cholesteatoma
DESCRIPTION
Cholesteatoma. Department of Otorhinolaryngoglogy the 2nd Hospital affliatted to Medical college Zhejiang University Xu Yaping. Overview. Definition Classification and Theories Management Complications. Definition. Named by Johannes Mueller in 1838 - PowerPoint PPT PresentationTRANSCRIPT
Department of Otorhinolaryngoglogythe 2nd Hospital affliatted to Medical college
Zhejiang UniversityXu Yaping
Cholesteatoma
Page 2
Overview
Definition
Classification and Theories
Management
Complications
Page 3
Definition
Named by Johannes Mueller in 1838
1 Erroneous belief that one of the primary components
of the tumor was fat
2ldquoa pearly tumor of fathellipamong sheets of polyhedral
cellsrdquo
More appropriate name has been suggested to be kerato
ma to describe tumor composition
Page 4
Definition
Cholesteatomas are expanding lesions of the tempor
al bone that are composed of a stratified squamous
epithelial outer lining and a desquamated keratin ce
nter
Page 5
including
1 Cystic content desquamated keratin center
2 Matrix keratinizing stratified squamous epithelium
3 Perimatrix granulation tissue that secretes multiple pr
oteolytic enzymes capable of bone destruction
May develop anywhere within pneumatized portions of
the temporal bone
Most frequent locations Middle ear space
Mastoid
Page 6
Classification and Theories
It can be classified as one of two different types
Congenital
Acquired
1048708Primary
1048708Secondary
Page 7
Congenital Cholesteatoma
Definition (Levenson 1989) These criteria included
1 1048708White mass medial to normal tympanic membrane
2 1048708Normal pars flaccida and pars tensa
3 1048708No prior history of otorrhea or perforations
4 1048708No prior otologic procedures
5 1048708Prior bouts of otitis media were not grounds for me
dia exclusion as was the case in original definition
Page 8
Two prominent theories include
1 the failure of the involution of ectodermal epithelial t
hickening that is present during fetal development in
proximity to the geniculate ganglion
2 metaplasia of the middle ear mucosa
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 2
Overview
Definition
Classification and Theories
Management
Complications
Page 3
Definition
Named by Johannes Mueller in 1838
1 Erroneous belief that one of the primary components
of the tumor was fat
2ldquoa pearly tumor of fathellipamong sheets of polyhedral
cellsrdquo
More appropriate name has been suggested to be kerato
ma to describe tumor composition
Page 4
Definition
Cholesteatomas are expanding lesions of the tempor
al bone that are composed of a stratified squamous
epithelial outer lining and a desquamated keratin ce
nter
Page 5
including
1 Cystic content desquamated keratin center
2 Matrix keratinizing stratified squamous epithelium
3 Perimatrix granulation tissue that secretes multiple pr
oteolytic enzymes capable of bone destruction
May develop anywhere within pneumatized portions of
the temporal bone
Most frequent locations Middle ear space
Mastoid
Page 6
Classification and Theories
It can be classified as one of two different types
Congenital
Acquired
1048708Primary
1048708Secondary
Page 7
Congenital Cholesteatoma
Definition (Levenson 1989) These criteria included
1 1048708White mass medial to normal tympanic membrane
2 1048708Normal pars flaccida and pars tensa
3 1048708No prior history of otorrhea or perforations
4 1048708No prior otologic procedures
5 1048708Prior bouts of otitis media were not grounds for me
dia exclusion as was the case in original definition
Page 8
Two prominent theories include
1 the failure of the involution of ectodermal epithelial t
hickening that is present during fetal development in
proximity to the geniculate ganglion
2 metaplasia of the middle ear mucosa
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 3
Definition
Named by Johannes Mueller in 1838
1 Erroneous belief that one of the primary components
of the tumor was fat
2ldquoa pearly tumor of fathellipamong sheets of polyhedral
cellsrdquo
More appropriate name has been suggested to be kerato
ma to describe tumor composition
Page 4
Definition
Cholesteatomas are expanding lesions of the tempor
al bone that are composed of a stratified squamous
epithelial outer lining and a desquamated keratin ce
nter
Page 5
including
1 Cystic content desquamated keratin center
2 Matrix keratinizing stratified squamous epithelium
