Mastoid Obliteration Decreases the Recurrent and Residual Disease: Systematic Review and Meta-analysis

Principles of Cholesteatoma Management

Surgery for cholesteatoma should be tailored to individual patients, considering demographic and disease factors, to obtain a dry, safe, and functional ear. The EAONO/JOS classification and staging system provide a valuable framework for data collection and outcome assessment. Canal wall-up and canal wall-down surgical approaches each have their advantages and disadvantages, though it is not definitive that one approach is clearly more advantageous than the other. Mastoid obliteration techniques show promise in reducing recidivistic disease rates but require further research and standardization. Endoscopic ear surgery further augments our surgical capabilities to visualize and eradicate cholesteatoma.

Techniques in Management of Cholesteatoma: Radical and Canal Wall down Mastoidectomy

Canal wall down mastoidectomy is performed when demanded by the extent of disease: presence of a large labyrinthine fistula, extensive erosion of posterior auditory canal wall, prior failed intact canal wall surgery, a contracted, sclerotic mastoid with extensive disease, or need for exteriorization due to inadequate exposure or inability to remove disease safely with a canal wall up approach.

Pediatric Cholesteatoma Follow-Up: Residual and Recurrence in 239 Cases with Over 5-Year Hindsight

INTRODUCTION

Pediatric cholesteatoma is an aggressive disease which requires long-term evaluation to assess management strategies. The objective was to determine optimal follow-up duration in pediatric cholesteatoma to detect residual and recurrent diseases.

METHODS

This cohort study was set in a tertiary referral center. All consecutive patients with a minimum 5-year follow-up were included. Medical history, initial extension, surgical procedures, and follow-up were collected. The main outcome measure were Kaplan-Meier survival curves of residual and recurrence cumulative incidence.

RESULTS

Totally 239 ears with the first tympanoplasty between 2008 and 2014 were studied including 25% congenital. At first surgery (S1), mean age was 8.4 years and mean follow-up time 7.9 years. Mastoidectomy was performed in 69% and stapes was absent in 38% of cases. Notably, 83% (199 ears) had a second procedure (S2) of which 186 were planned. After S1, maximum cumulated incidence of residual was 45% [95%CI, 38%; 52%] at 74 months, with probability of residual of 39% at 3 years. After S2 (n = 199), maximum cumulated residual incidence was 21% [95%CI, 12%; 32%] at 62 months and 16% at 3 years. Concerning recurrence, maximum cumulated incidence after S1 (n = 239) was reached at 98 months with 21% [95%CI, 12%; 32%], 13% at 3 years and 16% at 5 years. Congenital disease had significantly less residuals after S1 (p = 0.02), but similar recurrence rate (p = 0.66) compared with acquired.

CONCLUSIONS AND RELEVANCE

We recommend MRI follow-up of at least 5 years after the last surgery for residual disease and clinical follow-up of at least 10 years to detect recurrence.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4789-4798, 2024.

Mastoid Obliteration With Freeze-Dried Bone Allograft in Canal Wall Down Tympanoplasty: Description of a Novel Technique and Case Report

Mastoid obliteration can be performed after canal wall down (CWD) mastoidectomy with various materials. Homologous bone tissue harvested from cadaver donor represents a feasible option with advantages. The purpose of the study is to describe the case of a patient diagnosed with middle ear cholesteatoma treated with mastoidectomy of the CWD and mastoid obliteration with homologous freeze-dried corticocancellous bone particulate in the Cittadella Hospital Ear, Nose, Throat (ENT) unit. The preoperative characteristics of the patients, the procurement and processing of bone allografts, the surgical technique, and postsurgical outcomes are described. No perioperative and postoperative complications were observed, and no rejection or foreign body reactions occurred. The patient then underwent a seriated follow-up. Audiometric tests showed an improvement in hearing levels. The volume of the neoexternal ear canal was 2.01 cm3. The case demonstrated clinical stability, substantial hearing recovery, and no need for specialist cleaning of the reformed external ear canal (EEC). The freeze-dried bone tissue allograft, in the technical way we used, appears to be a viable option in mastoid obliteration because homologous bone is not affected by material shortage, has fast assimilation, and ensures a useful radiological examination scan, at a low cost.

ESR Essentials: imaging of middle ear cholesteatoma-practice recommendations by the European Society of Head and Neck Radiology

Although non-malignant, middle ear cholesteatoma can result in significant complications due to local bone erosion and infection. The treatment of cholesteatoma is surgical, but residual disease is common and may be clinically occult, particularly when the canal wall is preserved or reconstructive techniques are employed. Imaging plays a pivotal role in the management of patients with middle ear cholesteatoma-aiding clinical diagnosis, identifying complications, planning surgery, and detecting residual disease at follow-up. Computed tomography is the primary imaging tool in the preoperative setting since it can provide both a surgical roadmap and detect erosive complications of cholesteatoma. The ability of magnetic resonance imaging with non-echoplanar diffusion-weighted sequences to accurately detect residual disease has led to a shift in the diagnostic paradigm for post-surgical follow-up of cholesteatoma, such that routine "second-look" surgery is no longer required. The following practice recommendations are aimed at helping the radiologist choose appropriate imaging approaches and understand the key diagnostic considerations for the evaluation of pre- and post-surgical middle ear cholesteatoma. KEY POINTS: In the preoperative setting, CT is the first-line imaging modality and MRI is reserved for rare clinical scenarios (low evidence). Non-echoplanar imaging (EPI) DWI is the optimal MRI sequence for the detection of residual cholesteatoma (moderate evidence). Non-EPI DWI plays an important role in the postoperative surveillance of cholesteatoma (moderate evidence).

