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Scutumplasty: costal cartilage versus bone paté
Auris Nasus Larynx 25 (1998) 155 – 159
Scutumplasty: costal cartilage versus bone pate´ S. Bacciu a,*, E. Pasanisi a, G. Perez Raffo a, J. Avendano Arambula a, F. Piazza a, A. Bacciu a, P. Govoni b, M. Guida a, C. Zini a a
Department of Otolaryngology, ENT Clinic, Uni6ersity of Parma, Via Gramsci, 14, 43100 Parma, Italy b Institute of Histology and Embryology, Uni6ersity of Parma, Via Gramsci, 14, 43100 Parma, Italy Received 19 May 1997; received in revised form 22 September 1997; accepted 14 November 1997
Abstract This study was carried out to evaluate the anatomical and hearing results of the reparation of attic defects in closed tympanoplasty. Reparation was carried out in 194 patients by using a costal cartilage allograft, and in 159 patients with a bone pate´ autograft. The follow-up was from 1 to 5 years. The study was not truly randomized owing to an occasional lack of allogenic costal cartilage. In the group ‘costal cartilage’ a partial resorption was observed in 5.7% and a complete resorption in 4.7% of the cases. In the group ‘bone pate´’, partial resorption was observed in 5.5% and total resorption in 2.7% of the patients. Satisfactory hearing results were obtained in 86% of the patients of the group ‘costal cartilage’ and in 82% of the patients of the group ‘bone pate´’. Both graft materials may be recommended for repairing erosions caused by the cholesteatoma in the wall of the external auditory canal. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Closed technique; Cholesteatoma surgery; Scutumplasty; Posterior canal wall defect; Allograft cartilage; Bone pate´
1. Introduction Retraction pockets and subsequent formation of recurrent cholesteatoma are the consequence of the retraction of the new tympanic membrane inside an attic defect after a closed (intact canal wall) tympanoplasty [1 – 9]. In order to prevent this complication, which occurs in 2.2%, up to * Corresponding author.
20% of the patients [4,5,7,10,11], it is essential to repair any defect existing in the superior or posterior canal wall. For this reparation, which is called scutumplasty, various materials have been recommended: cortical bony autograft [8,10,11]; autograft cartilage [6,12,13]; allograft cartilage [14–17]; autograft bone pate´ [18]; xenograft cartilage [19] and alloplastic materials [20,21]. The aim of this study is to compare the anatomical and hearing results of scutumplasty
0385-8146/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0385-8146(98)00005-4
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S. Bacciu et al. / Auris Nasus Larynx 25 (1998) 155–159
carried out with two different materials: allogenic costal cartilage or autogenous bone pate´.
tween the mean preoperative bone conduction and the mean post-operative air conduction. Dead ears (2/353) were excluded from the study. The follow-up ranged from 1 to 5 years.
2. Materials and methods From January 1990 to December 1994, 412 patients suffering from chronic otitis media with cholesteatoma underwent a closed tympanoplasty (in one or two stages) at the Department of Otolaryngology of the University of Parma. Patients were subdivided into two groups, according to the material used to reconstruct the scutum:
2.1. Group ‘costal cartilage’ This group included 194 patients in which attic reconstruction was performed using allogenic costal cartilage. The grafts were obtained from donors and were placed immediately after removal in a 50% rifampin solution for 24 h. Afterwards, they were placed in a 70% ethyl-alcohol solution until needed for surgery. At the time of surgery, the cartilage was taken out of the solution under sterile conditions and thoroughly washed with saline.
