Management of Cholesteatoma in the 21st Century

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Management of Cholesteatoma in the 21st Century

• John Rutka MD FRCSC
• Department of Otolaryngology
• University of Toronto

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Mastoid Misery Index(Why mastoidectomy surgery
fails)

• Mucosal disease (incomplete epithelialization)
• High facial ridge
• Inadequate meatoplasty
• Recurrent cholesteatoma

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Question

• Does surgery for cholesteatoma prevent
  complications from occurring?
• Historical controls
• Glasgow study (Nunez Browning, JLO 1990)

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Complications TTH Experience 1987-97

• From cholesteatoma
• LSCC fistula - 13 pts (5.8)
• Brain abscess / meningitis - 4 pts (1.8)
• Facial paralysis - 4 pts (1.8)
• SNHL - 6 pts (3)
• Mastoiditis - 3 pts (1.5)

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Complications TTH Experience 1987-97

• Iatrogenic
• Facial paralysis - 10 pts (5)
• Brain herniation - 2 pts (1)
• CSF leak - 1 pt (0.5)
• Symptomatic fistula - 1pt (0.5)
• Significant pain - 2pts (1)
• Facts
• all patients had 7th palsy on referral
• surgery was 2xs more likely to cause facial
  paralysis than cholesteatoma

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Controversies

• When does a retraction pocket become a
  cholesteatoma? (The Friedberg Doctrine)
• Does all cholesteatoma require surgery?

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Thai Rural Ear Nose and Throat Foundation

• Founded in 1972 by Dr Salyaveth Lekagul
• gt100 000 patients assessed
• gt4000 mastoidectomy procedures
• gt7000 tympanoplasty procedures

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Prevalence of ear disease from 1980-91

• data collected from mobile ENT unit

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Ear Disease in Thailand

• data collected from mobile ENT unit

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Why has ear disease decreased in Thailand?

• 1972
• Thailand had 26 ENT surgeons (25 were in Bangkok)
• In the 70 provinces, there were no ENT surgeons
  or operating microscopes
• Patients required to travel average 400 km for
  treatment

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Why has ear disease decreased in Thailand?

• 1998
• There are now 500 ENT surgeons in Thailand
• All provincial capitals have hospital with ENT
  surgeon and operating microscopes
• Patients now travel less than 50 km

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Why has ear disease decreased in Thailand?

• Complete immunization programs nationwide /
  national health care
• Better nutrition and little malnutrition
• Transportation
• District and community hospitals (600 hospitals,
  10-60 beds)
• Better education / teaching about dangers of ear
  disease
• - personal communication, Salyaveth Lekagul 1998

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Risks of Developing an Otogenic Intracranial
Abscess

• Annual risk with active CSOM is 1/10,000
• 3xs more common in males
• Lifetime risk of individual age 30 years with
  CSOM is 1/200
• 5 abscesses occur in the immediate postoperative
  period
• Nunez Browning 1990

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Cholesteatoma Surgery

• 225 Mastoidectomy procedures at TTH from 1987 -
  97
• 188 pts - primary cholesteatoma
• modified radical 134
• radical 45
• CAT 9
• 37 pts- revision surgery (referred)
• modified radical 25
• radical 12

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Revision Surgery (JAR)

• 9 patients
• mucosal disease - 5 patients
• recurrent cholesteatoma - 2 patients
• web formation - 1 patient
• cholesterol granuloma - 1 patient
• revision rate
• 9 / 225 pts (4.0)
• recurrence (recidivistic)
• 2 / 225 pts (1)
• hypotympanic cholesteatoma, petrous apex
  cholesteatoma

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• Over the past fifty years, there has been an
  apparent decline in
• prevalence of cholesteatoma
• surgery for cholesteatoma
• intracranial complications (brain abscess,
  meningitis)
• acute mastoiditis

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• Future challenges in cholesteatoma surgery in the
  21st century
• intralabyrinthine / petrous apex disease
• footplate / sinus tympani
• childhood cholesteatoma

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Childhood Cholesteatoma

• Probability of recurrence
• 40 at 10 years
• Reasons
• 40-50 of children have extensive pneumatization
• infiltrating nature of cholesteatoma
• less aggressive surgery performed
• Gristwood 1979, Clinical Otolaryngology

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Growth Rates of Cholesteatoma

• Variations in growth potential of residual
  cellular elements
• i.e. cholesteatoma doubling time attic (10
  months), mastoid (25 months)
• Blood supply to matrix
• Vascular factors / infection / growth factors /
  proteolytic enzymes
• Anatomic factors (i.e. pneumatization)

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Surgical Techniques

• Open Procedures
• atticotomy
• modified radical mastoidectomy
• attico-antrostomy
• Bondy variant
• radical mastoidectomy
• Closed Procedures
• combined approach tympanoplasty (canal wall up)
• Mastoid obliteration

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Surgical Management

• High resolution CT preop
• CO2 laser - footplate disease
• Facial nerve monitoring

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Cause for concern?

• Declining incidence of cholesteatoma may mean
• 1. Decreased recognition of disease
• Will more complications arise as a result?
• 2. Decreased surgical exposure
• Can surgical skills be maintained?
• 3. Decreased educational teaching (residency
  training)
• Should mastoidectomy surgery be considered
  fellowship material?

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Causes for Facial Paralysis