A review of current progress in acquired cholesteatoma management

Peptides rapidly transport antibiotic across the intact tympanic membrane to treat a middle ear infection

The tympanic membrane (TM) forms an impenetrable barrier to medical therapies for middle ear (ME) diseases like otitis media. By screening a phage-displayed peptide library, we have previously discovered rare peptides that mediate the active transport of cargo across the intact membrane of animals and humans. Since the M13 filamentous bacteriophage on which the peptides are expressed are large (nearly 1 µm in length), this offers the possibility of noninvasively delivering drugs, large drug packages, or gene therapy to the ME. To evaluate this possibility, EDC chemistry was employed to covalently attach amoxicillin, or neomycin molecules to phage bearing a trans-TM peptide, as a model for large drug packages. Eight hours after application of antibiotic-phage to the TM of infected rats, ME bacterial titers were substantially reduced compared to untreated animals. As a control, antibiotic was linked to wild-type phage, not bearing any peptide, and application to the TM did not affect ME bacteria. The results support the ability of rare peptides to actively deliver pharmacologically relevant amounts of drugs through the intact TM and into the ME. Moreover, since bacteriophage engineered to express peptides are viral vectors, the trans-TM peptides could also transport other viral vectors into the ME.

Peptide-Mediated Transport Across the Intact Tympanic Membrane Is Intracellular, with the Rate Determined by the Middle Ear Mucosal Epithelium

The tympanic membrane forms an impenetrable barrier between the ear canal and the air-filled middle ear, protecting it from fluid, pathogens, and foreign material entry. We previously screened a phage display library and discovered peptides that mediate transport across the intact membrane. The route by which transport occurs is not certain, but possibilities include paracellular transport through loosened intercellular junctions and transcellular transport through the cells that comprise the various tympanic membrane layers. We used confocal imaging to resolve the phage's path through the membrane. Phages were observed in puncta within the cytoplasm of tympanic membrane cells, with no evidence of phages within junctions between epithelial cells. This result indicates that transport across the membrane is transcellular and within vesicles, consistent with the transcytosis process. The trans-tympanic peptide phages display a wide range of transport efficiencies for unknown reasons. This could include variation in tympanic membrane binding, entry into the membrane, crossing the membrane, or exiting into the middle ear. To address this, we titered phages recovered from within the membrane for phages with differing transport rates. We found that differences in the transport rate were inversely related to their presence within the tympanic membrane. This suggests that differences in the transport rate primarily reflect the efficiency of an exocytotic exit from the mucosal epithelium rather than entry into, or passage across, the membrane.

Exclusive endoscopic tympanoplasty efficacy in the treatment of cholesteatoma without mastoid involvement

PURPOSE

The purpose of this study is to determine the recurrence rate of cholesteatoma in patients who have undergone exclusive endoscopic tympanoplasty at our tertiary referral institution. A secondary objective is to analyze different clinical aspects that could be considered risk factors for recurrence to establish if it is possible to determine when a second-look procedure is indicated instead of a clinical follow-up.

METHODS

A retrospective study was performed on patients who had undergone exclusive endoscopic tympanoplasty for cholesteatoma in the last eight years and who were followed up for at least one year. The efficacy of the treatment performed only with the exclusive endoscopic technique was analyzed. Then, the anamnestic and intraoperative data were studied to identify possible factors that could increase the risk of recurrence.

RESULTS

The recurrence rate (14.5%) in patients (164) who underwent primary surgery with the exclusive endoscopic technique between January 2014 and January 2022 was similar to that in patients who underwent the microscopic technique with mastoidectomy in literature. In addition, we analyzed several clinical factors such as age, ossicular chain erosion, extension and localization of the cholesteatoma finding that only the last one could potentially be a risk factor for recurrence in this selected population.

CONCLUSION

Exclusive endoscopic tympanoplasty has been shown to be effective in removing cholesteatoma in patients without evidence of mastoid involvement, with recurrence rates comparable to traditional microscopic technique and a minimally invasive approach, even considering the patient's age, ossicular chain erosion and extension of the disease.

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.

