease process of cholesteatoma [1]. The canal wall itself might be involved in the disease process in cases with meatomastoid fistula (two cases), border air cell involvement with granulation tissue (two cases), and sagging (two cases), so its removal would be a part of disease eradication not only of disease exposure. In this series, adequate exposure was achieved by skeletonization of the vertical part of the facial nerve canal, together with tilting the patient’s head and the microscope, to improve visualization of the difficult posterior mesotympanum. Eradication of all stratified squamous epithelium and surrounding granulating mucosa with safety margin of healthy mucosa in the middle ear could be effectively done through this wide approach. Palva [10] found that the squamous epithelium could migrate along the perforation edge and grow inward, on the medial side of the pars tensa, with receding of the columnar epithelium accordingly. Moreover, it could advance along the distorted collagen fibers formed by the inflammatory reaction. One can say that cholesteatoma behaves like a locally malignant process; however, it is non-neoplastic. Thus, adequate eradication is a must in cholesteatoma surgery; otherwise, in case of doubt, exteriorization should be the rule. Establishment of Eustachian tube patency is an essential step before considering reconstruction. Tos [11] reported removal of the pathology at the tympanic orifice of the tube and bouginage of the tube with a soft rubber bougie to improve tubal function. Saline injection through the tympanic orifice of the tube is more safe and will clear any inspissated plugs obstructing tubal lumen. After adequate exposure, eradication of the pathology, and establishment of Eustachian tube patency, one-stage reconstruction was done. It would be easier to reconstruct in the same procedure with virgin tissues and less harmful to the patient and his relatives. The fear that canal wall reconstruction or mastoid obliteration may hide a residual disease in the mastoid bowl is without convincing practical evidence. The reported incidence of residual cholesteatoma in the mastoid bowl was 1% in cases with CWD with reconstruction and 0% in cases with CWU procedure [3], 0% in cases with obliteration [12], and one ear out of 680 reconstructed cases [2]. In our series, there was no recorded case of residual or recurrent cholesteatoma in the mastoid bowl.
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Several materials have been used in the reconstruction of bony meatal wall. The patient’s own tissues are the material of choice in reconstruction [10]. In this series, autogenous conchal cartilage with its covering perichondrium, i.e., a chondro-perichondrial graft, covered with temprofascial graft/flap was used at the time of initial surgery. No difference in the healing power was observed between cases in which a temprofascial graft or flap was used. It had the advantages of being self, readily available, economic, requiring neither time-consuming reshaping nor extensive tissue flaps for coverage. Epithelial breakdown and material exposure with autogenous cartilage was not observed in any case. This was obviously due to the facts of being self, pliable tissue with no marked foreign body inflammatory reaction causing devitalization of soft tissue coverage [13]. The only technical difficulty in using autogenous conchal cartilage was to anchor the cartilage graft securely into the large defect of the entire posterior canal wall. Wehrs [14] and Wigand et al. [15], using cartilage grafts in reconstruction, also reported this difficulty. To overcome this problem, the lower cut of the cartilage was fashioned to fit the contour of the taken down facial ridge, and it was supported with gelfoam. Bergon [16] reported that the cartilage could lose bulk with subsequent retraction. By using cartilage covered with its perichondrium, this problem was met in only one case without anatomic or functional effects. Thus, successful reconstruction of the bony meatal wall using autogenous conchal cartilage occurred in all cases over 8 weeks. Recently, bone substitute was reported to be the material of choice for rebuilding the posterior canal wall, however, with a high incidence of failure in 36% of cases reported by Weit et al. [17], 25% of cases reported by Grote [8], both using hydroxylapatite, and 31% of cases reported by Geyer et al. [9] using ionomeric cement which necessitated revision surgery and removal of canal wall. The main reason for failure, as reported by these authors, was postoperative implant exposure despite good soft tissue coverage with extensive flapping using periosteal flap, fibrovascular flap, and skin flaps [8,9]. Geyer et al. [9] advised restriction of ionomeric cement implantation to middle ears with permanent ventilation and no trace of infection. With the use of autogenous cartilage, one-stage eradication of the pathology and reconstruction could be performed in the presence of active middle ear cleft infection complicated in three cases with mastoid abscess/sagging. So, we can say that autogenous cartilage is a suitable material for meatal wall reconstruction. Graft failure with persistent middle ear infection occurred in one case, in which TORP prosthesis was used for ossicular reconstruction, with extensive inflammatory reaction surrounding the prosthesis, necessitating its removal and exteriorization. Schuknecht and Shi [13] found that alloplast prostheses of polyethylene incite foreign body reactions as a cause for failure that often leads to revision procedures. No single case of residual or recurrent cholesteatoma was detected in the mesotympanum. Moreover, the only case that developed recurrent cholesteatoma was due to a technical fault in the orientation of the cartilaginous plate used for attic obliteration with its mediolateral concavity towards the canal side. With office management, it is now free of disease, achieving a 100% success in eradication of extensive cholesteatoma for the first time to the best of our knowledge. Functional success was achieved in 18:31 cases (58.1%). It was achieved in 14:24 cases (58.3%) in which the graft was applied directly over the stapes head. This is comparable to
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that reported by Grote [8] who performed ossicular reconstruction with dense hydroxylapatite prosthesis and achieved functional success in 24:44 cases (54.5%).
