Surgical treatment of labyrinthine fistula in cholesteatoma surgery

Managing cholesteatomas with labyrinthine fistula

Introduction

A retrospective study (2011 to 2018) was conducted to evaluate the management of cholesteatomas with labyrinthine fistulae (LFs), clinical characteristics and postoperative hearing outcomes in a hospital.

Methods

Demographic data of patients with primary middle ear mastoidectomies for cholesteatoma were extracted. Preoperative high-resolution computed tomography (HRCT) temporal bone and intraoperative findings, and hearing levels preoperatively and postoperatively were evaluated.

Results

Of the middle ear cholesteatomas, 15.6% (n = 14) of ears were complicated by LF. HRCT scans showed 92.9% sensitivity and 94.7% specificity in the identification of LFs. Intraoperative findings of LFs include stapes erosion (78.6%), malleus erosion (78.6%), incus erosion (92.9%), dehiscence of tegmen tympani (28.6%) and tympanic facial canal (64.3%). Compared to the non-LF group, the LF group showed significantly higher incidence of stapes erosion (P < 0.001), tegmen tympani dehiscence (P = 0.016) and semicircular canal dehiscence (P < 0.001). Matrix was removed completely in 85.7% (n = 12) and was left behind in 14.3% (n = 2) of ears. Also, 21.5% (n = 3) had preoperative dead ears. Postoperative hearing results had a mean follow-up time of 2.1 (standard deviation 1.5, range 0.14-4.84) years. In the matrix removal group (n = 9), 77.9% had unchanged hearing levels, 11.1% showed improvement and 11.1% showed decrease in hearing levels. The matrix preservation group (n = 2) had deteriorated hearing levels.

Conclusion

Preservation of hearing in LFs is possible with cautious matrix removal. Despite matrix preservation to preserve hearing in large LFs, our patients' hearing deteriorated postoperatively. Longer follow-up of hearing with matrix preservation may show poorer hearing outcomes.

Clinical Study of Labyrinthine Fistula in Cholesteatomatous Chronic Otitis Media: A Tertiary Care Hospital-Based Retrospective Study in a South Indian Population

INTRODUCTION

Among the extracranial complications of cholesteatoma, the most common is labyrinthine fistula (LF). The causes are still poorly understood for cholesteatoma-induced labyrinthine fistula. Some of the possible factors described in the literature are the patient's age, duration of the disease, growth pattern of cholesteatoma, and disease aggressiveness. These affect the site of development of labyrinthine fistula. Cholesteatoma and its complications pose a great burden on the economic and health sector of developing nations.

AIM AND OBJECTIVE

 The objective is to estimate the incidence of labyrinthine fistula in cholesteatomatous chronic otitis media (COM) and analyze the clinical presentation and post-surgical improvement in hearing and vertigo in the study cohort.

MATERIALS AND METHOD

The study was conducted in the Department of Otorhinolaryngology. It involved retrospective data collection of case records between 2018 and 2022. All patients diagnosed with chronic otitis media (COM) with cholesteatoma were reviewed retrospectively in a tertiary healthcare center. Of the 324 cases reviewed, 21 had an LF.

RESULTS

The incidence rate of LF in our study was 6.48%. Sixteen (76.1%) patients were male, and five (23.9%) were female. The youngest patient was a 10-year-old male, and the oldest was a 51-year-old female. The mean ± standard deviation (SD) age was 34.09 ± 10.05 years. The left ear (76.1%) was affected more than the right ear. All cases were from rural areas, and 16 (76.1%) of them were farmers. Ear discharge (85%) was the most common symptom, followed by hearing loss (76%) and then vertigo (47%). A very peculiar risk factor of self-cleansing the ear was noticed in all patients. Out of the 21 patients who underwent surgery, it was observed that the lateral semicircular canal (LSCC) was the commonest site of the fistula. According to the Dornhoffer and Milewski classification, type II LF was the commonest type. In one patient with a type III LF, a foreign body (a piece of a twig) was found intraoperatively near the LSCC fistula site. Two patients had multiple fistulae. Six patients had associated mastocutaneous fistula, and one had facial nerve paralysis. All patients, except one, were free of vertigo following surgery. Postoperatively, the bone conduction thresholds were similar to the pre-surgical values in 12 of 16 (74%) patients.

CONCLUSION

 The incidence of LF is still higher in developing countries, predominantly in rural populations, where the habit of self-cleansing the ear is a common practice. The common symptoms of COM with LF are ear discharge, hearing impairment, and vertigo. All the cases had a habit of frequent self-cleansing of the external ear as an important risk factor. Therefore, implementing awareness programs on maintaining aural hygiene in rural health centers may reduce the incidence of cholesteatomatous LF, thereby preserving hearing and vestibular functions and improving the quality of life. However, the above statement needs further validation with large multicenter studies.