Predicting residual cholesteatoma with the Potsic staging system still lacks evidence: a systematic review and meta-analysis

PURPOSE

To investigate the rate of residual disease in the Potsic staging system for congenital cholesteatomas.

METHODS

A protocol registration was published on PROSPERO (CRD42022383932), describing residual disease as a primary outcome and hearing improvement as secondary. A systematic search was performed in four databases (PubMed, Embase, Cochrane Library, Web of Science) on December 14, 2022. Articles were included if cholesteatomas were staged according to the Potsic system and follow-up duration was documented. Risk of bias was evaluated using the Quality In Prognosis Studies (QUIPS) tool. In the statistical synthesis a random effects model was used. Between-study heterogeneity was assessed using I2.

RESULTS

Thirteen articles were found to be eligible for systematic review and seven were included in the meta-analysis section. All records were retrospective cohort studies with high risk of bias. Regarding the proportions of residual disease, analysis using the χ2 test showed no statistically significant difference between Potsic stages after a follow-up of minimum one year (stage I 0.06 (confidence interval (CI) 0.01-0.33); stage II 0.20 (CI 0.09-0.38); stage III 0.06 (CI 0.00-0.61); stage IV: 0.17 (CI 0.01-0.81)). Postoperative and preoperative hearing outcomes could not be analyzed due to varied reporting. Results on cholesteatoma location and mean age at staging were consistent with those previously published.

CONCLUSION

No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging system's applicability for outcome prediction could not be proven based on the available data. Targeted studies are needed for a higher level of evidence.

Cholesteatoma Severity Determines the Risk of Recurrent Paediatric Cholesteatoma More Than the Surgical Approach

OBJECTIVE

To evaluate factors that influence the rate of cholesteatoma recurrence (growth of new retraction cholesteatoma) in children.

METHODS

Review of children with primary acquired or congenital cholesteatoma. Severity was classified by extent and EAONO-JOS stage, and surgery by SAMEO-ATO. Primary outcome measure was 5-year recurrence rate using Kaplan-Meier or Cox regression analysis.

RESULTS

Median age was 10.7 years for 408 cholesteatomas from which 64 recurred. Median follow up was 4.6 years (0-13.5 years) with 5-year recurrence rate of 16% and 10-year of 29%. Congenital cholesteatoma (n = 51) had 15% 5-year recurrence. Of 216 pars tensa cholesteatomas, 5-year recurrence was similar at 14%, whereas recurrence from 100 pars flaccida cholesteatomas was more common at 23% (log-rank, p = 0.001). Sub-division of EAONO-JOS Stage 2 showed more recurrence in those with than without mastoid cholesteatoma (22.1% versus 10%), with more in Stage 3 (31.9%; p = 0.0003). Surgery without mastoidectomy, including totally endoscopic ear surgery, had 11% 5-year recurrence. Canal wall-up tympanomastoidectomy (CWU) and canal wall-down/mastoid obliteration both had 23% 5-year recurrence. Multivariate analysis showed increased recurrence for EAONO-JOS Stage 3 (HR 5.1; CI: 1.4-18.5) at risk syndromes (HR 2.88; 1.1-7.5) and age < 7 years (HR 1.9; 1.1-3.3), but not for surgical category or other factors.

CONCLUSION

Young age and more extensive cholesteatoma increase the risk of recurrent cholesteatoma in children. When controlling for these factors, surgical approach does not have a significant effect on this outcome. Other objectives, such as lower post-operative morbidity and better hearing outcome, may prove to be more appropriate parameters for selecting optimal surgical approach in children.

Recurrence in cholesteatoma surgery: what have we learnt and where are we going? A narrative review

Treatment of cholesteatoma is surgical and has historically encompassed two main techniques: canal wall up (CWU) and canal wall down (CWD) tympanoplasty. Follow-up for cholesteatoma is still debated and can be either radiological or with second-look surgery. MRI with diffusion weighted sequences has proved to have high sensitivity and specificity in detecting recurrent or residual disease. Specifically, non-echo planar imaging DWI (non-EPI DWI) has been shown to be superior to other imaging techniques, allowing, in some cases, to avoid second-look surgery. Both residual and recurrence rates are higher in CWU compared to CWD procedures. Endoscopic ear surgery (EES) has become popular with the advantage of “looking around corners”. The endoscope is used in addition to a microscope or exclusively to reduce cholesteatoma recurrence. In addition, it has been demonstrated that mastoid obliteration and the use of potassium titanyl phosphate laser (KTP) can reduce cholesteatoma recurrence, with better functional outcomes. A synthetic sulphur compound (MESNA) may have an interesting role in the overall improvement in recurrence and residual cholesteatoma disease. This narrative review critically appraises the factors associated with the risk of recurrent cholesteatoma.