Classic mastoidectomy and modified mastoidectomy are traditional surgical procedures for middle ear cholesteatoma with the goals of eradicating diseases, creating dry ears and preventing severe complications. However, the drawback of these procedures is that there is no hearing improvement.1 With the development of otological microsurgery and our advanced understanding of the pathogenesis, and etiology of middle ear cholesteatoma, as well as people's demands for higher quality of life, it is now possible for us to create novel strategies for preserving or improving the biologic structures of middle ear, external canal and hearing function in addition to eliminating diseases.2,3 The close-cavity, open-cavity, and intact-bridge tympanoplasties represent three typical examples currently in this field. Each of them has its own advantages and disadvantages. Surgeons still remain divided on their applications for cholesteatoma particularly because of its recurrence.1,4 Therefore, our present study aimed to develop a novel surgical approach for middle ear cholesteatoma by modifying the closed tympnoplasty.
From June to December 2003, 83 (62 left ears and 21 right ears) out of 98 patients diagnosed as middle ear cholesteatoma in Department of Otorhinolaryngology Head and Neck Surgery, Second Affiliated Hospital of Sun Yat-sen University were recruited when meeting the inclusion criteria. Based on oto-endoscopy and auditory tests as well as temporal CT and MRI examinations, both of following two recruitment criteria were applied: patients with middle ear cholestetoma in one ear; patients with normally functional eustachian tubes and with neither intracranial nor extracranial complications. Males made up 51 cases and 32 cases were females. Patients' age ranged from 14 to 62 years old with an average of 32 years old. Average disease duration was 7.5 years and ranged from 3 to 27 years. According to audiometry, the preoperative pure tone audiometry (PTA) in 19 ears was no more than 30 dB, 58 ears between 30 and 60 dB, and 6 ears between 61 and 90 dB, with an average for the group of 47 dB. The air-bone gaps of all cases were between 15 dB and 50 dB with an average of 32 dB.
A postauricular skin incision was made before a “U” shaped periosteal flap with an anterior pedicle elevated anteriorly from the bone.5 Once the mastoid cortex and zygomatic arch were exposed, the tympanic cavity and mastoid cavity were opened through a cribriform approach followed by removal of all the cholestetoma and granuloma in order to skeletonize the mastoid cavity. The posterior wall of the external canal was then thinned through the mastoid cavity. The antrum and attic were opened to explore their roofs before the disease in attic was cleared and the malleus-incus joint was exposed without touch. The facial recess was left intact. The skin flap of the posterior wall of the external canal was elevated and cut on a curve at about 0.5 cm away from the tympanic annulus in order to expose the whole tympanic membrane. A skin-membrane flap was made by two parallel incisions at 6 o'clock and 12 o'clock. The lateral walls of the attic and posterior tympanic cavity were drilled away to explore the whole tympanic cavity (Figures 1-3). Before resection of the cholesteatoma, the stapes-incus joint was dislocated and the decayed incus and malleus were taken away to allow complete exposure and direct removal of cholesteatoma. It is especially important to address the cholesteatoma within two blind areas — the epitympanic recess (Figure 2) and the tympanic sinus (Figure 3) during close-cavity tympanoplasty. The lateral walls of the attic and posterior tympanic cavity were reconstructed by the palisade conchal cartilage technique (Figure 4).
All the cases underwent inspection of the tympanic cavity and were determined to have normal tympanic openings of their eustachian tubes and mild mucosa edema of their mesotympanum and hypotympanum but were without epithelialization. Sixty-one out of 83 ears with intact suprastapedial structures and unfixed foots underwent type 3 tympanoplast by partial ossicular replacement prosthesis (PORP) (Medtric Corp., USA) (Figures 3 and 5). Among the other 22 ears which had only foots remained, myringoplasy was performed in six fixed cases and type 3 tympanoplast by total ossicular replacement prosthesis (TORP) (Medtric Corp.) in 16 unfixed cases. The materials for all the membrane repairs were tragus cartilage-perichondral complex. The meatal skin flap was repositioned and the retroauricular periosteal flap was inverted to the external canal according to Fisch's method.6 The external canal was packed by gelfoam soaked with methylpredinisolone and antibiotic gauze. The retroauricular incision was sutured and had a compressed packing.
