Clin[ Otolaryn`ol[ 0887\ 23, 137Ð141

Atticotomy with reconstruction for limited cholesteatoma

D[M[EASTDepartment of Otolaryn`olo`y\ Manor Hospital\ Walsall\ UK

Accepted for publication 08 January 0887

EAST D [M ["0887# Clin[ Otolaryn`ol[ 23, 137Ð141

Atticotomy with reconstruction for limited cholesteatoma

Several authors have con_rmed that it is entirely reasonable to perform a one!stage atticotomy for atticcholesteatomas which are limited in size[ Over a period of 09 years\ 084 primary procedures were performedfor cholesteatoma\ and\ out of this total\ 54 were operated on by an established technique of cartilagerepair[ In this group of a limited atticotomy there were only two recurrences "2)# and so the technique isconsidered reliable and\ furthermore\ using the author|s modi_cation\ there is no need to dissect outperichondrial ~aps[ It is recommended that attic cholesteatomas are operated on while they are as smallas possible*no damage to the hearing occurred in 52 "85[8)# of the ears in this series*as the results ofossicular repair in ears damaged by cholesteatoma are unpredictable\ especially when there is eustachiantube dysfunction[

Keywords chronic otitis media cholesteatoma sur`ery atticotomy

Surgery for cholesteatoma should be performed in such a waythat all the matrix is removed^ this is the surgeon|s primaryobjective[ An ideal operation would have the advantage ofsimultaneously allowing total excision of disease and re!storation of hearing[ It should have the following charac!teristics]!

0[ It should result in a permanently dry and safe ear withsocially useful hearing[

1[ It should not require routine revision surgery[2[ It should require minimal aftercare[3[ It should have a low recurrence rate[

Two distinct procedures have evolved to deal with the seem!ingly intractable problems inherent in making an ear both safeand usable*the open cavity technique and the intact canalwall operation[ The advantages and disadvantages of therespective procedures have been discussed at length[0Ð2 Com!bining the two approaches by reconstruction of the canal walleither at the time of operation or at a later date\ has theattraction of allowing full excision of disease while at the sametime making resumption of normal activities possible[ Canalwall reconstruction can be carried out with a variety ofmaterials\ both natural and arti_cial[ For limited defects thereseems to be agreement among a number of authors that car!tilage is both mechanically stable\ biologically well tolerated

Correspondence] D[M[ East\ Department of Otolaryngology\ ManorHospital\ Moat Road\ Walsall\ West Midlands WS1 8PS\ UK[

137 Þ 0887 Blackwell Science Ltd

in the mastoid and middle ear\ and readily obtainable at thetime of operation[3Ð5

At the outset of this study\ the author proposed that nodefect in which the attic was opened posteriorly beyond thefossa incudis and lateral semicircular canal would be closedin this way\ and that any larger defect would be managedas a canal!wall down operation\ even if the resulting cavityrequired obliteration[

Materials and methods

OPERATIVE TECHNIQUE

Between 0875 and the _rst quarter of 0885\ 084 primary oper!ations for cholesteatoma were carried out by the author[ Anendaural incision was made\ followed by extensive wideningof the bony meatus] superiorly to the level of the dural plate\anteriorly to expose fully the body of the malleus and pos!teriorly to the limit of the cholesteatoma sac "Figure 0#[ Thesituation was then assessed[ If the ossicles were a}ected by thecholesteatoma\ a combination of malleus head removal\ incusremoval and:or transposition was carried out[ If the incus wasnot salvageable\ an incus replacement prosthesis was inserted"see below#[ Most importantly\ if the disease extended too farbackwards a cavity was created\ and a meatoplasty performed\but if the cholesteatoma could be properly removed\ a pieceof conchal cartilage was used to cover the defect\ itself being

Atticotomy with reconstruction for limited cholesteatoma 138

Figure 0[ Atticotomy cavity prior to closure[

Figure 1[ Positioning of the cartilage and temporalis fascia[

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covered by a temporalis fascia graft and then by canal skin"Figure 1#[