2.2. Group ‘bone pate´’ This included 159 patients in which the scutum reconstruction was performed using bone pate´ following the technique described by Gersdorff [18]. Initial attempts at randomization failed as a result of occasional lacking of allogenic costal cartilage. Therefore, the study is not truly randomized. A total of 59 cases were excluded from the statistical evaluation: seven because the reconstruction was carried out using bone pate´ plus cartilage, and 52 because no reconstruction of the scutum was needed. The anatomical results were evaluated by means of an operating microscope during the second stage procedure (in case of staged surgery) and during the postoperative control examinations. The functional results were based on the mean residual air-bone gap at 0.5, 1 and 2 kHz, after the functional stage. Residual air-bone gap was defined as the difference be-
3. Results Surgical success was defined as complete integrity of the canal wall without further retraction pocket in the attic or in the posterosuperior quadrant and a postoperative residual air-bone gap 5 25 dB HL. Out of a total of 353 cases (including both adults and children), a scutum reconstruction with costal cartilage was performed in 194 cases (55%), while a scutumplasty using bone pate´ was performed in 159 cases (45%) (Fig. 1). At second stage tympanoplasty, in the group ‘costal cartilage’, the scutum was found normal (Fig. 2) in 155 cases (89.6%). A partial resorption of the graft was observed in ten cases (5.7%), a complete resorption in eight cases (4.7%) (Table 1) and a recurrent retraction pocket in nine cases (5.2%). At second stage tympanoplasty, in the group ‘bone pate´’, the scutum was found normal (Fig. 3) in 134 cases (91.8%). In 42 patients there was a remarkable hypertrophy of the bone pate´ which was thinned out during the second stage by using a diamond burr. A partial resorption of the bone pate´ was observed in eight patients (5.5%) and a total resorption in four cases (2.7%) (Table 1). The incidence of recurrent cholesteatoma was 4/ 353 cases (1.1%): one case was included in group
Fig. 1. Reconstruction of the scutum (353 cases, 1989 – 1994).
S. Bacciu et al. / Auris Nasus Larynx 25 (1998) 155–159
Fig. 2. Intraoperative findings (II stage). The costal cartilage graft is in correct position. the chondroprostheses is put in place.
A, while three cases were included in group B (minimum follow up: 1 year). The incidence of residual disease, in case of staged surgery, was 26% (46/173) in the group A and 22% (32/146) in the other group (Table 2). Figs. 4 and 5 show hearing results following scutumplasty with cartilage or bone pate´. The results were evaluated at 3 months, 1 and 3 years. At the 3-year follow-up satisfactory hearing results (postoperative residual air-bone gap 5 25 dB) were obtained in 86% of the patients of the group ‘costal cartilage’ and in 82% of the patients of the group ‘bone pate´’.
4. Discussion Recurrent cholesteatoma is a term used to define a new cholesteatoma occurring in an ear
Fig. 3. Intraoperative findings (II stage). The autogenous bone pate´ graft is in normal position and integrity.
which has already been operated on. It develops from a retraction pocket that grows inside the attic or the posterior mesotympanum or from ingrowth of the skin due to the failure of the graft which was used to repair the erosion caused by the cholesteatoma in the wall of the external auditory canal [1,3–5,13,22–25]. In order to avoid the formation of retraction pockets, every bone defect of the posterior canal wall must be repaired [1–3,5,7,13]. Not all the retraction pockets have the same clinical relevance: small self-cleansing retraction pockets are innocent, while large invaginations are cleaned with difficulty and may be infected [3]. Smyth and Robinson have demonstrated that the incidence of retraction pockets have decreased from 15 to 5% when a systematic reconstruction of the scutum is Table 2 Curative failures
Table 1 Intraoperative graft findings at second stage tympanoplasty Findings
Normal Total resorption Partial resorption
Graft material Cartilage (%), n= 173
Bone pate´ (%), n= 146
155 (89.6) 8 (4.7) 10 (5.7)
134 (91.8) 4 (2.7) 8 (5.5)
157
Retraction pockets Recurrent cholesteatoma Perforations neotympanum Myringitis Residual cholesteatoma a
Cartilage (%), n =194)
Bone pate´ (%), n =159
5.2a 0.5a
2.5a 2.0a
5.2
0.6
1.5 46/173 (26%)
2.0 32/146 (22%)
Follow up: (1 – 5) years.
