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M. Tan et al.
19.10.4 Audiometric Evaluation
Every patient with chronic otitis media should be evaluated audiologically. If the
cholesteatoma involves the ossicular chain, conductive hearing loss will result. If
the cochlea is also involved, sensorineural hearing loss is added to the picture. If
both situations are present, it is called mixed hearing loss. Normal hearing does not
exclude cholesteatoma. Although a cholesteatoma damages the ossicular chain by
causing mass effect conduction, it may cause hearing to be better than it should be.
Tympanometry ndings are not specic to cholesteatoma [97–99].
19.11 Treatment ofCholesteatomas
Cholesteatoma is treated surgically. The purpose of surgery is to completely remove
the disease, leaving no residual disease and no opportunity for recurrent cholesteatoma development. The lesions found after surgical treatment of cholesteatoma can
be classied as residual cholesteatoma and recurrent cholesteatoma. Residual cholesteatoma is the leaving of cholesteatoma matrix in the middle ear, mastoid cavity,
and especially in graft intact and vital patients without retraction pouch in the postoperative period. On the other hand, recurrent cholesteatoma refers to the picture in
which cholesteatoma recurs in patients who have undergone surgery for eradication
of cholesteatoma and causes discomfort in the postoperative period, and retraction
pouch, graft perforation or attic destruction is seen in otoscopic examination.
Complete clearance of the disease should be the priority, and if functional procedures are necessary, they can be postponed to later sessions. Open and closed techniques are used in surgery. The closed technique preserves or reconstructs the
posterior wall of the external auditory canal in an attempt to create a ventilated
physiologic middle ear. The open technique removes the posterior wall of the external auditory canal and combines the middle ear cavity and the mastoidectomy cavity into a single cavity.
19.11.1 Closed Techniques
In this technique, the posterior wall of the external auditory canal is preserved or
repaired after removal and the posterior wall is rebuilt. This repair may be accomplished by replacing the removed posterior bone wall with otologic materials such
as cartilage, cortical bone, or alloplastic materials such as titanium.
In the classic closed technique, a complete mastoidectomy is performed through
a retroauricular incision. After ensuring that the aditus ad antrum is open, the tympanomeatal ap is lifted and the middle ear is entered. After cleaning the cholesteatoma in the mastoid and middle ear, ossicular chain reconstruction and tympanic
membrane repair can be performed. Preservation of the posterior wall of the external auditory canal, ventilated mastoid cavity, and provision of physiologic middle
ear ventilation are among the advantages of this technique. Due to inadequate access
19 Cholesteatoma
399
to the facial recess and extension of the tympanic sinus of posterior mesotympanic
cholesteatomas developed from retraction pockets, especially in the pars tensa of
the posterior upper segment, the use of this technique in such situations will increase
the recurrence rate. Residual cholesteatoma results from inadequate cleaning of the
epithelium during closed procedures. Residual cholesteatoma can be seen in the
postoperative period as well as after planned second-look procedures. Planned second-look surgery is recommended one year after surgery in children and two years
after surgery in adults. Residual cholesteatomas have a well-capsulated, pearl-like
appearance and do not contact the tympanic membrane unless they are too large.
Although MRI is helpful in the presence of residual cholesteatoma, it may not be
diagnostic. The sites where residual disease is most commonly seen after closed
surgery are those segments that are difcult to clean, such as the posterior mesotympanum (around the tympanic sinus and stapes), anterior epitympanum, and rarely
the mastoid and hypotympanum. The most difcult cases are those in which the
cholesteatoma moves to the posterior of the labyrinth. If the residual cholesteatoma
has a pearl-like shape, removal of the cholesteatoma is easy and effective in the
second session. If the cholesteatoma does not have a capsule border, this is a negative nding in terms of prognosis. If the cholesteatoma extends to the mastoid
antrum, a complete mastoidectomy should be performed and all cells should be
opened and cleaned. Posterior tympanotomy is a method used in closed cholesteatoma surgery. With this method, facial recess cholesteatoma can be cleaned more
easily, and in the case of anterior, posterior isthmus closure, by establishing the
connection between the mastoid and the middle ear, mastoid ventilation can be
ensured. Because this method provides access to the lateral side of the facial recess,
the medial tympanic sinus is difcult to access. With the advent of otoendoscopes,
this method is no longer used for cholesteatoma surgery. In posterior tympanotomy,
a diamond burr is used to create the fossa incudis with the distance between the
second elbow lateral facial canal and the corda tympany. This is a method that has
recently been used to place a cochlear implant.