Congenital Middle Ear Cholesteatoma: A Report of 3 Cases and a Literature Review

Background: Congenital cholesteatoma is defined as a white mass behind an intact eardrum without a history of otitis media or previous otologic procedures. Congenital cholesteatoma is a relatively rare disease that accounts for about 2% to 5% of all cholesteatomas. However, the actual incidence rate of congenital cholesteatoma may be underestimated. Conductive hearing loss is the most common presenting symptom. The current study aims to describe the clinical characteristics and management of patients with congenital cholesteatoma and promote awareness of the disease in unilateral or asymmetric conductive hearing loss patients. Methods: In this study, we report a case series of 3 patients including 1 child, 1 adolescent, and 1 young adult, managed in our department between June and August 2023, and present a summary of the literature. Results: Congenital cholesteatoma is primarily a pediatric disease, but it has also been reported in adults. Two cases presented with unilateral secretory otitis media, and 1 case presented with asymmetric unilateral conductive hearing loss. Two patients of Potsic stage III congenital middle ear cholesteatomas underwent transcanal endoscopic ear surgery, and 1 patient of Potsic stage IV underwent conventional microscopic approach canal wall-up mastoidectomy combined with endoscopy. Conclusions: In children or young adults with persistent unilateral or asymmetric conductive hearing loss, congenital middle ear cholesteatoma should be considered. Congenital cholesteatoma cannot be ruled out in children with unilateral secretory otitis media.

A French Preoperative Cholesteatoma Management: Current Preoperative Consultation and Tendencies

Objectives: This study aimed to characterize the information delivery during preoperative consultations for cholesteatoma removal surgery in 2024. The secondary objective was to identify any factors influencing the information delivered. Methods: This study was a practice survey which included 33 closed-ended questions and 1 open-ended question. Seven questions concerned the participants' characteristics and 2 questions concerned the physiopathology of cholesteatoma. Nine questions focused on surgical information, six questions focused on the procedure modalities and ten questions focused on the risks of complications from the intervention. Results: Eighty-two surgeons answered the survey. In 75% of the cases, an information form written by a professional society was provided. The risk of recurrence or residual post-operative cholesteatoma was systematically stated in 78% of cases (n = 64), while the risk of aesthetic sequelae was only stated in 1% (n = 1). Participants working in a university hospital were more likely to inform patients about the risks of vertigo (p = 0.04), aesthetic risks (p = 0.04), poor functional outcomes (p = 0.04), surgical revision (p = 0.05) and the risk of peripheral facial paralysis (p = 0.05). Surgeons who mainly practiced otology were more likely to inform patients about the risks of recurrence and/or residual cholesteatoma (p = 0.02) and taste disturbances (p = 0.02). Conclusions: Cholesteatoma surgery was well explained to patients during the preoperative consultation, mostly with written support, even if the information given was not the same for all complication risks. It could be useful to create an information form dedicated to cholesteatoma surgery to improve comprehensive information and maintain a trustworthy relationship with patients.

Cost-Effectiveness of Diffusion Weighted MRI Versus Planned Second-Look Surgery for Cholesteatoma

OBJECTIVE

To compare the cost-effectiveness of serial non-echo planar diffusion weighted MRI (non-EP DW MRI) versus planned second look surgery following initial canal wall up tympanomastoidectomy for the treatment of cholesteatoma.

METHODS

A decision-analytic model was developed. Model inputs including residual cholesteatoma rates, rates of non-EP DW MRI positivity after surgery, and health utility scores were abstracted from published literature. Cost data were derived from the 2022 Centers for Medicare and Medicaid Services fee rates. Efficacy was defined as increase in quality-adjusted life year (QALY). One- and 2-way sensitivity analyses were performed on variables of interest to probe the model. Total time horizon was 50 years with a willingness to pay (WTP) threshold set at $50 000/QALY.

RESULTS

Base case analysis revealed that planned second-look surgery ($11 537, 17.30 QALY) and imaging surveillance with non-EP DWMRI ($10 439, 17.26 QALY) were both cost effective options. Incremental cost effectiveness ratio was $27 298/QALY, which is below the WTP threhshold. One-way sensitivity analyses showed that non-EP DW MRI was more cost effective than planned second-look surgery if the rate of residual disease after surgery increased to 48.3% or if the rate of positive MRI was below 45.9%. A probabilistic sensitivity analysis at WTP of $50 000/QALY found that second-look surgery was more cost-effective in 56.7% of iterations.

