Treatment of cholesteatoma in children

An Observational Study to Assess the Outcome of Canal Wall Window Tympanomastoidectomy in Chronic Suppurative Otitis Media

This study was undertaken to assess the outcome of canal wall window tympanomastoidectomy in chronic suppurative otitis media in a tertiary care centre of central India. A total of 50 patients were taken for this study in which the youngest patient was 13-year-old male and oldest 55-year female. Maximum patients were in between age group 10 to 20 years, 20 (40%) patients and minimum 03 (6%) between age group 51 to 60 year. The study mainly emphasized on: To study the clinical profile of the cases of chronic suppurative otitis media, to study the hearing outcome after 3 months of Canal wall window tympanomastoidectomy technique, to study the post-operative condition of ear after 3 months whether dry or wet and to study the post-operative follow up of cases to assess the graft uptake. Average PTA & ABG improvement of different tympanoplasty was also calculated in our study in which Type I tympanoplasty had 12.20dB gain, Type II of 10.50 and Type III of 10.31dB.An overall average improvement in all patients with tympanoplasty was 11.00dB.At the end of the study 100% dry ears were achieved. The technique of canal wall window tympanomastoidectomy involves formation of a window in the outer attic wall to look at the disease extent which was then closed by a snuggly fitting cartilage.It is a novel technique & without compromising the structural integrity in case of a limited disease which is only extending till attic and aditus good anatomical and hearing results could be gained.

[The status of contralateral ear in children with cholesteatoma]

INTRODUCTION

Recently published data indicate that over 60% of patients with middle ear cholesteatoma (MEC) have concomitant changes in the contralateral ear (CE). Studies concerning the condition of the CE are few and rarely present the situation in the pediatric population.

THE AIM OF THIS STUDY

was to assess the frequency of pathological changes occurring in the CE in children operated on MEC, as well as to determine their clinical evolution.

MATERIAL AND METHOD

Retrospective analysis was performed on basis of medical records of 193 patients treated surgically for MEC in 1998-2008 at the Department of Pediatric Otolaryngology in Bialystok. The comparison of otoscopic evaluation before first operation with the latest examination was undertaken. The evolution of abnormalities was analyzed and the effect of age and type of cholesteatoma was assessed.

RESULTS

The opposite ears were abnormal in 46.1% of patients. Most frequently observed changes in the CE were retraction pockets (23%). Cholesteatoma was found in 8 of 45 identified cases of retraction pocket. The incidence of abnormalities in the CE was not correlated with patients age or type of cholesteatoma. Cholesteatoma occurred on both sides in 9,3% of children. In these cases, the attic cholesteatoma was presented in 66.67%, tensa cholesteatoma in 16.67%.

CONCLUSIONS

In patients with MEC contralateral ear should be systematically examined to detect early any abnormality, or to assess their evolution and take appropriate treatment.

Paediatric small cavity mastoid surgery: second look tympanotomy

OBJECTIVE

Following surgery for retraction pocket/cholesteatoma there is risk of residual disease, after canal wall up surgery a second look tympanotomy is routinely recommended. After canal wall down (CWDM) surgery this is not routine. In certain situations the senior author recommends second look tympanotomy. This report examines the outcome of this management paradigm applied to small cavity mastoid surgery for children.

METHOD

A retrospective review of small cavity mastoid surgery for children with cholesteatoma or discharging retraction pocket disease. The primary procedure and surgical findings at second look tympanotomy are reported as well as the pre- and 1 year post-operative air and bone conduction thresholds and air-bone gap averaged across frequencies 0.5, 1, 2 and 4kHz and the mean pre- and post-operative bone conduction threshold at 4kHz. A Student t-test was used to compare hearing results.

RESULTS

Forty five were children reviewed at 1 year. Twelve (27%) were recommended second look tympanotomy, of which 10 had surgery; all were free of residual disease. At second look two children had ossiculoplasty performed, four had adhesions divided. Six children had formed a myringostapediopexy after their first surgery. The mean pre-op bone conduction threshold was 6.3dB for those having single stage surgery and 5.6dB for those having a second look and the post-operative thresholds were 7.8 and 10.2dB, respectively. The mean preoperative air conduction threshold was 32.6dB for single stage surgery and 31.1dB for staged surgery and at 1 year 29.2 and 40.8dB. This was a significant difference. After second look, the air conduction threshold was 34.5dB, and not significantly different from those who had single stage surgery. The mean pre-treatment 4kHz bone conduction threshold was 6.3 and 5.6dB for single stage surgery and second look tympanotomy and after surgery, respectively, 9.8 and 14.5dB. These changes are not statistically significant.

CONCLUSION

The small cavity mastoidectomy approach allows meticulous removal of disease from the middle ear and for certain indications second look tympanotomy is recommended. Planned second look tympanotomy has demonstrated excellent early disease control as well as allowing timely management of any pathology affecting the middle ear sound transformation mechanism.