3 Perimatrix granulation tissue that secretes multiple pr
oteolytic enzymes capable of bone destruction
May develop anywhere within pneumatized portions of
the temporal bone
Most frequent locations Middle ear space
Mastoid
Page 6
Classification and Theories
It can be classified as one of two different types
Congenital
Acquired
1048708Primary
1048708Secondary
Page 7
Congenital Cholesteatoma
Definition (Levenson 1989) These criteria included
1 1048708White mass medial to normal tympanic membrane
2 1048708Normal pars flaccida and pars tensa
3 1048708No prior history of otorrhea or perforations
4 1048708No prior otologic procedures
5 1048708Prior bouts of otitis media were not grounds for me
dia exclusion as was the case in original definition
Page 8
Two prominent theories include
1 the failure of the involution of ectodermal epithelial t
hickening that is present during fetal development in
proximity to the geniculate ganglion
2 metaplasia of the middle ear mucosa
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 4
Definition
Cholesteatomas are expanding lesions of the tempor
al bone that are composed of a stratified squamous
epithelial outer lining and a desquamated keratin ce
nter
Page 5
including
1 Cystic content desquamated keratin center
2 Matrix keratinizing stratified squamous epithelium
3 Perimatrix granulation tissue that secretes multiple pr
oteolytic enzymes capable of bone destruction
May develop anywhere within pneumatized portions of
the temporal bone
Most frequent locations Middle ear space
Mastoid
Page 6
Classification and Theories
It can be classified as one of two different types
Congenital
Acquired
1048708Primary
1048708Secondary
Page 7
Congenital Cholesteatoma
Definition (Levenson 1989) These criteria included
1 1048708White mass medial to normal tympanic membrane
2 1048708Normal pars flaccida and pars tensa
3 1048708No prior history of otorrhea or perforations
4 1048708No prior otologic procedures
5 1048708Prior bouts of otitis media were not grounds for me
dia exclusion as was the case in original definition
Page 8
Two prominent theories include
1 the failure of the involution of ectodermal epithelial t
hickening that is present during fetal development in
proximity to the geniculate ganglion
2 metaplasia of the middle ear mucosa
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 5
including
1 Cystic content desquamated keratin center
2 Matrix keratinizing stratified squamous epithelium
3 Perimatrix granulation tissue that secretes multiple pr
oteolytic enzymes capable of bone destruction
May develop anywhere within pneumatized portions of
the temporal bone
Most frequent locations Middle ear space
Mastoid
Page 6
Classification and Theories
It can be classified as one of two different types
Congenital
Acquired
1048708Primary
1048708Secondary
Page 7
Congenital Cholesteatoma
Definition (Levenson 1989) These criteria included
1 1048708White mass medial to normal tympanic membrane
2 1048708Normal pars flaccida and pars tensa
3 1048708No prior history of otorrhea or perforations
4 1048708No prior otologic procedures
5 1048708Prior bouts of otitis media were not grounds for me
dia exclusion as was the case in original definition
Page 8
Two prominent theories include
1 the failure of the involution of ectodermal epithelial t
hickening that is present during fetal development in
proximity to the geniculate ganglion
2 metaplasia of the middle ear mucosa
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 6
Classification and Theories
It can be classified as one of two different types
Congenital
Acquired
1048708Primary
1048708Secondary
Page 7
Congenital Cholesteatoma
Definition (Levenson 1989) These criteria included
1 1048708White mass medial to normal tympanic membrane
2 1048708Normal pars flaccida and pars tensa
3 1048708No prior history of otorrhea or perforations
4 1048708No prior otologic procedures
5 1048708Prior bouts of otitis media were not grounds for me
dia exclusion as was the case in original definition
Page 8
Two prominent theories include
1 the failure of the involution of ectodermal epithelial t
hickening that is present during fetal development in
proximity to the geniculate ganglion
2 metaplasia of the middle ear mucosa
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 7
Congenital Cholesteatoma
Definition (Levenson 1989) These criteria included
1 1048708White mass medial to normal tympanic membrane
