Abstract Otology 2000 B10-1

Daniela Soldati MD, Albert Mudry MD

ENT Department University Hospital CHUV CH-Lausanne

Objective: The aim of this study is to understand the historical development of the knowledges on the pathogenesis of cholesteatoma. Material and Methods: Review of the literature published between 1800 and 1998 and concerning the date-related knowledges about cholesteatoma. Results: In 1683, Duverney first described a temporal bone tumor probably corresponding to a cholesteatoma. Until 1838, as Müller first named it cholesteatoma, nothing new appeared in medical publications. After 1838, three main theories about its pathogenesis were published : the first, form Virchow in 1855, considered the cholesteatoma as a tumor arising from mesenchymal cells which had undifferenciate and then redifferenciate to epidermal cells and begun to grow as tumoral cells. The second, of Toynbee, in 1857, considered cholesteatoma as the result of immigration of the external ear canal epidermis in the tympanic cavity via a marginal perforation following an acute or chronic otitis. The third, of Wendt and von Troeltsch, in 1868, considered the cholesteatoma as the result of a metaplasia of tympanic mucosa into a malpighian epithelium, which desquamated and produced cholesteatoma because of chronic inflammation. It took 40 years of discussions about theese three theories, to finally confirm that Toynbee was right. Conclusion: Knowledges about cholesteatoma have evolved with other medical branches. As otologists begun to follow their patients « in vivo », not limiting their observations to temporal bones' dissections, the genesis of cholesteatoma became well understood. Today, with immunology and new histopathological techniques, we will certainly learn much more about cholesteatoma.

Abstract Otology 2000 B10-2

Eric Truy MD, MSc (11), Sonia Ayari MD (1), Christian Dubreuil MD (2)

(11) Service ORL, Pavillon U Hôpital Edouard Herriot F-Lyon Cedex 03

The authors present a 25 cases series of intratemporal bone cholesteatomas . Symptoms are described: all types of hearing losses can be observed (conductive, mixed, total deafness) and also facial palsy, which is a very suggestive sign. The natural history is various and will be developped. This allowed us to make differences between congenital and acquired cholesteatomas. No parallelism exists between the signs, the otoscopic aspect of the tympanic membrane and the extension of the tumor. So, the accent is stressed on the importance of the medical imaging including CT-Scan, and MRI in some cases to precise the limit of the lesion with the labyrinth and/or the dura. The imaging allowed us to classify the extension according to Hawthorne and Fisch. The extensions are supralabyrinthine, infralabyrinthine, posterior peri- and translabyrinthine, and in some rare cases involving quite entirely the totality of the temporal bone. Of course, findings of medical imaging lead to an appropriate surgical approach. Indications of these different approaches (infratemporal, translabyrinthine, transcochlear, and of the middle fossa) are discussed. The problem of the choise between the closing or the opening of the cavity is to be considered in light of the extension of the cholesteatoma, the risk of recurrence, the exposition of the dura, and of the possibilty to keep a functional hearing.

Abstract Otology 2000 B10-3

Hiromi Ueda MD, PhD, Seiji Nakata MD,PhD, Tutomu Nakashima MD,PhD

ENT Department Nagoya University School of Medicin J-Showa-ku, Nagoya

From 1982 to 1997, 52 children (54 ears) with cholesteatoma had underwent surgery in our department. In the early period (1982-1990), the open method was performed in 47% (17 ears) of the ears and the closed method in 53% (19 ears). Cholesteatoma recurred more frequently in the closed method group than in the open method group (58% vs. 12%). Other postoperative complications, such as erosion of the mastoid cavity, otorrhea, perforation of the ear drum, occurred more often in the open method group than the closed method group. In the later period (1991-1997), 18 ears with cholesteatoma had underwent surgery. The closed method was performed in 16 ears. In the closed method group, 10 ears had underwent one-stage surgery. Planned staged tympanoplasty was completed in 6 ears. After one stage surgery, 4 of 10 ears had underwent residual cholesteatoma. Two of the recurrent ears had underwent planned staged tympanoplasty. As revealed by postoperative computed tomography (CT) image, 11 of 14 ears had aeration in the attic and antrum as well as in the tympanic cavity. In these cases, no attic retraction pocket formation was observed. Our strategy for pediatric cholesteatoma in the future is to use the closed method as often as possible. If aeration in the attic and antrum is seen to exist by preoperative CT-scan image, the one-stage surgery will be chosen. If not, planned staged tympanoplasty will be needed. By this choice, a high incidence of aeration of the attic and antrum will occur and we will be able to prevent the attic retraction pocket and detect residual cholesteatoma early by postoperative CT scan.

