Long term outcomes of canal wall up and canal wall down tympanomastoidectomies in pediatric cholesteatoma

A tailored approach in cholesteatoma surgery

PURPOSE

In recent years, new techniques have been added to cholesteatoma surgery, and established microsurgical approaches are being reconsidered. This study aims to present the importance of individualized decision-making for the selection of an intact canal wall (CWU) or canal wall down (CWD) surgical procedure for each patient.

METHODS

Using the "ChOLE" classification we categorized 264 operations retrospectively. 162 CWU and 102 CWD surgeries were performed. We focus to determine why a CWD procedure was chosen quite frequently despite some low-stage cases. Furthermore, we evaluated recidivism and hearing outcomes.

RESULTS

Smaller cholesteatomas (Ch-stage 1a, 1b & 2a) were found in 182 patients (70%), ossicular chain status feasible for straightforward reconstruction (O-stage 0, 1 & 2) was present in 186 patients (70%), minor complications due to the cholesteatoma (L-stage 1) were infrequent with 28 cases (11%) and a well-pneumatized mastoid was found in 144 cases (55%). Recidivism rates were low (7%) without any difference in both groups and a mean follow-up time of 4 years and 8 months. In primary surgeries there was a significant difference (p < 0.05) in postoperative mean air-bone gap (ABG) between CWU (17dB) and CWD (27dB).

CONCLUSION

The main goals of cholesteatoma surgery remain the avoidance of recidivism and optimal hearing rehabilitation. We recommend a tailored approach in the treatment of cholesteatomas and not a dogmatic one. Surgeons should not hesitate to perform a CWD procedure if required. Performed correctly it results in a dry ear and CWD surgery should remain in the skill set of the otologic surgeon.

Outcomes of Tympanoplasty After Cleft Palate Repair: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze graft success rates and hearing outcomes in patients with a history of cleft palate (CP) repair undergoing tympanoplasty.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

Per PRISMA guidelines, the databases were searched from date of inception through December 14, 2021. Studies of patients with previous CP repair who underwent tympanoplasty were included. Meta-analysis of proportions, continuous measures, odds ratios (ORs), and meta-regression were used to analyze graft success and hearing outcomes after tympanoplasty.

RESULTS

A total of 323 patients with CP repair and 1169 controls were included. The proportion of graft success was 86.7% (95% CI, 76.1%-94.5%) in patients with CP repair and 88.8% (95% CI, 76.9-96.8) in controls. There was no difference in odds of graft success between patients with CP repair and controls (OR, 1.0 [95% CI, 0.5-1.8]; P = .870). Age was not a significant moderator of graft success in patients with CP repair (r = 0.1 [95% CI, -0.2 to 0.3]; P = .689) or controls (r = -0.0 [95% CI, -0.1 to 0.1]; P = .952). Comparing mean differences between pre- and postoperative air-bone gap was not statistically significant in patients with CP repair and controls (0.2 dB [95% CI, -3.1 to 3.4]; P = .930). Odds of functional success (postoperative air-bone gap <20 dB) were not different between the groups (OR, 0.8 [95% CI, 0.5-1.4]; P = .450).

CONCLUSION

This meta-analysis does not endorse anatomic or functional differences between patients with CP repair and controls after tympanoplasty. However, there is a paucity of evidence for younger children. Further studies are warranted to elucidate specific risk factors for tympanoplasty outcomes in young patients with previous CP repair.

Recurrence in cholesteatoma surgery: what have we learnt and where are we going? A narrative review

Treatment of cholesteatoma is surgical and has historically encompassed two main techniques: canal wall up (CWU) and canal wall down (CWD) tympanoplasty. Follow-up for cholesteatoma is still debated and can be either radiological or with second-look surgery. MRI with diffusion weighted sequences has proved to have high sensitivity and specificity in detecting recurrent or residual disease. Specifically, non-echo planar imaging DWI (non-EPI DWI) has been shown to be superior to other imaging techniques, allowing, in some cases, to avoid second-look surgery. Both residual and recurrence rates are higher in CWU compared to CWD procedures. Endoscopic ear surgery (EES) has become popular with the advantage of “looking around corners”. The endoscope is used in addition to a microscope or exclusively to reduce cholesteatoma recurrence. In addition, it has been demonstrated that mastoid obliteration and the use of potassium titanyl phosphate laser (KTP) can reduce cholesteatoma recurrence, with better functional outcomes. A synthetic sulphur compound (MESNA) may have an interesting role in the overall improvement in recurrence and residual cholesteatoma disease. This narrative review critically appraises the factors associated with the risk of recurrent cholesteatoma.

Efficiency of intraoperative endoscopic inspection in reducing residuals in canal-wall-up surgery for pediatric cholesteatoma involving the mastoid

OBJECTIVE

To investigate the efficiency of additional intraoperative endoscopic inspection in reducing residual cholesteatoma in pediatric cholesteatoma involving the mastoid treated with classic canal-wall-up mastoidectomy and tympanoplasty.

