Acquired Cholesteatoma Surgery: The Hybrid Approach

Background: Chloesteatoma is a dangerous disease. It carries the risk for intracranial, cranial and extra-cranial complications. The standard surgical techniques used to remove cholesteatoma from the middle ear cleft for the sake of safety, dryness and possibly hearing is the canal wall up (CWU) and the canal-wall down (CWD). Canal-wall reconstruction
(CWR) approach is associated with posterior canal wall reconstruction which combines the advantages of the two techniques. Cartilage, bone and different alloplasts have been used to reconstruct the meatal wall after its removal. Aim of the study: To assess the efficacy of the surgical techniques in which the posterior canal wall is removed and reconstructed after proper cleaning of cholesteatoma.
Materials and Methods: Thirty-five patients suffering
from CSOM with cholesteatoma (41 ears) were included and admitted at the Otorhinolaryngology (ORL) department, Assiut University Hospitals, between 2012-2015. Patients were subjected to preoperative clinical, audiological and radiological evaluation. Three surgical techniques have been used to reconstruct the posterior meatal wall (PMW)
after removing cholesteatoma. Primary ossiculoplasty was done in 25 ears (61 %). Patients were followed up after surgery to evaluate the anatomical and functional success and complications.
Results: All patients complained of ear discharge and hearing loss. The majority presented by either attic perforation 12 ears (29.3 %) or retraction pocket 10 ears (24.4%). Twenty eight years (68.3%) had extensive cholesteatoma eroding the ossicles. Temporary removal of PMW and reposition in place in CWU mastoidectomy was done in 26 ears (63.4%), cortical bone to reconstruct part of the PMW (in ears of retrograde mastoidectomy) in 7 ears (17%), and cortical bone to reconstruct the whole PMW (after CWD mastoidectomy) in 8 ears (19.6%). The mean postoperative follow-up was 14 months. Good postoperative healing was achieved in 36 ears (87.5%) with no narrowing of the external auditory canal. Postoperative complication included otorrhea in 9 ears (21.9%), broken graft in 2 ears (4.9%), granulation tissue in 3 ears (7.3 %), extruded material in 1 ear (2.4%), and recidivism of cholesteatoma 3 in ears (7.3 %). There was a significant improvement of hearing postoperatively in the 25 ears that underwent ossiculoplasty.

Conclusion: Surgical management of cholesteatoma and reconstruction of the ear in a single surgery is a highly successful procedure for the eradication of cholesteatoma. Radical cavities can be avoided if the posterior auditory canal wall is removed only temporarily at operation and is reimplanted finally.