The cartilage and perichondrium were harvested from theposterior aspect of the pinna through a separate incision[ Afree graft approximately 4 mm across can be removed leavingan insigni_cant deformity[ The perichondrium lateral to thecartilage was left in situ\ so the graft had perichondrial coveronly on one side[ This does not appear to a}ect the viabilityof the graft[

S ITE OF CARTILAGE GRAFT

The desirable characteristics of conchal cartilage are _rst itsthickness\ which enables the graft to act as the outer attic wallwithout retraction\ and second the natural curvature whichallows the surgeon to position the concave side outwards\following the shape of the deep meatus[ In this respect it is animprovement on tragal cartilage[ Other authors have main!tained the necessity for perichondrial ~aps as a means ofpreserving the cartilage\3Ð5 but this author|s experience is thatthe cartilage can be placed en bloc lateral to the surgicaldefect "Figure 2#\ and that providing perichondrium is presentlaterally\ the graft will survive[ The fact that the operationtakes less time is\ of course\ a coincidental bene_t[

TYPES OF OPERATION

In the present study\ atticotomy using conchal cartilage wasperformed in 54 cases out of 084 "22[2)#\ in 00 "4[5)# ofwhich the defect was so small that no cartilaginous support

Figure 2[ Closure of the defect[

149 D[M[East

was considered necessary\ and these cases are not included inthe study[ In the remaining 029 "55[5)# a cavity was createdbecause the excavation to remove the cholesteatoma was bythen too large to be successfully repaired[ In the group ofpatients who had an atticotomy carried out\ ossicular repairwas performed in 23 "41[3)#\ as a one!stage procedure withthe atticotomy[ The criteria for ossiculoplasty were] "0# normalmiddle ear mucosa^ "1# mobile footplate^ and "2# bone con!duction at an adequate level to ensure usefulness of the oper!ated ear[

If the incus was una}ected by cholesteatoma it was removedand transposed[ Otherwise\ solid hydroxyapatite TORPs andPORPs were used up to 0881 and from 0881 onwards\ CausseFlex!HA prostheses\ as described by Vincent et al[6 In 20patients out of the 54 "36[5)# no reconstruction was carriedout\ either because the above criteria were not met\ or becausethe ossicular chain was intact and mobile[ In 10 patients"21[2)# a grommet was inserted at the time of surgery becausethere was secretion within the middle ear cleft[

Results

Two patients defaulted immediately after removal of packing"2)#\ and have not reappeared in spite of our attempts tocontact them[ A further six patients "8[1)# defaulted after aperiod of 2Ð01 months[ At least an audiogram was obtainedfrom these six patients[

Of the remaining 46 patients\ two "2)# had recurrencesduring the _rst 1 years^ both in the region of the facial recessthat was not fully uncovered during the procedure\ and whichwas dissected blindly using a long elevator[ One was suc!cessfully revised and the other had by then su}ered a cer!ebrovascular accident\ and was un_t for surgery[ The remain!ing ears healed up rapidly and the patients continue to lead anormal life[

HEARING RESULTS IN 54 PATIENTS

Hearing improvement was assessed by averaging the air!con!duction gain over the frequencies of 499 Hz\ 0 kHz and 1 kHz[The hearing improvement obtained by surgery is tabulated inTable 0[ Two points should be noted] "0# two patients "2[0)#had deterioration of hearing postoperatively\ and "1# in somepatients the hearing was normal preoperatively[

The overall hearing results in the 52 out of 54 patients whoattended for follow!up are shown in Table 1[

With regard to the state of the middle ear at the time ofoperation\ as indicated by the presence or absence of secretion\the postoperative hearing loss was as shown in Figure 3[

The overall hearing results in ears with otitis media withe}usion are very much less satisfactory than in those earswhere the middle ear mucosa is normal[ Nevertheless\ takingthose patients in whom no ossicular repair was undertaken

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Table 0[ Hearing improvement