5. Conclusion One-stage reconstruction becomes a safe procedure in management of extensive cholesteatoma when the operation achieves three goals: 1. Adequate exposure by CWD procedure with skeletonization of the vertical part of the facial nerve canal 2. Wide eradication of cholesteatoma, granulating mucosa with safety margin of healthy mucosa, and all air cells 3. Establishment of Eustachian tube patency Autogenous conchal cartilage is a safe and suitable material for canal wall reconstruction with high success rate within a short time. If the stapes is present, good anatomic and functional results can be obtained if the graft is applied as a columella without the use of alloplastic materials for ossicular reconstruction.
References [1] J. Hough, The canal wall up or down debate. The case for the canal wall down, J. Laryngol. Otol. (Suppl. 8) (1983) 92 – 94. [2] A. Palva, K. Jokinen, K. Ojala, Cholesteatoma after radical mastoidectomy with cavity obliteration, Acta Otolaryngol. (Stockh.) (Suppl. 386) (1982) 57 – 59. [3] G.D.L. Smyth, Cholesteatoma surgery: the influence of the canal wall, Laryngoscope 95 (1985) 92 – 94. [4] M. Nyrop, P. Bonding, Extensive cholesteatoma: long-term results of three surgical techniques, J. Laryngol. Otol. 111 (1997) 521 – 526. [5] A. Males, R. Grey, Mastoid misery: quantifying the distress in a radical cavity, Clin. Otolaryngol. 16 (1991) 12 – 14. [6] P.J. Wormald, E. Nilssen, The facial ridge and the discharging mastoid cavity, Laryngoscope 108 (1998) 92 – 96. [7] J.L. Sheehy, Recurrent and residual disease in cholesteatoma surgery, Clin. Otolaryngol. 3 (1978) 393 – 403. [8] J.J. Grote, Results of cavity reconstruction with hydroxylapatite implants after 15 years, Am. J. Otol. 19 (1998) 565 – 568. [9] G. Geyer, S. Dazert, J. Helms, Performance of ionomeric cement (ionocem) in the reconstruction of the posterior meatal wall after curative middle ear surgery, J. Laryngol. Otol. 111 (1997) 1130 – 1136. [10] T. Palva, The pathogenesis and treatment of cholesteatoma, Acta Otolaryngol. (Stockh.) 109 (1990) 323 – 330. [11] M. Tos, Management of tubal function in reconstructive middle ear surgery, J. Laryngol. Otol. 94 (1980) 25 – 30. [12] T. Palva, Surgical treatment of chronic middle ear disease: II. Canal wall up and canal wall down procedures, Acta Otolaryngol. (Stockh.) 104 (1987) 487 – 494. [13] H.F. Schkuknecht, S.R. Shi, Surgical pathology of middle ear implants, Laryngoscope 95 (1985) 249 – 258. [14] R.E. Wehrs, Reconstructive mastoidectomy with homograft knee cartilage, Laryngoscope 82 (1972) 1177 – 1188.
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[15] M.E. Wigand, M. Weidenbecher, P. Bumin, et al., Tympanoplastik nach radickaloperation: mit konchen oder knorpel, Arch. Otorhinolaryngol. 207 (1974) 542 – 544. [16] J. Bergon, Principles of tissue transplantation as applied to otology, Arch. Otoloaryngol. 97 (1973) 70 – 73. [17] R.J. Wiet, S.A. Harvey, M.G. Pyle, Canal wall reconstruction: a newer implantation technique, Laryngoscope 103 (1993) 594 – 599.