2 1048708Normal pars flaccida and pars tensa
3 1048708No prior history of otorrhea or perforations
4 1048708No prior otologic procedures
5 1048708Prior bouts of otitis media were not grounds for me
dia exclusion as was the case in original definition
Page 8
Two prominent theories include
1 the failure of the involution of ectodermal epithelial t
hickening that is present during fetal development in
proximity to the geniculate ganglion
2 metaplasia of the middle ear mucosa
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 8
Two prominent theories include
1 the failure of the involution of ectodermal epithelial t
hickening that is present during fetal development in
proximity to the geniculate ganglion
2 metaplasia of the middle ear mucosa
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 9
cholesteatoma
ossicular erosion
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 10
Acquired Cholesteatomas
Common factor
keratinizing squamous epithelium has grown beyond
its normal limits
Acquired cholesteatomas are subdivided into primary
acquired and secondary acquired cholesteatoma
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 11
Primary Acquired Cholesteatomas
Ultimately form due to underlying Eustachian tube
dysfunction that causes retraction of pars flaccida
Results in poor aeration of epitympanic space whi
ch draws pars flaccida medially on top of malleus n
eck forming retraction pocket
Normal migratory pattern of the tympanic membra
ne epithelium altered by retraction pocket
Enhances potential accumulation of keratin
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 12
Primary Acquired Cholesteatomas
Pars flaccida retraction Pars tensa retraction
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 13
Secondary Acquired Cholesteatomas
Implantation theory
Squamous epithelium implanted in the middle ear as a result of surgery f
oreign body blast injury etc
Metaplasia theory
Desquamated epithelium is transformed to keratinized stratified squamou
s epithelium secondary to chronic or recurrent otitis media
Epithelial invasion theory
Squamous epithelium migrates along perforation edge medially along und
ersurface of tympanic membrane destroying the columnar epithelium
Papillary ingrowth theory
Inflammatory reaction in Prussackrsquos space with an intact pars flaccida
(likely secondary to poor ventilation) may cause break in basal membrane
allowing cord of epithelial cells to start inward proliferation
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 14
Cholesteatoma Spread
Predictable in that they are channeled along charact
eristic pathways by
1048708Ligaments
1048708Folds
1048708Ossicles
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 15
Common Sites of Cholesteatoma Origin
Posterior epitympanum
Posterior mesotympanum
Anterior epitympanum
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 16
Cholesteatoma Spread
Posterior epitympanic cholesteatoma passing through superior incudal space and aditus antrum
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 17
Posterior mesotympanic cholesteatoma invading the sinus tympani and facial recess
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 18
Anterior epitympanic cholesteatoma with extension to with geniculate ganglion
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 19
Patient Evaluation
Detailed otologic history
1 Hearing loss
2 Otorrhea malodorous
3 Otalgia
4 Tinnitus
5 Vertigo
Progressive unilateral hearing losswith a chronic foul smelling otorrhea should raise suspicion
Previous history of middle ear disease
1 Chronic otitis media
2 Tympanic membrane perforation Pars flaccida
3 Prior surgery
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 20
Otologic examination
Otomicroscopy is essential in evaluating the extent of disease
Clean ear thoroughly of otorrhea and debris with cotton and co
tton-tipped applicators or suction
Culture wet infected ears and treat with topical andor oral anti
biotics
Pneumatic otoscopy should be performed in every patient with
cholesteatoma
Positive fistula (pneumatic otoscopy will result in nystagmus a
nd vertigo) response suggests erosion of the semicircular cana
ls or cochlea
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 21
Hearing evaluation
conductive hearing loss
1 Pure tone audiometry with air and bone conduction
2 Speech reception thresholds
3 Word recognition
512Hz tuning fork exam