CONCLUSION

Non-EP DW MRI surveillance is a cost-effect alternative to planned second-look surgery following primary canal wall up tympanomastoidectomy for cholesteatoma. Cholesteatoma surveillance decisions after initial canal wall up tympanomastoidectomy should be individualized.

LEVEL OF EVIDENCE

V.

The Safety and Efficacy of Hydroxyapatite Repair of Cholesteatoma Skull Base Defects

Objective

To investigate the possibility of hydroxyapatite as a safe and effective alternative to currently used bioavailable materials for repair of tegmen defects and labyrinthine fistulas in the setting of cholesteatoma.

Study Design

Retrospective study.

Setting

Tertiary-level-care hospital.

Methods

Electronic medical records of patients 18+ years undergoing cholesteatoma-removal surgery between 2013 and 2022 were reviewed.

Results

Twenty-two patients diagnosed with cholesteatoma who underwent repair of either a tegmen defect or labyrinthine fistula using hydroxyapatite were evaluated. There were 17 canal wall up (CWU) and 5 canal wall down (CWD) surgeries. The cholesteatoma recidivism rate was 18.2% (n = 4) and the recurrence rate was 4.5% (n = 1). To ensure that these rates were similar to cholesteatoma-removal surgeries in which hydroxyapatite was not used, a 22 age, gender, and operative technique-matched cohort was evaluated. For patients with CWU surgeries, the rate of recurrence and recidivism were identical between both cohorts (0% and 23.5%, respectively; P = 1 for both). While in CWD surgeries, there was a nonstatistically significant difference in the recurrence as there was only 1 patient with recurrence in the hydroxyapatite group (P = 1). Three (13.5%) patients in the hydroxyapatite group had a local infection and 1 (4.5%) had a subacute mastoid infection. All patients with semicircular canal fistulas had consistent bone lines on postoperative audiograms, with no worsening sensorineural hearing loss.

Conclusion

In our cohort, hydroxyapatite was safe and successful in repairing skull base defects and inner-ear fistulas in the setting of cholesteatoma with a low rate of postoperative infection and no evidence of a higher rate of cholesteatoma recurrence. Further studies are needed to assess population generalizability.

Pediatric Acute Mastoiditis in Saudi Arabia: Demographic Insights, Clinical Profiles, and Prognostic Factors

Acute mastoiditis, a complication of otitis media, poses significant challenges in diagnosis and treatment, particularly in pediatric populations. This study aims to comprehensively evaluate the demographic characteristics, clinical features, and prognostic factors associated with acute mastoiditis in pediatric patients in Saudi Arabia. Analysis of a multicenter dataset was conducted to assess demographic variables, symptomatology, disease course, and predictors of acute mastoiditis in pediatric patients. Significant associations were found between demographic variables (age group, gender, nationality) and acute mastoiditis risk. Symptomatology analysis revealed consistent frequencies of otalgia across age groups and genders. Disease course analysis highlighted a mean duration from symptom onset to diagnosis of 14.11 days, with frequent complications like mastoid abscess and meningitis. Predictor identification identified symptoms (otalgia, fever, otorrhea), duration of illness, and complications as significant predictors of disease severity. These findings contribute valuable insights into the epidemiology and clinical management of acute mastoiditis, informing targeted interventions to improve patient outcomes.

Facial ridge management in canal wall down tympanoplasty for middle-ear cholesteatoma

OBJECTIVE

To estimate whether leaving a high facial ridge during canal wall down tympanoplasty increases the risk of residual cholesteatoma.

METHODS

In this retrospective case review, 321 patients treated with primary canal wall down tympanoplasty for middle-ear cholesteatoma were divided into a completely lowered facial ridge group and a non-completely lowered facial ridge group. Factors affecting facial ridge management, residual disease rate and disease-free survival were analysed.

RESULTS

Residual disease rates were 10.8 per cent in the non-completely lowered facial ridge group and 16.6 per cent in the completely lowered facial ridge group (p = 0.15). Localisation at sinus tympani, mesotympanum or supratubal recess, pre-operative extracranial complications, and destroyed ossicular chain or fixed platina were associated with a completely lowered facial ridge. Residual disease rates and disease-free survival did not significantly differ between the groups.