One-stage reconstruction in management of $ extensive cholesteatoma Ramadan Hashem Sayed * ENT Department, Sohag Faculty of Medicine, Sohag, Egypt
Abstract One-stage reconstruction utilizing mainly autogenous materials was done to assess feasibility, safety, and functional outcome. The study included 31 patients with extensive cholesteatoma. Wide exposure through canal wall-down (CWD) procedure, eradication of the pathology, and establishment of Eustachian tube patency were the principal goals leaving an area free of residual disease suitable for one-stage reconstruction. Autogenous conchal cartilage was utilized for reconstruction of the bony meatal wall. Plasti-Pore TORP prosthesis was used for ossicular reconstruction in cases with absent stapes (seven cases), otherwise, temprofascial flap/graft was applied directly over the stapes head as a columella. Intact, rigid, fully epithelialized canal wall was achieved in 100% of cases within 8 weeks. Graft failure with persistent middle ear infection occurred in one case (3.2%). Recurrent cholesteatoma occurred in one case that could be managed in the office, and now, it is free of disease. Hearing improvement occurred in 26:31 (83.9%) of cases with no significant difference between cases with columella type and those with TORP prosthesis reconstruction. We concluded that one-stage reconstruction is a safe procedure in management of extensive cholesteatoma. Autogenous conchal cartilage is a suitable material for canal wall reconstruction. Columella-type tympanoplasty, when stapes is intact, gives good anatomic and functional results without the need for alloplastic materials. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Cholesteatoma; One-stage; Autogenous
1. Introduction There is a wide controversy regarding management of cholesteatoma. Many authors recommend closed technique for anatomic preservation and better functional results. $ This paper was accepted for oral presentation at the XVII World Congress of the IFOS held on 28 September – 3 October 2002 with ref.: 1617O-0. * Tel.: +20-93-325850; fax: +20-93-602963. E-mail address: [email protected] (R.H. Sayed).
0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00837-9
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However, the failure rate is enormous and unacceptable to the public and to the profession [1]. Others recommend the canal wall-down (CWD) technique for proper exposure and eradication of cholesteatoma to overcome the drawbacks of the canal wall-up (CWU) technique [1– 4], however, with poor anatomic [5,6] and functional results. In two-stage procedures reconstruction is done in the second stage when it is sure that the ear is free of residual or recurrent disease [7,8] and with no trace of infection [9]. The author combined both approaches together in cases with extensive cholesteatoma, using mainly autogenous materials, in a one-stage procedure to assess feasibility, safety, and functional results.
2. Patients and methods The series included 36 patients with extensive cholesteatoma (Fig. 1), proved on exploration, operated upon in the ENT Department, Sohag University Hospital in the period from January 1, 1996 to June 1, 2000. Out of these cases, 5 patients were lost to follow-up and thus excluded. Table 1 shows age and sex distribution and type of operation at presentation in the remaining 31 cases. The patients were subjected to full clinical examination, ENT examination, preoperative audiologic evaluation, and conventional radiographic examination of the mastoids with Schu¨ller’s lateral projection. CT scanning of the temporal bone was done in revision cases. Table 2 shows the preoperative otoscopic findings in these cases. Atticoantral cholesteatoma with extension into the posterior mesotympanum, and in nine cases into the whole mesotympanum, was evident on exploration in all cases.
Fig. 1. Extensive cholesteatoma (ch) filling the mastoid and eroding the posterior bony meatal wall appeared after removal of mastoid cortex.