1048708Always correlate with audiometry results
Tympanometry
1048708May suggest decreased compliance or TM perforation
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 22
The degree of conductive loss will vary considerably depending on the extent of disease
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 23
Preoperative imaging with computed tomographies
(CTs ) of temporal bones (2mm ) section without con
trast in axial and coronal planes
1 Allows for evaluation of anatomy
2 May reveal evidence of the extent
3 Screen for asymptomatic complications
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 24
Cholesteatoma Management
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 25
Preventative Management
Tympanostomy tube for early retraction pockets
Surgical exploration for retraction persistence
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 26
Treated surgically with primary goal of total eradicat
ion of cholesteatoma to obtain a safe to and dry ear
1 Canal-wall -down procedures (CWD)
2 Canal-wall -up procedure (CWU)
3 Transcanal anterior atticotomy
4 Bondy modified radical procedure
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 27
Prior to the advent of the tympanoplasty
all cholesteatoma surgery was performed using CW
D surgery approach procedure involves
1048708Taking down posterior canal wall to level of vertica
l facial nerve
1048708Exteriorizing the mastoid into external auditory ca
nal
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 28
Classic CWD operation is the modified radical mastoidectomy i
n which middle ear space is preserved
Radical mastoidectomy is CWD operation in which
1048708 Middle ear space is eliminated
1048708 Eustachian tube is plugged
Meatoplasty should be large enough to allow good aeration of
mastoid cavity and permit easy visualization to facilitate posto
perative care and self cleaning
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 29
Indications for CWD approach
Cholesteatoma in an only hearing ear
Significant erosion of the posterior bony canal wall
History of vertigo suggesting a labyrinthine fistula
Recurrent cholesteatoma after canal-wall -up surger
y
Poor eustachian tube function
Sclerotic mastoid with limited access to epitympanu
m
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 30
Advantages
1048708Residual disease is easily detected
1048708Recurrent disease is rare
1048708Facial recess is exteriorized
Disadvantages
1048708Open cavity created
Takes longer to heal
1048708Mastoid bowl maintenance can be a lifelong problem
1048708Shallow middle ear space makes OCR (Ossicular Chain Recon
struction) difficult
1048708Dry ear precautions are essential
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 31
Canal-Wall -Down
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 32
Canal -Wall -Up
CWU procedure developed to avoid problems and maintenance
necessary with CWD procedures
CWU consists of preservation of posterior bony external audito
ry canal wall during simple mastoidectomy with or without a po
sterior with tympanotomy
Staged procedure often necessary with a scheduled second lo
ok operation at 6 to 18 months for
1048708Removal of residual cholesteatoma
1048708Ossicular chain reconstruction if necessary
Procedure should be adapted to extent of disease as well as sk
ill of otologist
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 33
CWU may be indicated in patients with large pneumatized mast
oid and well aerated middle space
1048708Suggests good eustachian tube function
CWU procedures are contraindicated in
1048708Only hearing ear
1048708Patients with labyrinthine fistula
1048708Long-standing ear disease
1048708Poor eustachian tube function
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 34
Canal-Wall -Up
Advantages
1048708Rapid healing time
1048708Easier long-term care
1048708Hearing aids easier to fit
1048708No water precautions
Disadvantages
1048708Technically more difficult
1048708Staged operation often necessary
1048708Recurrent disease possible
1048708Residual disease harder to detect
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 35
Canal-Wall -Up
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 36
Novel Techniques
In 2005 Gantz al reported 130 cases of canal wall reconstruction
tympanomastoidectomy with mastoid obliteration
1048708No evidence of recurrence = 985
1048708Recurrence treated with CWD (15)