CONCLUSION

Facial ridge can be managed according to cholesteatoma extension. The facial ridge can be maintained high if the cholesteatoma does not involve sinus tympani, mesotympanum or supratubal recess, without increasing the risk of residual disease.

Micro RNAs and Circular RNAs in Different Forms of Otitis Media

The aim of this comprehensive review was to present the current knowledge on the role of microRNAs (miRNAs) in acute, recurrent, and chronic forms of otitis media. Special attention was focused on cholesteatoma of the middle ear. MicroRNAs modulate gene expression, which, in turn, influences the development and likelihood of the recurrence of acute and aggressive chronic middle ear inflammatory processes. Moreover, this study discusses the modulating role of a specific subgroup of noncoding RNA, circular RNA (circRNA). Recognizing the precise potential pathways and the mechanisms of their function may contribute to a better understanding of the molecular bases of middle ear diseases and identifying novel methods for treating this demanding pathology. Articles published between 2009 and 2022 were used in this analysis. In this review, we provide a complete overview of the latest progress in identifying the role and mechanisms of particular miRNAs and circRNAs in acute, recurrent and chronic forms of otitis media.

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.

Use of bonalive in obliterative mastoidectomy: anatomical results and clinical outcome

PURPOSE

To investigate safety and efficacy of mastoid obliteration in canal-wall-down tympanoplasty performed for cholesteatoma using bioactive glass (BAG). The authors routinely adopt CWD tympanoplasty in case of massive cholesteatoma or revision surgery, performing obliteration with BAG to reduce the mastoid cavity and related disadvantages. We assessed anatomical results, infection control and cholesteatoma recurrence in obliterative mastoidectomy using BAG.

METHODS

The authors evaluated 66 patients treated with obliterative mastoidectomy using BAG during the period 2010-2021. 48.5% of the cases had first diagnosis of cholesteatoma, 48.5% had cholesteatoma recidivisms, and two patients underwent obliteration to improve clinical outcome. BAG granules were always moistened with venous blood to enhance their adhesion and reduce the risk of dispersion. Anatomical results were evaluated in otomicroscopy and infection control was assessed during follow-up visits. Periodical otomicroscopy was performed to check recurrent cholesteatoma. MRI-DWI was indicated only in case of clinical suspect of cholesteatoma.

RESULTS

Authors followed 66 patients during a mean of 23 months. No post-operative wound infections occured. The mean re-epithelialization time was 45 days. At the last visit, control of infection was achieved in 97% of patients and a clinical stable anatomical cavity in all patients. No clinical suspect for recurrent cholesteatoma was found.

CONCLUSIONS

The use of bioactive glass is safe and effective as obliteration material in cholesteatoma surgery. Authors pay a particular attention to obliterate only patients without suspect of epithelial residual, to correctly calibrate the ear canal and to completely cover the granules with graft.

Creation of an incus recess for a middle-ear microphone using a drill or laser ablation: a comparison of equivalent noise level and middle ear transfer function

PURPOSE

Studies have assessed the trauma and change in hearing function from the use of otological drills on the ossicular chain, but not the effects of partial laser ablation of the incus. A study of the effectiveness of a novel middle-ear microphone for a cochlear implant, which required an incus recess for the microphone balltip, provided an opportunity to compare methods and inform a feasibility study of the microphone with patients.

METHODS

We used laser Doppler vibrometry with an insert earphone and probe microphone in 23 ears from 14 fresh-frozen cadavers to measure the equivalent noise level at the tympanic membrane that would have led to the same stapes velocity as the creation of the incus recess.

RESULTS

Drilling on the incus with a diamond burr created peak noise levels equivalent to 125.1-155.0 dB SPL at the tympanic membrane, whilst using the laser generated equivalent noise levels barely above the baseline level. The change in middle ear transfer function following drilling showed greater variability at high frequencies, but the change was not statistically significant in the three frequency bands tested.

CONCLUSIONS

Whilst drilling resulted in substantially higher equivalent noise, we considered that the recess created by laser ablation was more likely to lead to movement of the microphone balltip, and therefore decrease performance or result in malfunction over time. For patients with greatly reduced residual hearing, the greater consistency from drilling the incus recess may outweigh the potential benefits of hearing preservation with laser ablation.