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Table 1 Age and sex distribution and type of operation at presentation (31 cases) Age
Sex
Type of operation
6 to < 15 years
15 – 54 years
male
female
first time
revision
13 (41.9%)
18 (58.1%)
17 (54.8%)
14 (45.2%)
21 (67.7%)
10 (32.3%)
CWD mastoidectomy with one-stage reconstruction was done in all cases with the following broad points on the technique: – The pathology in the mastoid bowl was eradicated until the confining bony plates were reached and the three semicircular canals were skeletonized, even in cases with sclerotic mastoid (Figs. 2 and 3). – CWD procedure was performed with skeletonization of the vertical part of the facial nerve canal (Fig. 4). – Eradication of cholesteatoma, granulation tissue, granulating mucosa with adequate safety margin of surrounding mucosa down to bare bone was done. – Patency of tympanic orifice of Eustachian tube was achieved by removing any granulations, fibrosis, and cholesteatoma in the region of protympanum, widening of the tympanic orifice, if needed, by careful drilling of overhanging anterior bony lip, and injecting sterile saline, using the sterile cannula of Abbocath-T vein catheter number 22G introduced through the tympanic orifice, to clear tubal lumen of any inspissated discharge. – At this point, one-stage reconstruction could be done with attic obliteration and building up the posterior bony meatal wall utilizing conchal cartilage with its covering perichondrium. If stapes or stapes superstructures were missing, Plasti-Pore TORP prosthesis was applied to the oval window, with intervening perichondrial or vein graft, or to the footplate. TORP prostheses were used in seven cases, three cases were operated upon for the first time, and four cases with revision mastoidectomy. Temprofascial flap or free temprofascial graft was placed beneath the tympanic membrane remnant and Table 2 Preoperative otoscopic findings Otoscopic findings
Number of cases
Posterosuperior pathology (retraction, perforation, granulations, polyp, cholesteatoma) Attic pathology (retraction, crust, perforation, granulations, polyp, cholesteatoma, cavity, erosion) Aural polyp filling the external auditory canal Mesotympanic pathology other than posterosuperior quadrant pathology (perforation, granulations, retraction, cholesteatoma) Meatomastoid fistula with overlying granulations and flakes of cholesteatoma Sagging of the posterosuperior bony meatal wall with tenderness over the mastoid Postauricular mastoid abscess
13
N.B. some patients presented with more than one finding.
9 6 6 2 2 1
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Fig. 2. Cortical mastoidectomy with skeletonization of tegmental plate (TP), sinus plate (SP), semicircular canals (scc).
draped over the head of stapes or prosthesis, with an intervening thin piece of cartilage, and then over the canal wall side of the reconstructing cartilage. Meatoconchoplasty and closure of post-auricular soft tissues and skin were done. Aural pack was removed 2 weeks postoperatively. Serial follow-up was scheduled, at first weekly for 8 weeks, then monthly for 3 months, and every 3– 6 months thereafter to evaluate the size of the meatus, the reconstructed external auditory canal (EAC), state of the tympanic membrane graft, state of middle ear cavity, development of retraction pocket,
Fig. 3. Cortical mastoidectomy with deep tip (T) and retrosigmoid (rs) air cells, removed.
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Fig. 4. Rt. CWD mastoidectomy with lowering the facial ridge down to the level of the facial nerve canal.
and residual or recurrent cholesteatoma. Functional results were assessed at the 12th week and 6th month postoperatively to record:
Functional success: closure of air – bone gap, using the preoperative bone conduction level and the postoperative air conduction level, to less than 20 dB at the hearing frequencies 500, 1000, and 2000 Hz Closure of air – bone gap by 10 dB or more No change in the preoperative hearing level Deterioration of hearing Follow-up period was ranged between 2.2 and 6.7 years with an average of 3.8 years.
3. Results The meatus was sufficiently wide in 30 cases (Fig. 5). In one case, mild decrease in the vertical height of the meatus was observed. Granulation tissue was found to develop in the EAC at the incision sites in 25:31 cases after 3 weeks with minimal serosanguinous, occasionally purulent, discharge. The granulations disappeared within 2 weeks with chemical cautery using chromic acid powder. After 6 – 8 weeks, complete epithelialization of the reconstructed EAC with no areas of epithelial deficits occurred in all cases (Figs. 5 and 6). Intact, well-formed, adequately wide, rigid, and completely epithelialized EAC was achieved in all cases. Mild posterior displacement of the cartilaginous wall occurred in two cases with subsequent increase in
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Fig. 5. Postoperative photograph with adequately wide meatus and epithelialized reconstructed external auditory canal.
the width of the canal without anatomic or functional effects. Mild resorption of the cartilaginous wall was evident in one case after 6 months without anatomic or functional effects. Neomembrane formation with well-aerated middle ear cavity occurred initially in all cases with full epithelialization within 4 –6 weeks (Fig. 6). One case, in which TORP prosthesis was used for ossicular reconstruction, developed graft failure with persistent discharge after 2 months. Revision was done, after failure of conservative treatment for 3 months, and revealed extensive inflammatory reaction surrounding the prosthesis displac-
Fig. 6. Intact, epitheliaslized, well-formed EAC with luster neo-membrane formation.