All the cases received antibiotics for 12 days after operation with the packing changed every day. The packing of the external canal was removed two weeks later, then 75% alcohol cotton was applied to the external pore every day. Follow-up was performed every week. All the cases had cured surgical fields after 4-6 weeks. The first reexamination of audiometry and endoscopy were performed three months later, and then once every six months or one year for 2-5 years with the average of 3.2 years.
Membrane healing and recurrence of choleastetoma
All 83 cases had dry ears after 4-6 postoperative weeks. Membranes healed and exhibited normal appearance (Figure 6). Three cases showed re-perforation at the membrane centers after 6 months due to severe upper respiratory infection and were cured after routinely correspondent management. Five cases had choleastetoma recurrence (6.02%) after 1.5 years due to cartilage absorption of new membranes. Among them two cases had recurrence within the attic and three cases within the posterior tympanic cavity.
According to the audiometry results after a year, the improvement of PTA in 27 cases was more than 30 dB, 33 cases had improvement between 20-29 dB, 14 cases between 10-19 dB, and 9 cases showed no improvement.
Surgery is the only therapeutic approach for middle ear cholesteatoma at present. The initial goal of surgery is to remove cholesteatom, create dry ear and prevent fatal complications. With our advanced understanding of the pathogenesis of middle ear cholesteatoma, the development of temporal dissection, operational instruments and surgical techniques, hearing reconstruction after resection of cholesteatoma has become possible. The most popular procedures for this purpose currently include close-cavity, open-cavity and intact-bridge tympanopalsty.7,8 Each of them has its own advantages and disadvantages. Although close-cavity procedure preserves the posterior wall of the external canal and normal sound-conduction structures, it has a high recurrence rate and surgeons have to face risks to open the facial recess in the cases of mastoid cavity dysplasia. The open-cavity procedure requires the removal of the posterior wall of the external canal in order to make a big common opening between the mastoid and tympanic cavity. Its advantage is complete resection of cholesteatoma whereas its disadvantages include no hearing improvement due to a superficial middle ear cavity, requiring lifetime postoperative cavity cleaning of a big mastoid cavity, and postoperative vertigo due to semi-canals directly exposed to atmospheric temperature. All those disadvantages can severely affect the patients' quality of life. Improvements in this procedure have been reported with different mastoid obliteration methods.8,9 The intact-bridge procedure is between close-cavity and open-cavity procedures and thus has the advantages of the other two procedures. Meanwhile, it also shares the weaknesses of the other procedures. For example, it is impossible to eliminate disease within the attic and posterior tympanic cavity; especially the tympanic sinus, facial recess, oval window and round window. This procedure can also cause postoperative adhesions within the posterior tympanic cavity and thus results in hearing loss and cholesteatoma recurrence.
One consensus is that the close-cavity procedure can keep the middle ear sound conduction structures and produces obvious and stable improvement in postoperative hearing. Surgeons have remained divided on the advantages, disadvantages and indications of these three traditional procedures over the past decades.6 The cholesteatoma recurrence rate of the close-cavity procedure is uncertain. Sheely and Robins10 reported that the rate was 5%, whereas Glasscock11 reported that the rate was 14%. Most other authors reported the rate was between 20% and 40%.12,13 In Nyrop and Bonding's14 10-year follow-up, 70% of patients needed second-look and open-cavity procedures.
Why does the close-cavity procedure have so high a
recurrence rate? The first reason is that the anterior epitympanic recess is a blind area and thus makes difficult the attic exploring through the mastoid-antrum route, especially when the zygomatic arch is dysplastic or the roof is low. The second is that the posterior tympanic cavity, as another blind area, can theoretically only be reached through the facial recess. This access route is only suitable for cochlear implantation and resection of mild disease within the posterior tympanic cavity.7 However, in the case of severe disease within the posterior tympanic cavity, the facial recess route becomes too narrow to clear the disease within the tympanic sinus and around the stapes. In order to completely resect disease and preserve intact tympanic structures, many surgeons recommend reconstructing the posterior wall of the external canal for the open-cavity procedure. Portmann et al5 cut the posterior wall bone of the external canal after skeletonization of the mastoid and repositioned the bone after complete resection of disease. Dornfhoffer15 cut the upper 1/2 posterior wall bone after skeletonization of the mastoid for complete resection of disease within the attic and posterior tympanic cavity, and reconstructed the posterior wall with cartilage. However, due to the poor blood supply of the free grafts for the posterior wall reconstruction the consequent ischemia and necrosis will lead to surgical failure in cases where infection occurs.