A fluorescent photoimmunoconjugate for imaging of cholesteatoma

Cholesteatoma is a potentially serious complication of chronic ear infections and requires surgical intervention for definitive management. Long-term complications include a frequent need for repeat surgical intervention for disease recurrence, and techniques to improve efficacy of single-stage surgery are an important area of continued research. This study investigates a novel application of the photosensitizer immune conjugate (PIC) cetuximab-benzoporphyrin derivative (Cet-BPD) for in vitro localization of human cholesteatoma tissue, coupled with an in vivo safety study for middle ear application of Cet-BPD in a murine model. In fresh human cholesteatoma tissues, Cet-BPD demonstrates selective localization to the hyperplastic squamous cell tissue associated with cholesteatoma, without localizing to other tissues such as middle ear mucosa. Applied to the murine middle ear, Cet-BPD does not demonstrate any deleterious effect on murine hearing when assessed by any of auditory brainstem response (ABR) thresholds, distortion product otoacoustic emission thresholds, or ABR wave I amplitudes. These findings demonstrate the technical promise and encouraging safety profile for the use of PICs for intraoperative localization and treatment of cholesteatoma.

The Relationship between the M1/M2 Macrophage Polarization and the Degree of Ossicular Erosion in Human Acquired Cholesteatoma: An Immunohistochemical Study

The differential involvement of the macrophage activation phenotypes (M1 vs. M2) has been linked to disease severity in various chronic inflammatory disorders. Pharmacologic manipulation of the M1/M2 macrophage polarization has shown therapeutic potential. Cholesteatoma is a destructive chronic middle ear disease with potentially life-threatening complications. The distribution of macrophage polarization phenotypes in middle ear cholesteatoma has not been described. In the present study, human cholesteatoma specimens acquired during tympanomastoidectomy were retrospectively retrieved and immunohistochemically characterized using a combination of antibodies labeling M1 macrophages (CD80), M2 macrophages (CD163), and total macrophages (CD68). The correlations between the immunohistochemical findings and clinical presentation were assessed. The findings revealed that cholesteatomas with more extensive ossicular erosion demonstrated a significantly higher number of M1 (CD80+) cells and a higher M1/M2 ratio than less invasive cholesteatomas (Wilcoxon test, p < 0.05). The extent of ossicular erosion correlated significantly with the M1/M2 ratio (Spearman correlation coefficient ρ = 0.4, p < 0.05). Thus, the degree of ossicular erosion in human acquired cholesteatoma appears to be related to the M1/M2 macrophage polarization. The investigation of macrophage polarization and functions in various clinical presentations of middle ear cholesteatoma is of great interest since it may contribute to the development of pharmaceutical treatment approaches.

Incidence and trends of middle ear cholesteatoma surgery and mastoidectomy in Australia-A national hospital morbidity database analysis

OBJECTIVE

To investigate the incidence of middle ear cholesteatoma surgery and assess trends in mastoidectomy procedures in Australia.

STUDY DESIGN

Cross-sectional population-based study using data from the National Hospital Morbidity Database.

METHODS

Admitted care episodes containing the principal diagnosis of middle ear cholesteatoma were analyzed for two 12-month periods of 2007-2008 and 2017-2018. Surgical admissions involving mastoidectomy were identified by procedure codes. Incidence rate per 100,000 person-years were compared between study periods.

RESULTS

Of the 3855 middle ear cholesteatoma admissions, 3558 (92.3%) involved surgery, with the incidence rate for cholesteatoma surgical admissions estimated at 8.6 per 100,000 (95% CI: 8.2-9.0) and 8.1 per 100,000 (95% CI: 7.7-8.5) for 2017-2018 and 2007-2008, respectively. Population aged 10-19 years had the highest age-specific incidence rate at 12.5 per 100,000 (95% CI: 11.3-13.9) for 2017-2018. The 60 years and over age groups had the highest decennial percentage increase. Mastoidectomy procedures were consistently used in over half of all surgical admissions. An increase in the rate of canal wall up (CWU) mastoidectomy procedure related admissions was observed (rate ratio of 1.62 [95%CI: 1.41-1.86], P <.001) and was offset by a decreased rate of canal wall down (CWD) procedure associated admissions (0.69 [95% CI: 0.61-0.78], P <.001]).