MATERIALS AND METHODS

32 cases of pediatric cholesteatoma involving the mastoid were enrolled in this perspective study and treated with classic canal-wall-up mastoidectomy and tympanoplasty. Transmastoid posterior tympanotomy, atticotomy and transecting tendon of tympani tensor were conducted to achieve adequate visualization of hidden spaces in the middle ear. After complete removal of cholesteatoma, endoscopic inspection was additionally performed to check residual cholesteatoma. All cases had at least a 2-year follow-up by routine otoscopy examination, CT scan or MR imaging. Residual rates of both intraoperative and follow-up findings were used to evaluate the efficiency of the endoscopic inspection in reducing residual cholesteatoma and compared with published reports.

RESULTS

The additional intraoperative endoscopic inspection did not find any residual in this case series. In the 2-year follow-up, 2 cases (2/32, 6.3%) with residual cholesteatoma and 3 cases with recurrence (3/32, 9.4%) were found. The mean duration of endoscopic inspection and microscopic procedure were 17.9 min and 93.6 min, respectively.

CONCLUSIONS

This study suggested that the additional intraoperative endoscopic inspection in microscopic CWU surgery for pediatric cholesteatoma involving the mastoid had no obvious value in reducing residual cholesteatoma but took extra time.

Surgical management of petrous apex cholesteatomas in the pediatric population: A systematic review

Background:

Cholesteatomas are growths of squamous epithelium that can form inside the middle ear and mastoid cavity and damage nearby structures causing hearing loss when located at the petrous apex. The primary goal of petrous apex cholesteatoma resection is gross total removal with tympanoplasty and canal-wall up or canal-wall down tympanomastoidectomy. At present, there is no definitive surgical approach supported by greater than level 4 evidence in the literature to date.

Methods:

A systematic review was conducted utilizing PubMed, Embase, and Scopus databases. Articles were screened and selected to be reviewed in full text. The articles that met inclusion criteria were reviewed for relevant data. Data analysis, means, and standard deviations were calculated using Microsoft Excel.

Results:

After screening, five articles were included in the systematic review. There were a total of eight pediatric patients with nine total cholesteatomas removed. Conductive hearing loss was the most common (77%) presenting symptom. Perforations were noted in seven ears (86%). Recurrence was noted in 50% of patients with an average recurrence rate of 3.5 years (SD = 1.73). Average length of follow-up was 32.6 months (SD = 21.7). Canal-wall up was the most utilized technique (60%) and there were zero noted surgical complications. Five of the seven (71%) patients that experienced hearing loss from perforation noted improved hearing.

Conclusion:

Due to its rarity, diagnostic evaluation and treatment can vary. Further, multi-institutional investigation is necessary to develop population-level management protocols for pediatric patients affected by petrous apex cholesteatomas.

Mastoid obliteration and external auditory canal reconstruction using 3D printed bioactive glass S53P4 /polycaprolactone scaffold loaded with bone morphogenetic protein-2: A simulation clinical study in rabbits

INTRODUCTION

The lack of good prosthetic materials and objective standards has limited the promotion of mastoid obliteration and external auditory canal reconstruction, and the quality of the surgery varies. In this study, bioactive glass S53P4 (S53P4), the most popular artificial prosthetic material, was modified and combined with polycaprolactone (PCL) and bone morphogenetic protein-2 (BMP-2) to produce an individualized biological scaffold using 3D printing technology to explore a better material and method for mastoid obliteration and external auditory canal reconstruction.

METHODS

3D-printed S53P4/PCL scaffolds were fabricated from 3D reconstruction data of bone defect areas in New Zealand rabbits simulating "Canal Wall Down Mastoidectomy". The water absorption, swelling rate, porosity, and Young's modulus of the scaffold were measured, and the morphology and pore size of the scaffold were observed using scanning electron microscopy. The cytotoxicity of the S53P4/PCL scaffolds was detected using the CCK8 assay, and the in vitro antibacterial activity of the S53P4/PCL scaffolds was detected using the inhibition circle method. The BMP-2-loaded S53P4/PCL scaffolds were prepared using the drop-in lyophilization method and implanted into animal models. The biocompatibility, osteogenic activity, and external auditory canal repair of the scaffolds were observed using endoscopy, micro-CT, and histological examination.

RESULTS

The S53P4/PCL scaffold was highly compatible with the defective area of the animal model, and its physicochemical properties met the requirements of bone tissue engineering. In vitro experiments showed that the S53P4/PCL scaffold was non-cytotoxic and exhibited better antibacterial activity than the same volume of the S53P4 powder. In vivo experiments showed that the S53P4/PCL scaffold had good biocompatibility and osteogenic activity, and could effectively repair bone defects and reconstruct the normal morphology of the external auditory canal in animal models. Furthermore, its osteogenic activity and repair ability were significantly improved after loading with BMP-2.

CONCLUSIONS

The 3D printed S53P4/PCL scaffold has great potential for clinical mastoid obliteration and external auditory canal reconstruction.