Labyrinthine Fistula in Chronic Otitis Media Surgery: Management and Outcomes

The objective of this retrospective study was to present the experience on the management of labyrinthine fistula secondary to chronic otitis media in a tertiary center. 263 patients, who underwent tympanomastoidecomy, in Centro Hospitalar Universitário do Porto, between 2015 and 2020 were reviewed, to select only those with labyrinthine fistulas. 26 patients (9.89%) had cholesteatoma complicated by fistula of the lateral semicircular canal. Most frequent symptoms were unspecific, such as otorrhea, hearing loss and dizziness. Preoperative high-resolution computed tomography predicted fistula in 54%. Using the Dornhoffer and Milewski classification, 10 cases (38.46%) were identified as stage I, 15 (57.69%) at stage II, and 1 (3.85%) as stage III. The choice between open or closed surgical procedure was independent of the type of fistulae. The cholesteatoma matrix was completely removed from the fistula and immediately covered by autogenous material. In one patient matrix was left over the fistula. After surgery, hearing (bone conduction) was preserved or improved in 73% of the patients. There was no statistically significant relationship between the extent of the labyrinthine fistula, type of material used in fistula repair and the hearing outcome. Also, we didn't find a statistically significant relationship between extent of the labyrinthine fistula and the presence of facial nerve canal dehiscence, tegmen timpani erosion, sigmoid sinus exposure or ossicular bone erosions. In conclusion, a complete and nontraumatic removal of cholesteatoma matrix over the fistula in a single-staged procedure, is a safe and effective procedure, which achieves a hearing preservation or improvement in most cases.

Presentation, Management, and Hearing Outcomes of Labyrinthine Fistula Secondary to Cholesteatoma: A Systematic Review and Meta-analysis

OBJECTIVE

The current study systematically reviewed the literature to compare auditory outcomes of patients treated for labyrinthine fistula (LF) based on characteristics of disease and surgical management.

DATABASES REVIEWED

PubMed, Scopus, Web of Science.

METHODS

Original series (at least five cases) published from 2000 reporting management and hearing results of LF secondary to cholesteatoma were included. Proportion and odds-ratio (OR) meta-analyses were conducted through inverse variance random-effects models based on logit transformation.

RESULTS

The prevalence of LF is estimated to be 7% (95% confidence interval [CI], 5-9%). Fistulae involving the lateral semicircular canal (90%; 95% CI, 87-93%) and larger than 2 mm (53%; 95% CI, 43-64%) were common, whereas membranous involvement was less frequent (20%; 95% CI, 12-30%). Complete removal of the cholesteatoma matrix overlying the LF was mostly applied. Bone conduction (BC) preservation was frequently achieved (81%; 95% CI, 76-85%); new-onset postoperative anacusis was rarely reported (5%; 95% CI, 4-8%). A higher chance of BC preservation was associated with sparing the perilymphatic space (OR, 4.67; 95% CI, 1.26-17.37) or membranous labyrinth (OR, 4.56; 95% CI, 2.33-8.93), exclusive lateral semicircular canal involvement (OR, 3.52; 95% CI, 1.32-9.38), smaller size (<2 mm; OR, 3.03; 95% CI, 1.24-7.40), and intravenous steroid infusion (OR, 7.87; 95% CI, 2.34-26.42).

CONCLUSION

LF occurs in a significant proportion of patients with cholesteatoma. In the past two decades, complete removal of the cholesteatoma matrix followed by immediate sealing has been favored, supported by the high proportion of BC preservation. Hearing preservation depends primarily on characteristics of the LF, and specific surgical strategies should be pursued. Intraoperative and postoperative intravenous steroid infusion is recommended.

Analysis of postoperative effects of different semicircular canal surgical technique in patients with labyrinthine fistulas

Objective

Different semicircular canal surgery techniques have been used to treat patients with labyrinthine fistulas caused by middle ear cholesteatoma. This study evaluated postoperative hearing and vestibular function after various semicircular canal surgeries.

Materials and methods

In group 1, from January 2008 to December 2014, 29 patients with middle ear cholesteatoma complicated by labyrinthine fistulas were treated with surgery involving covering the fistulas with simple fascia. In group 2, from January 2015 to October 2021, 36 patients with middle ear cholesteatoma complicated by labyrinthine fistulas were included. Cholesteatomas on the surface of type I labyrinthine fistulas were cleaned using the “under water technique” and capped with a “sandwich” composed of fascia, bone meal, and fascia. Cholesteatomas on the surface of type II and III fistulas were cleaned using the “under water technique,” and the labyrinthine fistula was plugged with a “pie” composed of fascia, bone meal, and fascia, and then covered with bone wax.

Results

Some patients with labyrinthine fistulas in group 1 exhibited symptoms of vertigo after surgery. In group 2 Patients with type II labyrinthine fistulas experienced short-term vertigo after semicircular canal occlusion, but no cases of vertigo were reported during long-term follow-up. “sandwich.” In patients with type II labyrinthine fistulas, the semicircular canal occlusion influenced postoperative hearing improvement. However, postoperative patient hearing was still superior to preoperative hearing.

Conclusion

The surface of type I labyrinthine fistulas should be capped by a “sandwich” composed of fascia, bone meal, and fascia. Type II and III labyrinthine fistulas should be plugged with a “pie” composed of fascia, bone meal, and fascia, covered with bone wax.

Development of semicircular canal occlusion

Surgical treatment of vertigo is performed with in-depth study of inner ear diseases. Achieving an effective control of vertigo symptoms while reducing damage to hearing and reducing surgical complications is the principle followed by scholars studying surgical modalities. Semicircular canal occlusion is aimed at treatment of partial peripheral vertigo disease and has attracted the attention of scholars because of the above advantages. This article provides a review of the origins of semicircular canal occlusion, related basic research, clinical applications, and the effects of surgery on vestibular and hearing function.