CONCLUSIONS

The incidence rate of cholesteatoma surgery in Australia is estimated at 8.6 per 100,000. Mastoidectomy continues to play an essential role in cholesteatoma surgery with a trend favoring CWU over CWD mastoidectomy. Level of evidence: 4.

A transcytotic transport mechanism across the tympanic membrane

Drug treatments for middle ear diseases are currently delivered systemically, or locally after opening the impermeable tympanic membrane (TM). We previously used bacteriophage display to discover novel peptides that are actively transported across the intact TM, with a variety of transport rates. Peptide structures were analyzed for evidence regarding the mechanism for this unexpected transport, which was then tested by the application of chemical inhibitors. Primary sequences indicated that trans-TM peptides share one of two amino acid motifs. Secondary structures revealed that linear configurations associate with higher transport rates than coiled structures. Tertiary analysis indicated that the shared sequence motifs are prominently displayed at the free ends of rapidly transported peptide phage. The shared motifs were evaluated for similarity to known motifs. The highest probability matches were for protein motifs involved in transmembrane transport and exosomes. Overall, structural findings suggest that the shared motifs represent binding sequences. They also implicate transcytosis, a polarized cell transport mechanism consisting of endocytosis, transcellular transport, and exocytosis. Inhibitor studies indicated that macropinocytosis, retrograde transport through Golgi and exocytosis participate in transport across the TM, consistent with transcytosis. This process can be harnessed to noninvasively deliver therapeutics to the middle ear.

Long-term follow-up of applying autologous bone grafts for reconstructing tympanomastoid defects in functional cholesteatoma surgery

Objectives

This study investigated the long-term surgical outcomes of functional cholesteatoma surgery with canal wall reconstruction using autologous bone grafts as the primary material in patients with acquired cholesteatoma.

Subjects and Methods

Medical charts were retrospectively reviewed for all patients admitted to one institution for surgical intervention between 2010 and 2018. We analyzed 66 patients (66 ears) who underwent functional tympanomastoidectomy involving the use of autologous bone grafts for canal wall defect reconstruction. Surgical outcomes were evaluated by comparing preoperative audiometric results with follow-up data (at least 36 months after surgery). Logistic regression analyses were performed to determine prognostic factors related to long-term hearing success. These factors included classification and stage of cholesteatoma, stapes condition, ossicular chain damage, active infection of the middle ear, state of the contralateral ear, preoperative hearing thresholds, gender, and age.

Results

The mean follow-up period was 49.2 months. The recidivism rate was 6% (four of 66 ears). The pure-tone average significantly improved from 50.78 ± 19.98 to 40.81 ± 21.22 dB hearing level (HL; p < 0.001). Air–bone gaps significantly improved from 26.26 ± 10.53 to 17.58 ± 8.21 dB HL (p < 0.001). In multivariate logistic regression analysis, early-stage disease (p = 0.021) and pars flaccida cholesteatoma (p = 0.036) exhibited statistically significant correlations with successful hearing preservation.

Conclusion

Functional cholesteatoma surgery with autologous bone grafts reconstruction is an effective approach to significantly improve hearing with low recidivism rates. Localized disease and pars flaccida cholesteatoma were two independent predictors of successful hearing preservation.

Long term outcomes of canal wall up and canal wall down tympanomastoidectomies in pediatric cholesteatoma

Cholesteatomas in children have a more aggressive growth pattern compared to adults, which leads to a higher incidence of both residual and recurrent disease. A staged canal wall-up or a canal wall-down tympanomastoidectomy (CWUT and CWDT, respectively) is selected depending on the extent of the disease and condition of the middle ear (ME) cleft and mastoid. Endoscopic ear surgery (EES) has been recently introduced as an adjuvant tool for the treatment of this pathology even in the pediatric population.

OBJECTIVES

To analyze long term outcomes of CWUT and CWDT in the pediatric population, focusing on residual and recurrence rates of cholesteatoma and hearing results. A literature review including cases treated with EES were discussed.

MATERIAL AND METHODS

Pediatric patients treated for cholesteatoma involving both the ME and mastoid with a follow-up (FU) of at least 4 years were retrospectively analyzed in a quaternary referral center for otology and lateral skull base surgery. Patients were grouped according to the surgical technique (CWUT versus CWDT). Rates of residual and recurrent cholesteatoma after each surgical technique were reported and compared. Mean Air-Bone Gap (ABG) of 0.5-1-2-4 KHz was measured and reported before the first surgery and at the last post-operative FU.