1048708Second look ossiculoplastyin 78
1048708Post-operative wound infection was 143 for first 42 patients
Decreased rate to 45 in last 88 patients with 2 days of postpos
t-operative IV antibiotics
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 37
Novel Techniques
Canal Wall Reconstruction technique
1048708Complete cortical mastoidectomy with opening of with facial rec
ess and removal of incus and malleus head
1048708Posterior canal wall skin elevated annulus elevated
1048708Microsagittal saw used to cut posterior canal wall
1048708Cholesteatoma removed
1048708Posterior canal wall bone replaced
1048708Cortical bone chips used to block attic and mastoid from tympa
num
1048708Bone patersquo holds bone chips in place
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 38
Complications
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 39
The expansion of cholesteatomas
Infectionotorrheabone destruction
1 extracranial complications
Hearing loss
Facial nerve paresis or paralysis
Labyrinthine fistula semicirculai canal erosion
extradural or perisinus abscess
serous or suppurative labyrinthitis
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 40
2 Intracranial complications
potentially life-threatening Periosteal abscess
Lateral sinus thrombosis sigmoid sinus
Thrombosisphlebitis
Meningitis
Epidural subdural or parenchymal brain abscess
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 41
Hearing Loss
Conductive hearing loss ossicular chain erosion (30)
10487081 Erosion of lenticular process andor stapes superstructure
process may produce 50dB conductive hearing loss
10487082 Hearing loss varies despite disease extent (natural myringo
stapediopexy transmission of sound through cholesteatoma
sac)
Sensorineural hearing loss involvement of labyrinth
Following surgery 30 have further impairment due to
1048708Extent of disease present
1048708Complications in healing process
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 42
Labyrinthine Fistula
Incidence as high as 10
Symptom Sensorineural hearing loss andor vertig
o induced by noise or pressure change
Absence of a positive fistula test does not rule out this complic
ation
Common site horizontal semicircular canal basal t
urn of cochlea
Diagnosis Fine cut temporal bone CT (1mm)
Management modified radical mastoidectomy with
management of matrix overlying fistula
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 43
Facial Paralysis
May develop
1048708Acutely secondary to infection
1048708Slowly from chronic expansion of cholesteatoma
Temporal bone CT localize the nerve involvement
Most common site geniculate ganglion due to disease in the a
nterior epitympanum
Management Needs immediate surgery
1 Removal of cholesteatoma and infected material with decompression
of the nerve (mastoidectomy middle fossa approach)
2 Administration of intravenous antibiotics and high-dose steroids
3 Iatrogenic injury to the nerve during surgery should be immediately re
paired with decompression of nerve proximal and distal to site of injur
y
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 44
Intracranial Complications
Potentially life-threatening
Incidence as high as 1
Complications
1 Periosteal abscess
2 Lateral sinus thrombosis
3 Intracranial abscess
4 Meningitis
Symptom
1 Suppurative malodorous otorrhea
2 Chronic headache
3 Fever
4 Otalgia
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 45
Management
1048708Presence of mental status changes with nuchal rigidity or cra
nial neuropathies warrant consultation with urgent interventio
n
1048708Epidural abscess subdural empyema meningitis and cerebr
al abscesses should be treated immediately prior to definitive o
tologic management of ear disease
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Page 46
Conclusions
Pathogenesis of cholesteatoma remains uncertain
Essential to possess basic knowledge of the important anatomic and functional characteristics of the middle ear for successful management of cholesteatomas
Careful and thorough evaluations are the key to early diagnosis and treatment
Treatment is surgical with primary goal to eradicate disease and provide a safe and dry ear
Surgical approaches must be customized to each patient depending on extent of disease
Surgeon must be aware of serious and potentially life-threatening complications of cholesteatomas
Thanks
- Slide 1
- Slide 47
-
Thanks
- Slide 1
- Slide 47
-