Clinical efficacy of the 'sandwich technique' in repairing cholesteatoma with labyrinthine fistula

BACKGROUND

Labyrinthine fistula is the most common complication of middle ear cholesteatoma.

AIMS/OBJECTIVES

To explore the postoperative hearing changes and surgical results of repairing middle ear cholesteatoma with labyrinthine fistula using the 'sandwich technique'.

MATERIALS AND METHODS

We retrospectively studied the clinical data of 36 patients (36 ears) who underwent surgical treatment for cholesteatoma with labyrinthine fistula. All patients were treated by completely removing the cholesteatoma matrix and repairing the fistula using the 'sandwich technique'. The hearing, clinical features, radiological data, intraoperative findings, and surgical results were respectively analyzed.

RESULTS

Most labyrinthine fistulas were located in the lateral semicircular canal (94%). Fifty percent of fistulas were of medium size. Based on Dornhoffer classification, 17 cases of labyrinthine fistulas were classified as I. In 34 patients, the average bone conduction threshold improved or did not change after surgery. Two patients had preoperative facial paralysis. During follow-up (3-60 months), all patients had no postoperative vertigo symptoms and disease recurrence.

CONCLUSIONS

Following the removal of the cholesteatoma matrix, the fistula is repaired using the "sandwich technique", which preserves or increases hearing and achieves an anti-vertiginous effect.

SIGNIFICANCE

This finding suggests that, 'sandwich technique' is a feasible procedure to treat cholesteatoma with labyrinthine fistula.

[A case of hearing preservation during surgical treatment of distributed fistula labyrinth in a patient with chronic purulent means otitis and cholesteatoma]

The article provides a brief overview of the epidemiology, diagnosis, clinical manifestations and surgical methods of treatment of labyrinthine fistulas (LF) in patients with chronic suppurative otitis media (CSOM) with cholesteatoma. The efficacy of various LF treatment techniques, their complications, and the principles of prevention of cochleovestibular disorders during surgical treatment are described. The prognostic criteria for the deterioration of bone conduction thresholds during LF surgery, which include a large LF size, the opening of the membranous labyrinth, and the extent of damage to the structures of the inner ear, are presented. A clinical case of surgical treatment of widespread LF in CSOM with cholesteatoma is presented, which proves the possibility of preserving the auditory and vestibular functions while observing the stages of sanitation, manipulations on the LF and obliteration of semicircular canals defects with auto tissues. Combined surgery of such a plan must certainly be accompanied by local instillation of solutions of hormonal preparations in case of a deficiency of perilymphatic fluid in the labyrinth and postoperative antibacterial and hormonal therapy.

Refining surgical techniques for efficient posterior semicircular canal gene delivery in the adult mammalian inner ear with minimal hearing loss

Hearing loss is a common disability affecting the world's population today. While several studies have shown that inner ear gene therapy can be successfully applied to mouse models of hereditary hearing loss to improve hearing, most of these studies rely on inner ear gene delivery in the neonatal age, when mouse inner ear has not fully developed. However, the human inner ear is fully developed at birth. Therefore, in order for inner ear gene therapy to be successfully applied in patients with hearing loss, one must demonstrate that gene delivery can be safely and reliably performed in the mature mammalian inner ear. In this study, we examine the steps involved in posterior semicircular canal gene delivery in the adult mouse inner ear. We find that the duration of perilymphatic leakage and injection rate have a significant effect on the post-surgical hearing outcome. Our results show that although AAV2.7m8 has a lower hair cell transduction rate in adult mice compared to neonatal mice at equivalent viral load, AAV2.7m8 is capable of transducing the adult mouse inner and outer hair cells with high efficiency in a dose-dependent manner.

Post-operative hearing among patients with labyrinthine fistula as a complication of cholesteatoma using "under water technique"

Introduction

During surgery in patients with labyrinthine fistula the mandatory complete removal of the cholesteatoma while preserving inner ear and vestibular function is a challenge. Options so far have been either the complete removal of the cholesteatoma or leaving the matrix on the fistula. We evaluated an alternative “under water” surgical technique for complete cholesteatoma resection, in terms of preservation of postoperative inner ear and vestibular function.

Methods

From 2013 to 2019, 20 patients with labyrinthine fistula due to cholesteatoma were operated. We used the canal wall down approach and removal of matrix on the fistula was done as the last step during surgery using the “under water technique”. The pre and postoperative hearing tests and the vestibular function were retrospectively examined.

Results

There was no significant difference between pre and post-operative bone conduction thresholds; 20% experienced an improvement of more than 10 dB, with none experiencing a postoperative worsening of sensorineural hearing loss. Among seven patients who presented with vertigo, two had transient vertigo postoperatively but eventually recovered.

Conclusion

Our data show that the “under water technique” for cholesteatoma removal at the labyrinthine fistula is a viable option in the preservation of inner ear function and facilitating complete cholesteatoma removal.