RESULTS

Two-hundred and thirty-six cases fulfilled our inclusion criteria. The mean FU was 100.4 ± 44.2 months (median 89 months). One-hundred and five (44.5%) cases underwent a CWUT, whereas 131 (55.5%) a CWDT. A second stage surgery was performed in 73.5% of CWUT and 58.7% of CWDT. Among the CWUT group, residual cholesteatoma occurred in 22 (21%) ears and recurrence in 24 (22.9%). Patients undergoing CWDT showed lower rates of both residual and recurrent cholesteatoma (7.6% and 2.3%, respectively). ABG improvement was noted for both groups, even though CWUT showed better post-operative hearing results.

CONCLUSIONS

The CWDT technique offers a definite surgical therapy, with minimal residual and recurrence rates and audiological results comparable to the CWUT technique. EES must still prove its added benefit or equivalence to pure microscopic approaches.

Relevance of Modified Bondy Mastoidectomy in Pediatric Cholesteatoma

Modified Bondy mastoidectomy is a type of canal wall down mastoidectomy well described in literature for adult patients. We present our experience with the use of modified Bondy mastoidectomy in pediatric population. Using retrospective chart review, pediatric patients, who underwent modified Bondy procedure for attic cholesteatoma between 1983 and 2015 at our quaternary referral center for otology and lateral skull base surgery, were analyzed after obtaining permission from institutional review board. The demographic data, air-bone gap before and after surgery (at a follow up of 1 month, 6 months, 2 year and 5 years), intraoperative findings and postoperative outcomes were recorded. A total of 36 (5.8%) pediatric cholesteatoma patients underwent Modified Bondy procedure. Out of these, 5-year follow up was available for 31 patients and they were included in audiological analysis. Air-bone gap was maintained at preoperative levels or improve in all the patients during follow up and there were no incidences of sensorineural hearing loss. Two patients (5.5%) were found to harbor residual cholesteatoma and two patients (6.4%) of the 31 patients who had follow up of 5 years, developed recurrent disease during follow up. Modified Bondy procedure, when done in appropriately selected patients, is a reliable, effective and reasonably safe technique for pediatric cholesteatoma.

Osteoclastic activity in chronic otitis media with cholesteatoma-related bone destruction

BACKGROUND

Cholesteatoma-related bone destruction is the cause of many complications due to chronic otitis media. This study aimed to evaluate osteoclastic activity in cholesteatoma-related bone destruction using tartrate-resistant acid phosphatase 5b, an enzyme specific to osteoclastic activity.

METHOD

Seventy-two patients diagnosed with chronic otitis media were included in this study and were divided into two groups: with and without bone destruction. The blood serum and tissue tartrate-resistant acid phosphatase 5b levels from both groups were compared.

RESULTS

There were no significant differences in the level of serum enzymes between both groups. However, in tissue samples, tartrate-resistant acid phosphatase 5b levels were significantly lower in the bone destruction group than the group without bone destruction.

CONCLUSION

This study determined that the level of tartrate-resistant acid phosphatase 5b, a specific enzyme for osteoclastic activity in cholesteatoma-related bone destruction, is locally decreased. This data suggests that osteoclastic activity may decrease in cholesteatoma-related bone destruction. However, further experimental and clinical studies are required to clarify this highly complex mechanism.

The Viability and Growth of HaCaT Cells After Exposure to Bioactive Glass S53P4-Containing Cell Culture Media

HYPOTHESIS

Bioactive glass (BG) S53P4 reduces the viability of epidermal keratinocyte-derived immortalized cell line, HaCaT in sufficient concentrations in vitro.

BACKGROUND

Although used in mastoid obliteration surgery, there is no data available on whether BG S53P4 granules have an inhibitory or excitatory effect on keratinocytes, found in normal skin and ear cholesteatoma in vivo.

METHODS

HaCaT cell cultures were incubated with a direct BG S53P4 granule contact. Microscopic evaluation of the cultures was performed and interleukin-6 (IL-6) and -8 (IL-8) concentrations were measured from the medium samples. In addition, BG granules were incubated in two cell culture media for 6 days and the pure media were used in confluent HaCaT cultures preceding cell viability assay. Finally, a scratch assay test was performed to reveal the possible BG effect on HaCaT cultures.