Abstract Otology 2000 B10-4

Ulf Mercke MD

Dept. ORL Univ. Hosp. Lund S-Lund

Material and method Middle ear cholesteatoma in 131 patients was treated surgically by eradicating the cholesteatoma after a canal wall down procedure had been performed. During the same session the canal wall was rebuilt, the tympanic membrane repaired and the mastoid cavity and epitympanic space obliterated. One year later a second look and an ossiculoplasty with a short or long columella was performed. The patients have then been checked regularly with microscopic and audiologic examinations for a minimum of 5 years after the second look operation. The audiological findings after 5 years are reported. Results At the 5 years postoperative check all patients were free from recurrent and residual cholesteatoma. At that check 110 audiograms were available for analysis (i.e. in 90% of the total material) making possible to follow the changes in hearing from before the eradicating operation up to 5 years after the second look operation. No patient manifested a sensori-neural hearing loss, mean bone conduction level before the eradicating operation was 10dB and 5 years after second look 10.6dB. Patients with a real qualification for normal postoperative hearing are those with a normal preoperative bone conduction level (BC=/< 15dB), this was found in 82 patients. In 65 of these cases, i.e. 80%, a social hearing (AC=/< 30dB) was reached at the 5 year postoperative check. ABG is in this group -/< 20dBin 92,3%. The results are distinctly betterwhen a short columella can be used instead of a long one, social hearing beeing reached in 90,7% and 57,1% respectively. Conclusions A middle ear cholesteatoma operated with obliteration technique and staging is 5 years after second look 1) free from cholesteatoma and has 2) a social hearing in 80% of those cases where the bone conduction level is normal preoperatively.

Abstract Otology 2000 B10-5

Atsushi Haruta MD, PhD (1), Hirokazu Kawano MD, PhD (2), Tetsuya Tono MD, PhD (1), Tamotsu Morimitsu MD, PhD (1), Shizuo Komune MD, PhD (1)

(1) ENT Department Miyazaki Medical College J-Miyazaki
(2) ENT Department Miyazaki Medical College J-Miyazaki

Sixty three cases of open mastoidectomy ear with persistent ear discharge and/or hearing disorder were treated with a reconstruction of posterior wall of the external canal. Three different types of reconstruction method of rebuilding of posterior wall by cortical bone grafting (38 cases), mastoid obliteration with bone tips (10 cases) and T-shape assembled cortical bone grafting (10 cases) were employed. Clinical results in our department were summarized from 1987 to 1997. Aural discharge was arrested in 87%. Hearing was restored in 60%. No difference was found in these results among three reconstruction methods. However, long term observation revealed an apparent difference in three methods. 56% cases reconstructed by rebuilding of posterior wall developed a re-retraction of it. On the other hand, 30 % cases by mastoid obliteration with bone tips and T-shape assembled cortical bone grafting produced re-retraction of posterior wall. Our results indicated that reconstruction of posterior wall against open mastoidectomy is efficient in restoration of persistent ear discharge. To set a single bony plate grafting alone employed in 38 cases is not sufficient to prevent re-retraction of posterior wall of external canal.

Abstract Otology 2000 B10-6

Milan Stankovic MD, PhD

University ENT Clinic Medical Faculty YU-Nis

The incidence of postoperative complications after some operations for middle ear cholesteatoma is high. It is supposed that the localization of disease and the type of surgical operation can significantly influence on the success of such operations. To study the results of cholesteatoma surgery we reviewed 197 cholesteatoma cases that were divided in three groups: attic, sinus and tensa cholesteatoma. Each group was subdivided in cases operated using canal wall down (CWD) and intact canal wall technique (ICW). All the patients were followed for at least three years. The results of the operations were analyzed according to postoperative air-bone gap, and the presence of residual or recurrent disease. Audiological results were comparable in all the groups and air-bone gap in over 80% was achieved, especially in attic cholesteatoma group. The rate of residual cholesteatoma was less than 10% no matter localization. However, CWD technique gave significantly higher incidence of recurrent disease (13,2% for attic, 9,9% for sinus, and 9,9% for tensa cholesteatoma) in comparison to ICW technique (3,3%, 3,3% and 13,2% respectively). The significance of these results for surgical therapy of cholesteatoma is discussed.

Abstract Otology 2000 B10-7

Peter G.B. Mirck MD

Department of ENT Academic Medical Center NL-DE Amsterdam

Surgery for cholesteatoma is traditionally divided in canalwall-up and canalwall-down procedures. Keystone in selecting one technique over the other is the potentiality to remove all matrix. Taking down the posterior-superior canalwall creates the best opportunities to remove matrix from otherwise hidden areas i.e. the tympanic sinuses, facial recess, epitympanic space and cell tracts in the peritubal and hypotympanic areas. But the resulting cavity needs postoperative care for a lifetime and is susceptible for caloric stimulation during swimming. Preserving the canalwall creates better possibilities for ossicular chain reconstruction, but is more difficult and needs a second stage procedure any how . In the present operative technique the posterior-superior bony canalwall is taken out temporary in one piece, to create access to the mentioned hidden areas. At the end of the operation it will be replaced and fixated by its bevelled shape only. This operative technique pretends to combine the advantages of a canalwall-up procedure with the easy of access in a canalwall-down technique. A second stage operation is indicated to check for recurrent or residual cholesteatoma and to perform an ossicular chain reconstruction. In a series of 40 cases we found a residual cholesteatoma in 2 patients (5%) and a recurrence in 1 patient (2,5%). Finally 93% of the patients are free from cholesteatoma and got a tympanoplasty with TORP (Spandrel after Fisch) or incustransposition. Only 7% got a canalwall down procedure at second stage surgery (follow up 2-12 years). The surgical technique and the audiological results will be presented.