Endoscopic Management of Primary Acquired Cholesteatoma

Endoscopic ear surgery is increasingly accepted as a primary modality for cholesteatoma surgery. A major advantage is the enhanced visualization of the middle ear in traditionally poorly accessible locations by the microscope. We discuss novel techniques for selective mastoid obliteration when a canal wall down mastoidectomy is necessary. Postoperatively, indications for non-echo planar diffusion-weighted imaging MRI versus second-look surgery are discussed. Finally, outcome data for endoscopic versus microscopic ear surgery are reviewed, which show equivalent outcomes regarding residual and recurrent disease, similar rates of complications, decreased pain, and shorter healing time.

Imaging Analysis for Cholesteatoma Extension to the Perilymphatic Space in Labyrinth Fistulae

OBJECTIVES/HYPOTHESIS

Disturbed perilymph behind a labyrinth fistula can lead to hearing deterioration; thus, delicate manipulation is required during surgery for cholesteatomatous fistulae with matrix extension to the perilymphatic space (EPS). However, it remains challenging to identify the EPS preoperatively. This study aimed to evaluate the diagnostic value of computed tomography (CT) for preoperative prediction of the EPS of cholesteatomatous fistulae.

STUDY DESIGN

Retrospective study.

METHODS

We included serial high-resolution CT images showing a cholesteatomatous bone defect in the lateral semicircular canal (LSC) requiring mastoidectomy. CT and intraoperative findings were analyzed retrospectively. Using axial CT planes, we evaluated the length and angle between the margins of bone defects. Receiver operating characteristic (ROC) curves were constructed to determine the cutoff points.

RESULTS

We extracted data from 30 bone defects, of which six (20.0%) showed EPS intraoperatively. Bone defects with EPS (n = 6) had significantly greater length and angle values than those without EPS (n = 24) (P < .001 for both, Wilcoxon rank sum test). For length and angle, the area under the curve was 0.944 (95% confidence interval [CI]: 0.858-1.000) and 0.951 (95% CI: 0.875-1.000), respectively, according to the ROC analysis, and the optimal cutoff values were 3.65 mm and 71.6°, respectively, with 100% sensitivity and 91.67% specificity for both.

CONCLUSIONS

Results demonstrated that a length >3.65 mm and an angle >71.6° for LSC bone defects on axial CT images are reliable diagnostic markers of EPS. Preoperative high-resolution CT analysis can provide surgeons with a more conscientious preparation for handling deeper labyrinth fistulae.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1301-E1307, 2021.

Clinical Characteristics of Patients with Cochlear Fistulas Caused by Chronic Otitis Media with Cholesteatoma

OBJECTIVES

To analyze the clinical characteristics of cochlear fistulas (CFs) and propose a new fistula classification system with regard to the cochlea.

MATERIALS AND METHODS

A retrospective chart review was conducted between January 2008 and December 2015 to identify patients who had undergone surgery for cholesteatoma with an associated CF. The following data were collected: preoperative symptoms, findings of temporal bone computed tomography (TBCT), fistula stage, cholesteatoma classification, surgical technique, and pre- and postoperative pure-tone audiometry.

RESULTS

We analyzed a total of 159 patients, out of which 9 (5.7%) were diagnosed with a CF. The average duration of the chronic otitis media was 19.8 years. Cholesteatomas that induced CF rarely existed in the nonaggressive state; recurrent otorrhea was observed in all but one of our subjects. All the patients with CF had a distinct origin of cholesteatoma that developed from the retraction of posterior pars tensa; further, 88.9% cholesteatomas extended to and filled the sinus tympani. Preoperative audiometry revealed total hearing loss in 4 (44.4%) patients. Further, five patients with residual hearing before surgery had stage I fistulas, and the bone conduction thresholds remained stable after surgery.

CONCLUSION

Cochlear fistulas were often detected in patients with (1) a history of chronic otitis media (exceeding 10 years), (2) frequently recurring otorrhea, and (3) pars tensa cholesteatomas that extended to the posterior mesotympanum and filled the sinus tympani. Such patients can suffer from potentially severe and irreparable sensorineural hearing loss.

Comparison of Different Slice Thicknesses in Computed Tomography for Labyrinthine Fistula Evaluation

OBJECTIVES

The aim of the present study is to assess the impact of different slice thicknesses in computed tomography for labyrinthine fistula evaluation and to determine the appropriate slice thickness.

METHODS

A total of 258 patients who underwent mastoidectomy and tympanoplasty for chronic otitis media with cholesteatoma from 2010 to 2014 were reviewed. The radiological diagnoses were compared with intraoperative findings. Sensitivity and specificity of 2.0-, 1.5-, 1.0-, and 0.75-mm-thick computed tomographic (CT) images for the evaluation of labyrinthine fistulae were calculated. Cohen's κ coefficient was also calculated.

RESULTS

The sensitivities of 2.0-, 1.5-, 1.0-, and 0.75-mm-thick CT images for the evaluation of labyrinthine fistulae were 76.9, 86.5, 90.4, and 93.3% (observer 1) and 67.3, 76.0, 79.8, and 87.5% (observer 2), respectively. The specificities of 2.0-, 1.5-, 1.0-, and 0.75-mm-thick CT images for labyrinthine fistula evaluation were 96.1, 94.8, 95.5, and 95.5% (observer 1) and 99.4, 97.4, 95.5, and 94.8% (observer 2), respectively. Cohen's κ coefficients were 0.790, 0.788, 0.876, and 0.911 in 2.0-, 1.5-, 1.0-, and 0.75-mm-thick CT images, respectively.