158
S. Bacciu et al. / Auris Nasus Larynx 25 (1998) 155–159
the Eustachian tube to the mastoid) and to the surgical treatment of the tube (when needed). One of the problems of the graft material used in scutumplasty was found to be its postoperative atrophy and resorption. Following our previous experience with septal and meniscous allogenous cartilage, today, we prefer to use costal allogenic cartilage or bone pate´ because with these materials present a lower incidence of resorption. Most of the patients have reached a socially useful hearing at 2-year or more follow-up. Fig. 4. Functional results (cartilage, 194 cases).
performed [26]. According to Sade et al. [3], retraction pockets generally appear within 2 years from surgery, and this indicates that time plays only a limited role in the formation of postoperative pockets. In a previous study, carried out using septal or meniscous allogenic cartilage for reconstruction, we found an incidence of retraction pockets in intact canal wall of 9.2% [24]. In the present series, the incidence of retraction pockets was of 5.2% after reconstruction with cartilage and of 2.5% after reconstruction with bone pate´. Partial resorption was the same in the two groups. Total resorption was higher in the costal cartilage group (4.7%) than in the bone pate´ group (2.7%). We would like to point out that a low incidence of retraction pockets, and consequently of recurrent cholesteatoma, is not only related to the reconstruction of the scutum but also to the use of a thick silastic sheet (from
Fig. 5. Functional results (bone pate´, 159 cases).
5. Conclusion Reconstruction of the bony canal wall defects is one of the most important steps of closed tympanoplasty, in order to prevent the formation of retraction pockets. Partial graft resorption was the same in the two groups, while total resorption was higher in the costal cartilage group. Most of our patients have obtained a socially useful hearing at the 2-year or more follow-up. Both costal cartilage and bone pate´ present the features that all good graft materials should have: adaptability, availability, tolerance and low cost. References [1] Black B. Prevention of recurrent cholesteatoma: use of hydroxyapatite plates and composite grafts. Am J Otol 1992;13:273 – 8. [2] Chiossone E. Three cartilages’ technique in intact canal wall tympanoplasty to prevent recurrent cholesteatoma. Am J Otol 1985;6:226 – 30. [3] Sade` J, Berco E, Brown M. Results of mastoid operations in various chronic ear diseases. Am J Otol 1981;3:11 – 20. [4] Karmarkar S, Bhatia S, Saleh E, DeDonato G, Taibah A, Russo A, Sanna M. Cholesteatoma surgery: the individualized technique. Ann Otol Rhinol Laryngol 1995;104:591 – 5. [5] Sanna M, Zini C, Scandellari R, Jemmi G. Residual and recurrent cholesteatoma in closed tympanoplasty. Am J Otol 1984;5:277 – 82. [6] McCleve DE. Tragal cartilage reconstruction of the auditory canal. Arch Otol 1969;90:271 – 4. [7] Yanagihara N, Gyo K, Sasaki Y, Hinohira Y. Prevention of recurrent of cholesteatoma in intact canal wall tympanoplasty. Am J Otol 1993;14:590 – 4. [8] Pou J. Reconstruction of bony canal with autogenous bone graft. Laryngoscope 1977;87:1826 – 32.
S. Bacciu et al. / Auris Nasus Larynx 25 (1998) 155–159 [9] Black B. Mastoidectomy elimination. Laryngoscope 1995;105(76):1– 30. [10] Portmann M. Le conduit auditif externe osseux dans les tympanoplasties. Rev Laryngol 1966;17:957. [11] Sakay M, et al. Reconstruction of scutum defects (scutumplasty) for attic cholesteatoma. Am J Otol 1986;7(3):188 – 92. [12] Pfaltz CR. L’emploi de greffes cartilagineuses libres en cophochirurgie. CR LXIV Congr Soc France ORL, 1967:247. [13] Sheehy J, Brackmann DE, Graham M. Cholesteatoma surgery: residual and recurrent disease. A review of 1024 cases. Ann Otol Rhinol Laryngol 1977;86:451–62. [14] Jansen C. Uber radikaloperation und tympanoplastik. Sitz Ber Forbild 1958:18–22. [15] Smyth GDL. Cartilage canalplasty. Laryngoscope 1971;81:786 – 92. [16] Wehrs R. Reconstructive mastoidectomy with homograft knee cartilage. Arch Otolaryngol 1972;87:1177–87. [17] Pappas JJ, et al. Homograft septal cartilage for attic support in intact canal wall tympanomastoidectomy and tympanoplasty. Laryngoscope 1981;91:1457–62. [18] Gersdorff MCH, Robillard TAJ. A new procedure for bone reconstruction in oto-microsurgery: a mixture of bone dust and fibrinogen adhesive. Laryngoscope 1985;95:1278 – 80.