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Fig. 7. TORP prosthesis (P) surrounded with marked inflammatory reaction (IR).
ing it off the oval window niche (Fig. 7). Removal of the prosthesis and exteriorization were done. In another case, necrosis of the graft occurred at the edge of the cartilaginous plate used for attic obliteration 3 years after the operation. Migration of the external canal skin occurred at the necrosed edge into the attic above the cartilaginous plate with the formation of epithelialized pocket and recurrent cholesteatoma with surrounding granulations at the edges. The mesotympanum was healthy and well formed. This could be managed in the office, and now, it is free of disease over a follow-up period of 2 years. Thus, 30:31 cases had epithelialized healthy graft with well-aerated middle ear cavity (96.8%), 1 case had graft failure with revision (3.2%), and 1 case had recurrent attic cholesteatoma (3.2%) that could be managed in the office, achieving a 100% success in eradication of cholesteatoma. Displaced TORP prosthesis occurred in one case seen through an intact graft. Table 3 shows the functional results in these cases. Deterioration by 10 dB occurred in 2:31 cases (6.4%). One case that developed graft failure with TORP prosthesis, and the second case was a 55-year-old patient with revision surgery and preoperative mixed hearing loss. No significant changes in the functional results were observed on reassessment at 6 months. Table 3 Functional results 12 weeks postoperatively Hearing improvement = 26:31 (83.9%)
First time cases, 21:31 Revision cases, 10:31 TORP reconstruction, 7:31 Columella-type, 24:31
Functional success, 18:31 (58.1%)
Gain of z 10 dB, 8:31 (25.8%)
13:21 5:10 4:7 14:24
4:21 4:10 1:7 7:24
(61.9%) (50%) (57.1%) (58.3%)
(19%) (40%) (14.3%) (29.2%)
No change, 3:31 (9.7%)
Deterioration, 2:31 (6.4%)
3:21 0 1:7 2:24
1:21 1:10 1:7 1:24
(14.3%) (0%) (14.3%) (8.3%)
(4.8%) (10%) (14.3%) (4.2%)
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4. Discussion Eradication of the pathology through an adequate approach is the principal goal in management of cholesteatoma. Variability of the extent of the pathology necessitates tailoring the surgical procedure according to the operative findings. In our locality, late presentation of cholesteatoma cases with high incidence of extensive cholesteatoma is evident. By extensive cholesteatoma, authors meant ears in which mastoidectomy was a necessary step for complete removal of cholesteatoma [3,4]. Eradication of the pathology in the mastoid, even in cases with markedly sclerotic mastoids, was done, leaving a safe mastoid bowl suitable for reconstruction. In many of these cases, deeper air cells filled with granulations were found within the hard bone of the sclerotic mastoid, which if left behind, recurrence would occur. CWD procedure was done in all cases as it provides the best direct view of important areas, namely, the epitympanum and sinus tympani with successful removal of the disease process of cholesteatoma [1]. The canal wall itself might be involved in the disease process in cases with meatomastoid fistula (two cases), border air cell involvement with granulation tissue (two cases), and sagging (two cases), so its removal would be a part of disease eradication not only of disease exposure. In this series, adequate exposure was achieved by skeletonization of the vertical part of the facial nerve canal, together with tilting the patient’s head and the microscope, to improve visualization of the difficult posterior mesotympanum. Eradication of all stratified squamous epithelium and surrounding granulating mucosa with safety margin of healthy mucosa in the middle ear could be effectively done through this wide approach. Palva [10] found that the squamous epithelium could migrate along the perforation edge and grow inward, on the medial side of the pars tensa, with receding of the columnar epithelium accordingly. Moreover, it could advance along the distorted collagen fibers formed by the inflammatory reaction. One can say that cholesteatoma behaves like a locally malignant process; however, it is non-neoplastic. Thus, adequate eradication is a must in cholesteatoma surgery; otherwise, in case of doubt, exteriorization should be the rule. Establishment of Eustachian tube patency is an essential step before considering reconstruction. Tos [11] reported removal of the pathology at the tympanic orifice of the tube and bouginage of the tube with a soft rubber bougie to improve tubal function. Saline injection through the tympanic orifice of the tube is more safe and will clear any inspissated plugs obstructing tubal lumen. After adequate exposure, eradication of the pathology, and establishment of Eustachian tube patency, one-stage reconstruction was done. It would be easier to reconstruct in the same procedure with virgin tissues and less harmful to the patient and his relatives. The fear that canal wall reconstruction or mastoid obliteration may hide a residual disease in the mastoid bowl is without convincing practical evidence. The reported incidence of residual cholesteatoma in the mastoid bowl was 1% in cases with CWD with reconstruction and 0% in cases with CWU procedure [3], 0% in cases with obliteration [12], and one ear out of 680 reconstructed cases [2]. In our series, there was no recorded case of residual or recurrent cholesteatoma in the mastoid bowl.