CONCLUSIONS

The sensitivity of CT for labyrinthine fistula evaluation increases with decreasing slice thickness, while the specificity does not improve.

[Variants of treatment of the head direction at the festulars of the labi-rint of inflammatory genesis]

PURPOSE

To analyze the effectiveness of various methods of treating dizziness with fistulas of the labyrinth (FL) of inflammatory genesis. An analysis of the surgical treatment of 216 patients with chronic suppurative otitis media (CSOM) with cholesteatoma complicated by FL using a variety of FL treatment methods is presented. All patients underwent a debridement operation on the middle ear or revision of the postoperative cavity: in 48 patients with a matrix of cholesteatoma in situ on the fistula, in 109 patients with matrix removal followed by plastic repair or FL filling with various autotissues, in 59 patients with matrix conservation, plastic removal or filling FL and SLD labyrinth. In the last two groups, filling of a semicircular canal (SC) defect was performed in 33 patients, and mastoidoplasty - in 47.

CONCLUSION

All used FL treatment techniques are effective in the treatment of peripheral vestibular disorders. Careful treatment of SC fistula after removal of all pathological conditions in the absence of active inflammation and the appointment of hormone therapy in the postoperative period are the main factors in preserving the functions of the labyrinth in any surgical technique. Filling of the lumen of the SC and mastoidoplasty in patients with CSOM with FL can eliminate peripheral dizziness.

Assessment of Bone Conduction Thresholds After Surgical Treatment in Patients with Labyrinthine Fistula

Objective

This study aimed to analyze the bone conduction thresholds before and after surgery in chronic otitis media patients with cholesteatoma who had labyrinthine fistula and whose cholesteatoma matrix had been completely cleaned.

Methods

The study was performed between 2013 to 2017 with 23 chronic otitis media patients who had labyrinthine fistula with cholesteatoma and who were operated at the Department of Otorhinolaryngology of Dicle University School of Medicine. Patients were assessed by anamnesis and examination and when necessary, by temporal computerized tomography and diffusion magnetic resonance imaging. Bone conduction thresholds at frequencies of 500, 1000, 2000, and 4000 Hz were determined by audiometric examination and they were compared before and after surgery.

Results

Of the 23 patients, 12 were female and 11 were male; their age range was 10-55 (26.04±14.13) years. In the post-operative period, it was possible to conduct audiological follow-up on 20 patients. In these follow-ups, 16 patients showed no change in bone conduction thresholds, two patients showed worsening, and two showed improvement. When pre- and post-operative bone conduction thresholds at each frequency were compared separately, no significant difference was found (p=0.937). No statistically significant difference was found between the pre- and post-operative means at the four frequencies (p=0.712).

Conclusion

In this study, we found that to reduce complications relating to cholesteatoma, it might be necessary to completely remove the matrix especially in the case of type 1 and 2 labyrinthine fistulas.

Management of labyrinthine fistula: hearing preservation versus prevention of residual disease

The objective of the study was to evaluate postoperative hearing and disease control after cholesteatoma surgery for labyrinthine fistulas. In a retrospective cohort study, we evaluated a consecutive cohort comprising 44 patients (45 ears) with labyrinthine fistulas associated with chronic otitis media with cholesteatoma who underwent surgery between 2002 and 2015. We looked at patient characteristics, pre- and postoperative bone conduction thresholds (BCT), operative approach and findings, extent of disease and the occurrence of residual disease. All deaf ears (24%) presented preoperatively with a large fistula. Opening the membranous labyrinth resulted in significantly worse postoperative BCT (p = 0.01). Neither the present study nor a literature search revealed a significant positive effect of corticosteroids on postoperative hearing preservation. Large fistulas were correlated with poorer preoperative BCTs, but not with poorer postoperative BCTs. Opening the membranous labyrinth during surgery is correlated with poorer postoperative BCTs and can be seen as a predictive parameter. The use of corticosteroids in the perioperative management of labyrinthine fistula was not found to result in any improvement in postoperative BCTs.

Imaging of labyrinthine fistula after repair with bone pate

OBJECTIVES/HYPOTHESIS

To demonstrate imaging of labyrinthine fistula due to cholesteatoma and illustrate outcome following repair with bone pate.

STUDY DESIGN

Retrospective review.

METHODS

Patients with labyrinthine fistula due to cholesteatoma were identified, and pre- and postoperative imaging was assessed. Method of repair was recorded. The fistula site was examined for patency and bone density after repair.

RESULTS

Twenty-nine fistulae were seen in a cohort of 375 cholesteatoma cases (8%). Preoperative computed tomography (CT) imaging for fistula detection showed sensitivity of 96% and specificity of 90%. The lateral semicircular canal was the most common site of dehiscence occurring in all cases. Facial nerve dehiscence is observed in 91% of fistula cases and stapes erosion in 69%. Severe hearing loss was present preoperatively in four (14%) cases. Bone pate was used to repair the fistula with CT-documented restoration of the otic capsule in 11/13 cases with postoperative imaging. When bone pate was not used, the otic capsule defect persisted.