Otoendoscopes that allow access to the sinus tympany and facial recess through
closed methods minimize the risk of residual disease. It is possible to completely
dominate the facial recess with a 30-degree endoscope and the sinus tympany with
a 70-degree endoscope. In addition, the middle ear, Eustachian tube entrance, mastoidectomy region, and aditus can be examined in detail and the presence of epithelium can be checked. A meta-analysis study showed a lower rate of residual
cholesteatoma in pediatric patients who underwent endoscopic cholesteatoma surgery compared to microscopic cholesteatoma surgery [100]. Endoscopy has both
advantages and disadvantages. The sense of depth may be lost, and the stapes head
and facial nerve may be damaged. Working with one hand, staining of the endoscope lenses by even a drop of blood, and damage to the facial nerve and inner ear
structures by the heat released by the endoscope are some disadvantages of
endoscopy.
If the cholesteatoma has invaded the medial part of the incudomalleal complex,
it is rather difcult to clean this cholesteatoma with the endoscope. It is possible
to inspect this region by removing the head of the malleus and the body of the
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incus. It is possible that cholesteatoma developing from posterior mesotympanic
and posterior epitympanic pockets may spread to these regions. Attention should
be paid to the horizontal segment of the facial nerve medial to these bones as they
are removed.
In cases where posterior epitympanic cholesteatomas extend through the attic
to the aditus, an atticotomy should be performed and the remaining tissue completely cleaned. The scutum should also be completely cleaned during the
atticotomy.
To prevent recurrence of cholesteatoma, reconstruction of scutum defects,
obliteration of mastoidectomy cavity and formation of resistant tympanic membranes should be performed. In cases where the scutum defect is not repaired and
the ossicular chain is absent, new retraction pockets may develop from these
regions and at epithelial progression from the weak areas may be observed.
Therefore, repair should be performed. If the negative pressure in the middle ear
persists after tympanoplasty, the transplanted graft may retract and lead to recurrent disease. Because unhealthy mucosa in the remaining mastoid in this region
after cholesteatoma removal in the mastoid may not perform gas exchange and
lead to negative pressure formation, many opinions support obliteration. However,
there are other opinions that this region traps air and acts as a reservoir for the
middle ear, and therefore it is not appropriate to obliterate it. Obliteration is most
commonly used in open techniques to reduce the cavity. Obliteration may allow
reconstruction of the middle ear in open surgery and prevent the recurrence of the
disease. If obliteration is to be performed, it is important to ensure that there is no
epithelium left in the area.
19.11.2 Open Techniques
In open technique surgery for cholesteatoma, the goal is to create a cavity from the
mastoidectomy cavity and the middle ear. As a result of the surgery, the cavity can
be left completely open and it is also possible to perform reconstruction by creating
middle ear cavity. Cholesteatoma can be completely removed during these operations. Anterior epitympanum and sinus tympanum, which are difcult to access in
the closed technique, can be easily exposed and cleaned. The recurrence rate is
lower compared to the closed technique [101]. However, the need for regular care of
the cavity and restriction of the patient from water sports in the postoperative period
are the disadvantages of the open technique. The involvement of the cholesteatoma,
the damage caused, the age of the patient, and the status of the opposite ear are
important factors in determining the type of surgery. Open rather than closed surgery should be considered for cholesteatoma involving the Eustachian tube, cholesteatoma in the tympanic sinus that cannot be controlled endoscopically, erosion of
the posterior wall of the external auditory canal, labyrinthine stula that cannot be
controlled, and cholesteatoma in the only hearing ear. Because the risk of residual
cholesteatoma is higher with the closed technique than with the open technique,
close follow-up of the patient is important. In elderly patients who cannot come for
19 Cholesteatoma
401
close follow-up and who do not have high functional expectations, the open technique is preferred to the closed technique. If the patient has Eustachian tube dysfunction and a small mastoid, such patients are at risk for recurrent disease.