Technique n Hearing gain "dB#

No reconstruction 13 91 4Ð095 09Ð190 390 Default

Incus transposition 00 90 4Ð094 09Ð191 140 Default

Malleus!stapes head 1 93 19Ð29

Malleus!footplate 1 91 19Ð290 39

Table 1[ Hearing results

09Ð19 dB 03:52 "11[1)#19Ð39 dB 13:52 "27[0)#39Ð79 dB 14:52 "28[6)#

Figure 3[ The e}ect of eustachian tube dysfunction on the _nal hearingresults Ž\ 29Ð79 dB^ �\ 9Ð29 dB[

and where no ventilation tube was inserted "n � 14#\ and asimilar group who were arti_cially ventilated "n � 8#\ there isno signi_cant di}erence in the overall hearing improvement"4[5 dB without a tube and 5[55 dB with a tube# nor in thepercentage of patients where there was no demonstrable hear!ing gain "61) compared to 55)#[ So the e}ect of eustachian

Atticotomy with reconstruction for limited cholesteatoma 140

tube obstruction may be related to other factors besides themobility of the tympanic membrane[

Discussion

Early detection and surgery of cholesteatoma are the cor!nerstones of successful treatment[ A limited operation on asmall cholesteatoma sac with a normal ossicular chain willinevitably result in a trivial surgical defect with hearing pres!ervation\ so the end!result is always going to be more sat!isfactory for the patient than the cavity or canal!wall!up tym!panoplasty resulting from a more extensive operation[

No claims are made for originality[ Goodhill7 was usingcartilage for the reconstruction of tympanic membranes andossicles in 0856[ McCleve5 reported the use of tragal cartilagefor the closure of bony defects in 0858\ and in 08748 publishedan account of over 099 cases observed for up to 07 years witheminently satisfactory results[ Linde3 reported 09 cases wheretragal cartilage:perichondrial autografts were successfullyemployed to close posterosuperior bony canal defects\ but in0873 Adkins and Osguthorpe4 had two failures out of 39operations for cholesteatoma\ subsequently revised[

The majority of authors seem to prefer tragal cartilage[Adkins and Osguthorpe4 considered conchal cartilage {incon!venient| when an endaural incision was employed^ McCleve5

used tragal cartilage throughout^ but Linde3 found conchalcartilage satisfactory[ Tos09 commented favourably on thecurvature of conchal cartilage[ The major user of cartilage intympanoplasty and mastoidectomy\ the ENT Department atthe Krupp Hospital\ Essen\ employs both sites[ Heerman00

described the use of cartilage in no fewer than 02 999 tym!panoplasties[ Cartilage is widely used for cavity obliterationand for repair of the scutum\ as well as for ossicular anddrumhead repair[

There is clearly a limit to the size of defect that can be closedby this technique[ Bergon01 described the di.culties attendanton using cartilage to replace the entire posterior canal wall\and McCleve8 had similar failures[ Ideally one shouldapproach any case with the intention of leaving as much ofthe posterior canal wall in situ as possible\ before resigningoneself to the creation of a cavity which may in turn requireobliteration\ reconstruction or revision[ It is\ ironically\ in thefailure of the operator to lower the facial ridge that muchcavity surgery remains unsatisfactory[ Once the decision tofashion a mastoid cavity is taken\ then the principles of cavitysurgery should prevail[

In the author|s opinion the maximal size of cavity that cansafely be closed by cartilage\ as opposed to obliterated\ is onewhere the excavation proceeds posteriorly as far as the lateralsemicircular canal[ Even then\ cholesteatoma can be missedat operation\ as two of the present series of cases demonstrate\and if one were to extend the atticotomy into the antrum\ therecurrence rate would undoubtedly be higher[ The use of

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endoscopes to visualize accurately the region of the facialrecess is therefore recommended[ Grote02 and Magnan03 haveboth designed arti_cial prostheses applicable when the entireposterior canal wall is absent\ they are not considered furtherhere[