CONCLUSIONS

Spontaneous repair of the otic capsule following treatment of cholesteatoma is expected to be an uncommon occurrence. Repair of the fistula with bone can result in long-lasting restoration of the otic capsule.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1643-1648, 2018.

Surgery for Cholesteatomatous Labyrinthine Fistula

OBJECTIVE

There is uncertainty regarding the ideal surgical management of cholesteatomatous labyrinthine fistulae. The objective was to review the published evidence to determine whether a difference exists in hearing outcome for cholesteatoma matrix removal or matrix exteriorization.

DATA SOURCES

Systematic MEDLINE and Web of Science searches identified publications describing hearing results after cholesteatoma matrix removal or matrix exteriorization.

REVIEW METHODS

Three reviewers appraised the studies for quality, level of evidence, and extracted data. Fistula characteristics such as single-site, multisite, size, grade, and follow-up time were extracted for subanalyses, and when appropriate, data were pooled for statistical analysis.

RESULTS

Twenty-eight articles met inclusion criteria, and the level of evidence was judged no better than level 3b. There was no difference in hearing preservation detected between matrix removal and exteriorization (87% for matrix removal, 95% CI, 0.82-0.90; 95% for exteriorization, 95% CI, 0.85-0.98). An analysis of the individual cohort studies that compared these groups directly did not show a difference in calculated odds ratio (OR), 0.96 (95% CI, 0.66-1.40).

CONCLUSION

The level of evidence on which to base surgical decision making related to cholesteatomatous labyrinthine fistula is poor, and the data do not demonstrate significant differences in hearing outcomes based on surgical technique.

A retrospective study on post-operative hearing of middle ear cholesteatoma patients with labyrinthine fistula

CONCLUSIONS

There is no significant change in bone conduction threshold after operation, so the tympanoplasty can be done to maintain hearing when conditions allow.

OBJECTIVE

To study the impact of surgical treatment on hearing of cholesteatoma patients with labyrinthine fistula.

METHODS

The clinical data of 35 patients (35 ears) with labyrinthine fistula, which were caused by cholesteatoma, were analyzed retrospectively. The hearing of 21 patients was followed up.

RESULTS

Three months to 5 years follow-up of 21 patients were accomplished by pure tone audiometry and other details. There was no recurrent cholesteatoma in the patients. Compared with pre-operative average bone conduction at 0.5, 1, 2, 4, and 8 kHz, 12 cases had a difference less than 5 dB, three patients' hearing improved (more than 10 dB), and five cases declined (more than 10 dB). One patient received cochlear implantation 3 months after the surgery. The average bone and air conduction thresholds at 0.5, 1, 2, 4, and 8 kHz had no obvious change (p > 0.05) in 11 patients managed by a canal wall down mastoidectomy with tympanoplasty.

The effects of bone pâté on human osteoblasts cell cultures

The aim of the present study was to evaluate the effect of bone pate on human osteoblast differentiation by measuring cell viability, alkaline phosphatase activity and expression of the transcription factors and of the major components of the extracellular matrix. Although bone paté has been used in ear surgery for many years and when placed in contact with mastoid and external auditory canal bone become viable, the cellular mechanisms that lead to its osteointegration have never been described. Bone paté taken from four patients subjected to mastoidectomy and affected by middle ear and mastoid cholesteatoma was placed in contact with osteoblast-like cell cultures. Four experimental conditions were obtained: cell cultures treated with bone patè, with bone paté mixed with fibrin glue, with fibrin glue and untreated. After 24 h, the viability of the cells was evaluated; after 1 week, alkaline phosphatase activity and the expression of transcription factors and bone matrix proteins were assessed by quantitative polymerase chain reaction. After 24 h osteoblasts showed increased viability when treated with bone paté (19 % increase) and bone pate mixed with fibrin glue (34 % increase). After 1 week, the number of alkaline phosphatase positive cells increased by 97 and 94 % in cultures treated with bone paté alone and bone pate mixed with fibrin glue. Treatment with bone patè upregulated transcription factors and components of the extracellular matrix. The present data show that bone paté has a high osteoinductive potential on human osteoblasts, enhancing their activity.

Middle Ear Cholesteatoma Treated with a Mastoidectomy

Objectives

The inconsistent measures used to report outcomes after mastoidectomy to treat cholesteatoma make it impossible for clinicians to compare results and apply them appropriately to patient care. We sought to identify and assess the type and relative frequency of the reported measures.

Data Sources

PubMed, EMBASE, the Web of Science.

Review Methods

We searched 3 independent databases for articles that reported outcomes of middle ear cholesteatoma treated with mastoidectomy. Articles were assessed for eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and data were extracted by 2 independent investigators. Observational studies and randomized controlled trials from the past 30 years were included. Articles with less than 50 subjects and nonsurgical studies were excluded. The measures used by each study were recorded, and the relative frequency of each measure was calculated.

Results

Forty-three of 380 articles met criteria. Time to follow up was inconsistent. Most articles reported on preoperative qualitative parameters (77%); however, few reported on the severity of disease (19%) or formally staged the disease (12%). Not all studies reported on the presence of recurrent or residual disease (88%) or the postoperative audiogram results (70%). Only 12% presented results as a Kaplan-Meier disease-free curve. Most studies reported on complications (70%).