.
159
[19] Bruschini P, et al. La cartilagine costale bovina come materiale di ricostruzione in Otologia: risultati anatomofunzionali. Acta Otorhinolaryngol Ital 1992;5:443 – 50. [20] Grote JJ, Van Blitterswijk CA. Reconstruction of the posterior auditory canal wall with a hydroxyxpatite prosthesis. Ann Otol Rhinol Laryngol 1986;95(123):6– 9. [21] Magnan J, et al. Reconstruction of the ear canal wall. Transplant Implant Otol 1996;3:251 – 5. [22] Vartiainen E. Factors associated with recurrence of cholesteatoma. J Laryngol Otol 1995;109:590 – 2. [23] Abramson M, Lachenbruch P, Press B, McCabe B. Results of conservative surgery for middle ear cholesteatoma. Laryngoscope 1977;87:1281 – 7. [24] Sanna M, Zini C, Gamoletti R, Delogu P, Scandellari R, Russo A, Taibah A. Prevention of recurrent cholesteatoma in closed tympanoplasty. Ann Otol Rhinol Laryngol 1987;96:273 – 5. [25] Zini C, Bacciu S, Pasanisi E. Recurrent cholesteatoma after combined approach tympanoplasty: pathogenesis and prevention. Rev Laryngol 1991;112:11 – 6. [26] Robinson JM. Closed cavity tympanomastoidectomy with bone pate´ repair of the attic. A continuing study, year 9. Fifth International Conference on Cholesteatoma and Mastoid Surgery. Abstract Book. September 1 – 6, 1996, Alghero, Italy, pp. 195.
Scutumplasty: costal cartilage versus bone pate´ S. Bacciu a,*, E. Pasanisi a, G. Perez Raffo a, J. Avendano Arambula a, F. Piazza a, A. Bacciu a, P. Govoni b, M. Guida a, C. Zini a a
Department of Otolaryngology, ENT Clinic, Uni6ersity of Parma, Via Gramsci, 14, 43100 Parma, Italy b Institute of Histology and Embryology, Uni6ersity of Parma, Via Gramsci, 14, 43100 Parma, Italy Received 19 May 1997; received in revised form 22 September 1997; accepted 14 November 1997
Abstract This study was carried out to evaluate the anatomical and hearing results of the reparation of attic defects in closed tympanoplasty. Reparation was carried out in 194 patients by using a costal cartilage allograft, and in 159 patients with a bone pate´ autograft. The follow-up was from 1 to 5 years. The study was not truly randomized owing to an occasional lack of allogenic costal cartilage. In the group ‘costal cartilage’ a partial resorption was observed in 5.7% and a complete resorption in 4.7% of the cases. In the group ‘bone pate´’, partial resorption was observed in 5.5% and total resorption in 2.7% of the patients. Satisfactory hearing results were obtained in 86% of the patients of the group ‘costal cartilage’ and in 82% of the patients of the group ‘bone pate´’. Both graft materials may be recommended for repairing erosions caused by the cholesteatoma in the wall of the external auditory canal. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Closed technique; Cholesteatoma surgery; Scutumplasty; Posterior canal wall defect; Allograft cartilage; Bone pate´
1. Introduction Retraction pockets and subsequent formation of recurrent cholesteatoma are the consequence of the retraction of the new tympanic membrane inside an attic defect after a closed (intact canal wall) tympanoplasty [1 – 9]. In order to prevent this complication, which occurs in 2.2%, up to * Corresponding author.