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Several materials have been used in the reconstruction of bony meatal wall. The patient’s own tissues are the material of choice in reconstruction [10]. In this series, autogenous conchal cartilage with its covering perichondrium, i.e., a chondro-perichondrial graft, covered with temprofascial graft/flap was used at the time of initial surgery. No difference in the healing power was observed between cases in which a temprofascial graft or flap was used. It had the advantages of being self, readily available, economic, requiring neither time-consuming reshaping nor extensive tissue flaps for coverage. Epithelial breakdown and material exposure with autogenous cartilage was not observed in any case. This was obviously due to the facts of being self, pliable tissue with no marked foreign body inflammatory reaction causing devitalization of soft tissue coverage [13]. The only technical difficulty in using autogenous conchal cartilage was to anchor the cartilage graft securely into the large defect of the entire posterior canal wall. Wehrs [14] and Wigand et al. [15], using cartilage grafts in reconstruction, also reported this difficulty. To overcome this problem, the lower cut of the cartilage was fashioned to fit the contour of the taken down facial ridge, and it was supported with gelfoam. Bergon [16] reported that the cartilage could lose bulk with subsequent retraction. By using cartilage covered with its perichondrium, this problem was met in only one case without anatomic or functional effects. Thus, successful reconstruction of the bony meatal wall using autogenous conchal cartilage occurred in all cases over 8 weeks. Recently, bone substitute was reported to be the material of choice for rebuilding the posterior canal wall, however, with a high incidence of failure in 36% of cases reported by Weit et al. [17], 25% of cases reported by Grote [8], both using hydroxylapatite, and 31% of cases reported by Geyer et al. [9] using ionomeric cement which necessitated revision surgery and removal of canal wall. The main reason for failure, as reported by these authors, was postoperative implant exposure despite good soft tissue coverage with extensive flapping using periosteal flap, fibrovascular flap, and skin flaps [8,9]. Geyer et al. [9] advised restriction of ionomeric cement implantation to middle ears with permanent ventilation and no trace of infection. With the use of autogenous cartilage, one-stage eradication of the pathology and reconstruction could be performed in the presence of active middle ear cleft infection complicated in three cases with mastoid abscess/sagging. So, we can say that autogenous cartilage is a suitable material for meatal wall reconstruction. Graft failure with persistent middle ear infection occurred in one case, in which TORP prosthesis was used for ossicular reconstruction, with extensive inflammatory reaction surrounding the prosthesis, necessitating its removal and exteriorization. Schuknecht and Shi [13] found that alloplast prostheses of polyethylene incite foreign body reactions as a cause for failure that often leads to revision procedures. No single case of residual or recurrent cholesteatoma was detected in the mesotympanum. Moreover, the only case that developed recurrent cholesteatoma was due to a technical fault in the orientation of the cartilaginous plate used for attic obliteration with its mediolateral concavity towards the canal side. With office management, it is now free of disease, achieving a 100% success in eradication of extensive cholesteatoma for the first time to the best of our knowledge. Functional success was achieved in 18:31 cases (58.1%). It was achieved in 14:24 cases (58.3%) in which the graft was applied directly over the stapes head. This is comparable to
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that reported by Grote [8] who performed ossicular reconstruction with dense hydroxylapatite prosthesis and achieved functional success in 24:44 cases (54.5%).
5. Conclusion One-stage reconstruction becomes a safe procedure in management of extensive cholesteatoma when the operation achieves three goals: 1. Adequate exposure by CWD procedure with skeletonization of the vertical part of the facial nerve canal 2. Wide eradication of cholesteatoma, granulating mucosa with safety margin of healthy mucosa, and all air cells 3. Establishment of Eustachian tube patency Autogenous conchal cartilage is a safe and suitable material for canal wall reconstruction with high success rate within a short time. If the stapes is present, good anatomic and functional results can be obtained if the graft is applied as a columella without the use of alloplastic materials for ossicular reconstruction.
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