Conclusion

Reported measures were inconsistent among the studies, which makes comparisons between studies unreliable. Standardization will optimize future reporting and will allow for the establishment of best practices.

Current trends in the management of the complications of chronic otitis media with cholesteatoma

PURPOSE OF REVIEW

Complications of cholesteatoma can be of a different nature from those of other otitis media. This review aims to undertake an analysis of current literature regarding management of the complications of cholesteatoma.

RECENT FINDINGS

Despite a significant decline in the incidence of complications secondary to cholesteatoma in developed countries it is still a considerable problem in the developing countries. Among intratemporal complications, facial nerve paralysis and labrynthine fistula and among intracranial complications, meningitis, brain abscess and lateral sinus thrombosis are most common. In cases of facial nerve paralysis, decompression with complete disease eradication is considered to be the mainstay of treatment and usefulness of an epineural incision and the range of the decompression are still debatable. Labyrinthine fistula is commonly managed by a single staged matrix removal, followed by closure of the fistula. Partial labrynthectomy in difficult cases is gaining favor among surgeons today. Meningitis and brain abscesses are treated with antibiotics and steroid therapy followed by surgery when the patient is neurologically stable. In lateral sinus thrombosis, mastoidectomy and removal of infected tissue is the primary treatment. Sinus incision and thrombectomy does not seem to improve recanalization and anticoagulation is usually not necessary. Treatment of meningoencephalic herniations is based mainly on the diameter of the herniation.

SUMMARY

There is considerable debate in the management of almost every complication of cholesteatoma. Multicentric studies to compare the efficacies of various treatment modalities are the need of the hour to come to definitive conclusions regarding the best treatment options.

Matrix removal of labyrinthine fistulae by non-suction technique with intraoperative dexamethasone injection

CONCLUSION

Matrix removal by a non-suction technique with intraoperative dexamethasone injection is a safe and effective management modality, regardless of fistula size.

OBJECTIVE

Our goal was to evaluate the outcome of hearing treated by non-suction technique with intraoperative dexamethasone injection.

METHODS

This was a retrospective chart review of 720 mastoidectomy cases for cholesteatoma, performed at our tertiary otolaryngologic care centers between 2005 and 2012. A total of 17 patients with a unilateral labyrinthine fistula were encountered.

RESULTS

There was no recurrent cholesteatoma in any of the patients. In all cases, the matrix was removed by intraoperative dexamethasone injection with a bimanual non-suction technique, regardless of the fistula size. None of the patients showed deteriorated bone conduction (BC). Averaged BC was unchanged (n = 13) or improved (n = 4) in all patients and did not decrease by 10 dB more in any patient. The mean threshold of postoperative BC was significantly improved compared with preoperative mean threshold. Fistulae on the preoperative CT scans ranged from 1.41 to 7.12 mm and averaged 2.89 mm. There was no correlation between the fistula size and the postoperative BC level. Even with a large fistula, postoperative hearing preservation was possible with one-stage matrix removal.

Predictors of Hearing Preservation in the Management of Labyrinthine Fistulas Positioned on the Semicircular Canals

Objectives:

We sought to identify factors that would predict hearing preservation in the treatment of semicircular canal labyrinthine fistulas.

Methods:

Between 1990 and 2010, 97 patients with semicircular canal fistulas were operated on and enrolled in this retrospective study. In 62 patients the matrix was removed and the fistula was sealed, whereas in 35 patients the canal was drilled, the matrix was detached, and the canal was occluded. Perioperative corticosteroids were administered in 51 patients. The main outcome measures were the bone conduction thresholds evaluated at 1 year after the operation. Factors considered for possible association with hearing preservation included age, gender, site and size of the fistula, primary versus revision surgery, surgeon, perioperative corticosteroid treatment, and surgical management of the fistula.

Results:

The bone conduction hearing level was improved in 16 patients, remained unchanged in 73 patients, and had worsened in 11 patients. On the univariate analysis, good hearing was predicted by grade II fistula, canal plugging, and corticosteroid treatment. However, none of these factors attained significance in the logistic regression model.

Conclusions:

In surgery of semicircular canal fistulas, good hearing outcomes are to be expected if perioperative corticosteroids are administered, matrix removal and fistula sealing is performed in grade II fistulas, and canal occlusion is performed in grade III and IV fistulas.