Therefore, the open technique may be recommended in such cases. Patients who
have undergone open surgery should have regular cavity control. If an adequate cavity is created, debris accumulation will be minimal. Reduction of the mastoidectomy cavity by obliteration may be helpful in solving postoperative cavity problems
[102]. At the end of the surgery, the external auditory meatus is adequately dilated
by resection of large cartilaginous tissues from the cavum concha. When choosing
the technique for cholesteatoma surgery, the status of the cholesteatoma and the
patient should be considered, and it is necessary to know that these two techniques
are not different methods used against each other, but they are complementary
techniques.
One of the methods of open technique, Bondy surgery is applied in the attic
region cholesteatoma. The healthy middle ear is not touched and the cholesteatoma
in the attic region is cleaned.
In pediatric patients, the closed technique is usually preferred for cholesteatoma.
However, due to the aggressive nature of cholesteatoma in this age group, second
and third-look surgery may be necessary. Both residual and recurrent cholesteatomas may recur years after initial surgery. Therefore, long-term follow-up of patients
with cholesteatoma should be planned.
One of the major problems of cholesteatoma surgery is the possibility of postoperative residual or recurrent cholesteatoma. While recurrent cholesteatoma can be
caused by recurrent retractions, residual cholesteatoma is caused by residual epithelial debris that cannot be completely removed. The way to prevent this is to clean the
cholesteatoma so that no epithelial debris remains. The use of various chemicals
such as MESNA (sodium-2-mercaptoethanesulfonate) has been proposed to achieve
this. It has been reported that MESNA allows easy dissection of the cholesteatoma
epithelium because it breaks disulde bonds in the epithelium, thus reducing the
possibility of residual cholesteatoma by preventing epithelial debris in the surgical
eld [103–107]. It has also been reported that the use of chemicals such as 5 uorouracil may prevent the development of cholesteatoma [108]. The most important
situation limiting the use of chemical agents in middle ear surgery is the possibility
of facial paralysis and inner ear toxicity. No such side effects have been reported in
studies on MESNA [109, 110].
Several methods and radiologic imaging techniques are used to follow patients
after surgery. However, the ideal imaging technique and its timing have not been
claried. Thin-slice CT at follow-up does not show recurrent cholesteatoma, but it
is possible to see the bone erosion caused by cholesteatoma. However, it is not easy
to understand whether this erosion is caused by the primary surgery or a recurrent
cholesteatoma. Studies have shown high sensitivity and specicity of non-EPI DW
MRI in detecting residual or recurrent cholesteatoma after surgery [95, 96]. The
presence or absence of residual cholesteatoma can be assessed by endoscopy after
primary surgery. If residual cholesteatoma is suspected in the patient after followup, the mastoidectomy cavity and epitympanum can be examined by endoscopy.
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19.12 Conclusion
Cholesteatoma is the most common and life-threatening form of chronic otitis media.
Despite extensive research, the etiopathogenesis of cholesteatoma is not fully understood. The main characteristic of cholesteatoma is that it causes bone loss. The main
reason why cholesteatoma causes complications is that it causes lytic lesions in the
bone. Early diagnosis and treatment of the disease is very important. In addition, a
comprehensive understanding of the past and recent advances in biomolecular research
on acquired cholesteatoma may assist in the development of an effective management
strategy, given that no valid nonsurgical treatment has been developed to date.
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