The failure of surgery to improve hearing in patients wherea grommet was inserted "Figure 3# leads one to propose thata hearing aid\ either endomeatal or bone!anchored will prob!ably be necessary in such patients\ who should be advisedaccordingly before surgery is undertaken[

Conclusion

An established technique has been modi_ed to re!create anouter attic wall in selected cases of cholesteatoma where thedisease was limited in its posterior extent[ A very small numberof recurrences occurred due to inadequate removal of matrix\and the use of endoscopes is recommended[ The preoperativeintention of providing a safe\ dry ear which\ to the patient|sbene_t\ required minimal aftercare\ was ultimately achievedin all[ Hearing results\ where the ossicular chain is damaged\are unpredictable[ Since eustachian tube dysfunction was pre!sent in about one!third of patients\ long!term hearingimprovement is not always obtainable due to irreversiblemucosal damage[ Nevertheless the overall results con_rm the_ndings of other authors\ that limited autograft cartilagereconstruction in selected ears is a satisfactory technique withan excellent long!term prognosis[

Acknowledgements

The illustrations in this paper were drawn by Mrs GillianOliver\ FMAA\ AIMA\ RMIP[ The author would like tothank CIC Edizioni Internazionali for permission to repro!duce Figure 2[

References

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1 JANSEN C[ "0857# The combined approach for tympanoplasty"report on 09 years| experience#[ J[ Laryn`[ Otol[ 71\ 668Ð682

2 SMYTH G[D[L[ "0879# Chronic Ear Disease[ Churchill Livingstone\Edinburgh

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636Ð6424 ADKINS W[Y[ + OSGUTHORPE J[D[ "0873# Use of a composite

autograft to prevent recurrent cholesteatoma caused by canal walldefects[ Otolaryn`ol[ Head Neck Sur`[ 81\ 208Ð210

5 MCCLEVE D[E[ "0858# Tragal cartilage reconstruction of the audi!tory canal[ Arch[ Otolaryn`ol[ 89\ 24Ð27

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6 VINCENT R[\ GRATACAP B[ + VANDEVENTER G[ "0885# Ossic!uloplasty with J B Causse Composite Prostheses[ In Transplantsand Implants in Otolo`y III] Proceedin`s of the Third InternationalSymposium on Transplants and Implants in Otolo`y\ Bordeaux\France[ "ed[ PORTMANN M[# pp[ 109Ð108[ Kugler\ Amsterdam

7 GOODHILL V[ "0856# Tragal perichondrium and cartilage in tym!panoplasty[ Arch[ Otolaryn`ol[ 74\ 379Ð380

8 MCCLEVE D[E[ "0874# Repair of the bony canal wall defects intympanomastoid surgery[ Am[ J[ Otolaryn`ol[ 5\ 65Ð68

09 TOS M[ "0884# Manual of Middle Ear Sur`ery\ Vol[ 1[ MastoidSur`ery and Reconstructive Procedures[ Thieme\ New York

00 HEERMAN J[ "0881# Autograft tragal and conchal palisade cartilage

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and perichondrium in tympanomastoid reconstruction[ Ear NoseThroat J[ 60\ 233Ð238

01 BERGON J[ "0862# Principles of tissue transplantation as applied tootology[ Arch[ Otolaryn`ol[ 86\ 69Ð62

02 GROTE J[J[ + VAN BITTERSWIJK C[A[ "0875# Reconstruction of theposterior canal wall with a hydroxyapatite prosthesis[ Ann[ Otol[Rhinol[ Laryn`ol[ 84 "Suppl[ 012#\ 5Ð8

03 MAGNAN J[\ CHAYS\ A[\ PENCROFFI\ E[\ LOCATELLI P[ + BRUZZO

M[ "0885# Reconstruction of the ear canal wall[ In Transplantsand Implants in Otolo`y III] Proceedin`s of the Third InternationalSymposium on Transplants and Implants in Otolo`y\ Bordeaux\France[ "ed[ PORTMANN M[# pp[ 140Ð144[ Kugler\ Amsterdam