20% of the patients [4,5,7,10,11], it is essential to repair any defect existing in the superior or posterior canal wall. For this reparation, which is called scutumplasty, various materials have been recommended: cortical bony autograft [8,10,11]; autograft cartilage [6,12,13]; allograft cartilage [14–17]; autograft bone pate´ [18]; xenograft cartilage [19] and alloplastic materials [20,21]. The aim of this study is to compare the anatomical and hearing results of scutumplasty
0385-8146/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0385-8146(98)00005-4
156
S. Bacciu et al. / Auris Nasus Larynx 25 (1998) 155–159
carried out with two different materials: allogenic costal cartilage or autogenous bone pate´.
tween the mean preoperative bone conduction and the mean post-operative air conduction. Dead ears (2/353) were excluded from the study. The follow-up ranged from 1 to 5 years.
2. Materials and methods From January 1990 to December 1994, 412 patients suffering from chronic otitis media with cholesteatoma underwent a closed tympanoplasty (in one or two stages) at the Department of Otolaryngology of the University of Parma. Patients were subdivided into two groups, according to the material used to reconstruct the scutum:
2.1. Group ‘costal cartilage’ This group included 194 patients in which attic reconstruction was performed using allogenic costal cartilage. The grafts were obtained from donors and were placed immediately after removal in a 50% rifampin solution for 24 h. Afterwards, they were placed in a 70% ethyl-alcohol solution until needed for surgery. At the time of surgery, the cartilage was taken out of the solution under sterile conditions and thoroughly washed with saline.
2.2. Group ‘bone pate´’ This included 159 patients in which the scutum reconstruction was performed using bone pate´ following the technique described by Gersdorff [18]. Initial attempts at randomization failed as a result of occasional lacking of allogenic costal cartilage. Therefore, the study is not truly randomized. A total of 59 cases were excluded from the statistical evaluation: seven because the reconstruction was carried out using bone pate´ plus cartilage, and 52 because no reconstruction of the scutum was needed. The anatomical results were evaluated by means of an operating microscope during the second stage procedure (in case of staged surgery) and during the postoperative control examinations. The functional results were based on the mean residual air-bone gap at 0.5, 1 and 2 kHz, after the functional stage. Residual air-bone gap was defined as the difference be-
3. Results Surgical success was defined as complete integrity of the canal wall without further retraction pocket in the attic or in the posterosuperior quadrant and a postoperative residual air-bone gap 5 25 dB HL. Out of a total of 353 cases (including both adults and children), a scutum reconstruction with costal cartilage was performed in 194 cases (55%), while a scutumplasty using bone pate´ was performed in 159 cases (45%) (Fig. 1). At second stage tympanoplasty, in the group ‘costal cartilage’, the scutum was found normal (Fig. 2) in 155 cases (89.6%). A partial resorption of the graft was observed in ten cases (5.7%), a complete resorption in eight cases (4.7%) (Table 1) and a recurrent retraction pocket in nine cases (5.2%). At second stage tympanoplasty, in the group ‘bone pate´’, the scutum was found normal (Fig. 3) in 134 cases (91.8%). In 42 patients there was a remarkable hypertrophy of the bone pate´ which was thinned out during the second stage by using a diamond burr. A partial resorption of the bone pate´ was observed in eight patients (5.5%) and a total resorption in four cases (2.7%) (Table 1). The incidence of recurrent cholesteatoma was 4/ 353 cases (1.1%): one case was included in group
Fig. 1. Reconstruction of the scutum (353 cases, 1989 – 1994).
S. Bacciu et al. / Auris Nasus Larynx 25 (1998) 155–159
Fig. 2. Intraoperative findings (II stage). The costal cartilage graft is in correct position. the chondroprostheses is put in place.
A, while three cases were included in group B (minimum follow up: 1 year). The incidence of residual disease, in case of staged surgery, was 26% (46/173) in the group A and 22% (32/146) in the other group (Table 2). Figs. 4 and 5 show hearing results following scutumplasty with cartilage or bone pate´. The results were evaluated at 3 months, 1 and 3 years. At the 3-year follow-up satisfactory hearing results (postoperative residual air-bone gap 5 25 dB) were obtained in 86% of the patients of the group ‘costal cartilage’ and in 82% of the patients of the group ‘bone pate´’.