In order to take advantage of the close-cavity procedure and resolve its recurrence problems within the two blind areas, we modified the procedure on the basis of closed tympanoplasty. This procedure completely eliminated cholesteatoma within the mastoid, antrum, aditus and part of attic through the mastoid route and skeletonized the mastoid cavity without opening the facial recess. The tympanic cavity was accessed through the meatal route and totally explored after resection of the lateral wall of the attic and posterior tympanic cavity. The cholesteatoma can be removed directly and radically. The lateral wall of attic and posterior tympanic cavity were reconstructed by the palisade cymba cartilage technique.16 Five cases (6.02%) in this present study had cholesteatoma recurrence, which was close to the recurrence rate of the open-cavity procedure. All these recurrent cases appeared after 1.5 postoperative years and were due to the absorption of cartilage grafts which was consistent with other literature.17 All these recurrent cases were treated via otoendoscopy in an outpatient room without having secondary operations.
Is it better to perform simultaneous tympanoplasty or staged tympanoplasty? In 1963, Tabb18 introduced that the staged tympanoplasty concerns the function of the eustachian tube, the recurrence of cholesteatoma and the recovery of air-conduction hearing. This surgical procedure includes a first stage elimimation of disease, the second stage is membrane repair and the third stage is hearing reconstruction. However, this procedure took a long time for the recovery. Ten years later, Sheely19 modified this procedure by shortening it to a two-stage surgery. The first stage is disease eradication and membrane repair with silastic elastomer and the second stage of tympanic exploration and ossicular reconstruction 6-12 months later. From Sheely's point of view, only patients with one or more of following conditions needed a second-stage tympanoplasty; severe disease within the attic or posterior tympanic cavity, extensive granuloma, epithelialization, tympamosclerosis or acute inflammation. Otherwise, a simultaneous tympanoplasty is used. Our study was designed to recruit patients whose condition did not require a second-stage tympanoplasty so that no cases had irreversible disease within the attic and posterior tympanic cavities and had normal eustachian tubes. Dornhoffer's study15 suggested that only a one-stage tympanoplasty is needed in cases where cholesteatoma within the attic and tympanic sinus has been completely eradicated and there is no irreversible disease. There is no doubt that the modified procedure used in the present study can completely eradicate cholesteatoma within the attic and tympanic sinus with better exposure. More importantly, 77 out of 83 ears in our study underwent ossicle reconstruction with good hearing results, indicating that simultaneous tympanoplasty can produce good functional outcomes.
Another question is how to remove or preserve the malleous and incus during ossicular reconstruction. We think that the malleous and incus must be removed in order to eradicate cholesteatoma completely. First, the malleous and incus in middle ear cholesteatoma may be decayed and they should be removed to prevent recurrence of cholesteatoma. Second, it is hard to explore the anterior attic recess totally even if the lateral wall of attic is removed without removal of malleous and incus. So it is difficult to completely eliminate cholesteatoma within the anterior attic recess. We agreed that hearing can be improved and remain stable after type III tympanoplasty. We used the type III tympanoplasty if the suprastapedial structures were intact.15,16,20
In conclusion, our modified closed tympanoplasty for middle ear cholesteatoma in this present study has the advantages of both close-cavity and open-cavity procedures. It has low recurrence rate and good hearing improvement. It is not necessary to take the mastoid anatomy into account for the facial nerve recess which is opened in the modified procedure. The modified procedure is suitable for any type tympanoplasty and can reduce the injury to the facial nerve. This modified procedure also repairs the lateral wall of the attic and posterior tympanic cavity with conchal cartilage to restore normal anatomy of the tympanic cavity and thus prevents secondary cholesteatoma caused by defects of the lateral wall. Therefore, we suggest that the modification of closed tympanoplasy is a safe and effective procedure for patients with middle ear cholesteatoma.
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