Preserving bone conduction in patients with labyrinthine fistula

The management of labyrinthine fistula is a controversial issue. Hearing preservation represents a major challenge. Retrospective study of 31 patients with labyrinthine fistula confirmed intra-operatively during cholesteatoma surgery. In all cases, total matrix removal was performed, and the fistula covered with bone dust, periostium and/or cartilage. Twenty-five patients received a high intra-operative dosage (500 mg) of intravenously applied steroids at least 15 min before handling the fistula. Outcome measurements included comparison of the pre-operative and post-operative bone conduction to assess inner ear function. The results were, the fistula was located in the lateral semicircular canal (LSC) in 22 patients (71.8%) and in the oval window in eight. One patient had a double localization in the superior and lateral semicircular canals. Out of the LSC fistulas, five patients (16.12%) had a fistula type I, 8 had type IIa (25.8%), four (12.9%) type IIb, and six patients type III (19.35%). Three out of eight patients with fistula located in the oval window had a total absence of the footplate, other four presented a partial anterior resorption at the level of the fissula antefenestram and the remaining one had a fractured platina. Pre-operatively, the bone conduction displayed a mean threshold of 35 dB. Twenty-two (85%) out of 26 patients treated intra-operatively with steroids showed preservation or improvement of bone conduction. Patients with fistulas of the oval window, type I, IIa and III fistulas in the LSC treated with cortisone presented good sensorineural hearing outcome (preservation or significant improvement of inner ear function in the majority of cases-91%); the auditory results for group IIb were inconclusive. Five patients did not receive steroids, four of them developed partial sensorineural hearing loss and one went deaf. To conclude, cholesteatoma surgery with a single-staged matrix removal on perilymphatic fistulas, after intra-operative intravenous administration of a high dosage of steroids followed by a multilayer closure of the fistula achieved a hearing preservation or improvement in 85% of our patients.

Canal wall window mastoidectomy for extensive labyrinthine cholesteatoma: total dissection and hearing preservation

This case report highlights outcomes of a 6-year-old patient who preserved functional hearing after complete dissection of an extensive labyrinthine cholesteatoma causing two semicircular canals fistulas with endolymph leak, tympanic and labyrinthine fallopian canal erosion of the facial nerve and internal auditory canal invasion with cerebrospinal fluid leak. The patient preserved 40 dB average of bone conduction threshold and 92% of speech discrimination score at 26 months postoperatively. This article reveals that canal wall window mastoidectomy might be an option even in cases of extensive cholesteatomatous labyrinthine fistula therefore avoiding hearing loss and long life cleaning of a canal wall down mastoid cavity.

Prognostic indicators of hearing after complete resection of cholesteatoma causing a labyrinthine fistula

The objectives of this study are (1) to evaluate hearing change after complete cholesteatoma resection in the setting of a labyrinthine fistula, (2) to assess the sensitivity and specificity of the preoperative CT-scan in diagnosing a labyrinthine fistula, and (3) to determine the correlation between the type of the labyrinthine fistula and its radiologic size. A retrospective chart review of all patients operated for cholesteatoma between 2004 and 2009 was conducted. Primary outcome was defined as the average variation in bone conduction thresholds (BCTs) as well as speech discrimination score (SDS) after total excision of cholesteatoma causing a labyrinthine fistula. We reviewed all preoperative CT-scans and operative notes to assess sensitivity and specificity for the diagnosis of a labyrinthine fistula. Results show that 317 patients underwent mastoidectomy for cholesteatoma. Twenty-eight patients were found to have 32 labyrinthine fistulas caused by cholesteatomatous disease affecting the lateral semi-circular canal (SCC) (n = 25), the superior SCC (n = 5), the posterior SCC (n = 1) and the footplate (n = 1). Postoperative BCT and SDS (24.5 dB; 86.6%) were neither clinically nor statistically different from preoperative levels (23.2 dB; 87.5%) (p = 0.35). Sensitivity and specificity of the preoperative high resolution 0.55 mm cuts CT-scan was 100%. With a fistula of 3.55 mm in the axial plan, a membraneous fistula must be suspected with a sensitivity of 66% and a specificity of 71%. Complete matrix resection without suctioning at the site of a cholesteatomatous labyrinthine fistula is a safe and effective management option. High-resolution preoperative CT-scan is very precise in diagnosing labyrinthine fistula and its radiologic size helps to predict the type of the fistula.

Management of labyrinthine fistulae in Kyoto University Hospital

CONCLUSION

In cases of labyrinthine fistulae, we performed complete removal of the cholesteatoma matrix in a one-stage procedure, resulting in a satisfactory bone conduction (BC) hearing preservation rate. Preoperative evaluation of labyrinthine fistulae using high resolution computed tomography (HRCT) detected 86% of cases, and this contributed to favorable results achieved with the surgical treatment of labyrinthine fistulae. We aimed to review cases of labyrinthine fistulae to summarize their outcomes and establish standards of management.

METHODS

This was a retrospective chart review of 22 patients with labyrinthine fistulae at Kyoto University Hospital from 2001 to 2009. Patient background (age and sex), location and stage of the fistulae, facial nerve status, preoperative and postoperative BC hearing levels, preoperative CT diagnosis, and surgical procedures were analyzed.

RESULTS

The incidence rate of the labyrinthine fistulae was 11.2%. All but one patient had labyrinthine fistula due to cholesteatoma. The fistulae were found in the lateral semicircular canal in 17 cases (77%) and in multiple organs in 4 cases (18%). The BC hearing level was preoperatively scaled out in seven cases. Preoperative HRCT scan revealed the presence of fistulae in 19 cases (86%). For all cases of cholesteatoma, the matrix was completely removed in a one-stage procedure and the fistulae were sealed using bone pate, temporal fascia, and temporal bones. Of the 15 cases with residual BC hearing ability, BC hearing was preserved in up to 12 cases. Two cases with postoperative deterioration of BC hearing had stage 4 fistulae in the cochleae.