4. Discussion Recurrent cholesteatoma is a term used to define a new cholesteatoma occurring in an ear
Fig. 3. Intraoperative findings (II stage). The autogenous bone pate´ graft is in normal position and integrity.
which has already been operated on. It develops from a retraction pocket that grows inside the attic or the posterior mesotympanum or from ingrowth of the skin due to the failure of the graft which was used to repair the erosion caused by the cholesteatoma in the wall of the external auditory canal [1,3–5,13,22–25]. In order to avoid the formation of retraction pockets, every bone defect of the posterior canal wall must be repaired [1–3,5,7,13]. Not all the retraction pockets have the same clinical relevance: small self-cleansing retraction pockets are innocent, while large invaginations are cleaned with difficulty and may be infected [3]. Smyth and Robinson have demonstrated that the incidence of retraction pockets have decreased from 15 to 5% when a systematic reconstruction of the scutum is Table 2 Curative failures
Table 1 Intraoperative graft findings at second stage tympanoplasty Findings
Normal Total resorption Partial resorption
Graft material Cartilage (%), n= 173
Bone pate´ (%), n= 146
155 (89.6) 8 (4.7) 10 (5.7)
134 (91.8) 4 (2.7) 8 (5.5)
157
Retraction pockets Recurrent cholesteatoma Perforations neotympanum Myringitis Residual cholesteatoma a
Cartilage (%), n =194)
Bone pate´ (%), n =159
5.2a 0.5a
2.5a 2.0a
5.2
0.6
1.5 46/173 (26%)
2.0 32/146 (22%)
Follow up: (1 – 5) years.
158
S. Bacciu et al. / Auris Nasus Larynx 25 (1998) 155–159
the Eustachian tube to the mastoid) and to the surgical treatment of the tube (when needed). One of the problems of the graft material used in scutumplasty was found to be its postoperative atrophy and resorption. Following our previous experience with septal and meniscous allogenous cartilage, today, we prefer to use costal allogenic cartilage or bone pate´ because with these materials present a lower incidence of resorption. Most of the patients have reached a socially useful hearing at 2-year or more follow-up. Fig. 4. Functional results (cartilage, 194 cases).
performed [26]. According to Sade et al. [3], retraction pockets generally appear within 2 years from surgery, and this indicates that time plays only a limited role in the formation of postoperative pockets. In a previous study, carried out using septal or meniscous allogenic cartilage for reconstruction, we found an incidence of retraction pockets in intact canal wall of 9.2% [24]. In the present series, the incidence of retraction pockets was of 5.2% after reconstruction with cartilage and of 2.5% after reconstruction with bone pate´. Partial resorption was the same in the two groups. Total resorption was higher in the costal cartilage group (4.7%) than in the bone pate´ group (2.7%). We would like to point out that a low incidence of retraction pockets, and consequently of recurrent cholesteatoma, is not only related to the reconstruction of the scutum but also to the use of a thick silastic sheet (from
Fig. 5. Functional results (bone pate´, 159 cases).
5. Conclusion Reconstruction of the bony canal wall defects is one of the most important steps of closed tympanoplasty, in order to prevent the formation of retraction pockets. Partial graft resorption was the same in the two groups, while total resorption was higher in the costal cartilage group. Most of our patients have obtained a socially useful hearing at the 2-year or more follow-up. Both costal cartilage and bone pate´ present the features that all good graft materials should have: adaptability, availability, tolerance and low cost. References [1] Black B. Prevention of recurrent cholesteatoma: use of hydroxyapatite plates and composite grafts. Am J Otol 1992;13:273 – 8. [2] Chiossone E. Three cartilages’ technique in intact canal wall tympanoplasty to prevent recurrent cholesteatoma. Am J Otol 1985;6:226 – 30. [3] Sade` J, Berco E, Brown M. Results of mastoid operations in various chronic ear diseases. Am J Otol 1981;3:11 – 20. [4] Karmarkar S, Bhatia S, Saleh E, DeDonato G, Taibah A, Russo A, Sanna M. Cholesteatoma surgery: the individualized technique. Ann Otol Rhinol Laryngol 1995;104:591 – 5. [5] Sanna M, Zini C, Scandellari R, Jemmi G. Residual and recurrent cholesteatoma in closed tympanoplasty. Am J Otol 1984;5:277 – 82. [6] McCleve DE. Tragal cartilage reconstruction of the auditory canal. Arch Otol 1969;90:271 – 4. [7] Yanagihara N, Gyo K, Sasaki Y, Hinohira Y. Prevention of recurrent of cholesteatoma in intact canal wall tympanoplasty. Am J Otol 1993;14:590 – 4. [8] Pou J. Reconstruction of bony canal with autogenous bone graft. Laryngoscope 1977;87:1826 – 32.
S. Bacciu et al. / Auris Nasus Larynx 25 (1998) 155–159 [9] Black B. Mastoidectomy elimination. Laryngoscope 1995;105(76):1– 30. [10] Portmann M. Le conduit auditif externe osseux dans les tympanoplasties. Rev Laryngol 1966;17:957. [11] Sakay M, et al. Reconstruction of scutum defects (scutumplasty) for attic cholesteatoma. Am J Otol 1986;7(3):188 – 92. [12] Pfaltz CR. L’emploi de greffes cartilagineuses libres en cophochirurgie. CR LXIV Congr Soc France ORL, 1967:247. [13] Sheehy J, Brackmann DE, Graham M. Cholesteatoma surgery: residual and recurrent disease. A review of 1024 cases. Ann Otol Rhinol Laryngol 1977;86:451–62. [14] Jansen C. Uber radikaloperation und tympanoplastik. Sitz Ber Forbild 1958:18–22. [15] Smyth GDL. Cartilage canalplasty. Laryngoscope 1971;81:786 – 92. [16] Wehrs R. Reconstructive mastoidectomy with homograft knee cartilage. Arch Otolaryngol 1972;87:1177–87. [17] Pappas JJ, et al. Homograft septal cartilage for attic support in intact canal wall tympanomastoidectomy and tympanoplasty. Laryngoscope 1981;91:1457–62. [18] Gersdorff MCH, Robillard TAJ. A new procedure for bone reconstruction in oto-microsurgery: a mixture of bone dust and fibrinogen adhesive. Laryngoscope 1985;95:1278 – 80.
.
159
[19] Bruschini P, et al. La cartilagine costale bovina come materiale di ricostruzione in Otologia: risultati anatomofunzionali. Acta Otorhinolaryngol Ital 1992;5:443 – 50. [20] Grote JJ, Van Blitterswijk CA. Reconstruction of the posterior auditory canal wall with a hydroxyxpatite prosthesis. Ann Otol Rhinol Laryngol 1986;95(123):6– 9. [21] Magnan J, et al. Reconstruction of the ear canal wall. Transplant Implant Otol 1996;3:251 – 5. [22] Vartiainen E. Factors associated with recurrence of cholesteatoma. J Laryngol Otol 1995;109:590 – 2. [23] Abramson M, Lachenbruch P, Press B, McCabe B. Results of conservative surgery for middle ear cholesteatoma. Laryngoscope 1977;87:1281 – 7. [24] Sanna M, Zini C, Gamoletti R, Delogu P, Scandellari R, Russo A, Taibah A. Prevention of recurrent cholesteatoma in closed tympanoplasty. Ann Otol Rhinol Laryngol 1987;96:273 – 5. [25] Zini C, Bacciu S, Pasanisi E. Recurrent cholesteatoma after combined approach tympanoplasty: pathogenesis and prevention. Rev Laryngol 1991;112:11 – 6. [26] Robinson JM. Closed cavity tympanomastoidectomy with bone pate´ repair of the attic. A continuing study, year 9. Fifth International Conference on Cholesteatoma and Mastoid Surgery. Abstract Book. September 1 – 6, 1996, Alghero, Italy, pp. 195.