RESULTS

Eight to ten cell thick layers of dead HaCaT cells were noticed after a 2-day BG granule contact. With a BG concentration of 2.5%, IL-6 and IL-8 concentrations were smaller compared with the control group without BG after 2 days' incubation. Overall, HaCaT cell viability decreased when BG was incubated in keratinocyte growth medium, but did not change in Dulbecco's modified Eagle's medium. In a scratch assay test, cell regrowth in the scratch area was notable in cultures without BG.

CONCLUSIONS

BG S53P4 seems to have an inhibitory effect on HaCaT cell growth. Although further studies are needed, this observation seems advantageous for cholesteatoma treatment.

Predicting Recidivism for Acquired Cholesteatoma: Evaluation of a Current Staging System

OBJECTIVE

Assess the utility and prognostic capabilities of the European Academy of Otology and Neurotology (EAONO) and Japanese Otological Society (JOS) cholesteatoma classification system, specifically for retraction pocket cholesteatoma.

STUDY DESIGN

Retrospective.

SETTING

Tertiary referral hospital.

PATIENTS

Adults and children with retraction pocket cholesteatoma.

INTERVENTIONS

Primary and planned second-look tympanoplasty with mastoidectomy.

MAIN OUTCOME MEASURES

Incidence of recurrent or residual cholesteatoma at planned second-look surgery. Independent variables of age, gender, size of canal defect, and mucosa status were assessed. Additionally, the cholesteatoma classification, stage, and extent according to the EAONO/JOS system were recorded during the primary surgery.

RESULTS

A total of 125 cases were included. Twelve (9.6%) cases had recidivism over an average time of 7.5 months: the recurrence rate was 4% (n = 5), residual rate was 5% (n = 6), and one patient had both recurrent and residual disease (0.8%). Residual cholesteatoma occurred more frequently in children (p = 0.04, RR = 7.9 [1.0, 63.6]). Supratubal recess (S1) disease was associated with both recurrent cholesteatoma (p = 0.04, RR = 5.9 [1.3, 27.2]) and recidivism (p = 0.01, RR = 4.2 [1.5, 11.9]). Larger canal defects also showed an association with residual disease (p = 0.017).

CONCLUSION

Younger patients and those with large ear canal defects tend to have residual disease at second-look surgery. Supratubal recess disease is also associated with recurrence. Despite the utility of the EAONO/JOS classification and staging system for cholesteatoma description and type, the prognostic value remains uncertain.

Patency of Anterior Epitympanic Space and Surgical Outcomes After Endoscopic Ear Surgery for the Attic Cholesteatoma

OBJECTIVE

To reveal the patency of the anterior epitympanic space (AES) and the surgical outcomes after transcanal endoscopic ear surgery (TEES) for attic cholesteatoma with a classification of anatomical variation of the AES.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Seventy-four ears (72 patients with early-stage (I or II) attic cholesteatoma) aged between 16 and 85 years (mean: 48.9 yr) who underwent TEES between 2015 and 2017 were analyzed.

INTERVENTION

Tympanoplasty with atticoantrotomy was performed with TEES. TEES was performed using a rigid endoscope with an outer diameter of 2.7 mm.

MAIN OUTCOME MEASURE

The tensor fold in the AES anatomical classification, the postoperative patency of the AES evaluated by computer tomography images, and hearing outcomes based on the American Academy of Otolaryngology and Head and Neck Surgery criteria were evaluated after TEES for early-stage attic cholesteatoma.

RESULTS

There were 14 (18.9%) ears with a vertical tensor fold orientation, 29 (39.2%) ears with an oblique orientation, and 29 (39.2%) ears with a horizontal orientation. The total postoperative patency rate in the AES was 81.0%, without any significant difference in the anatomical variation in the AES, whereas the rate of preoperative complete tensor fold was 90.5%. Cholesteatoma recurrence was observed in three cases (4.1%), and all recurrent cases had obstructed AES. No significant difference was found in the postoperative air-bone gap regardless of the patency of the AES.

CONCLUSION

Our findings indicate that TEES is useful in restoring ventilation in the AES, resulting in favorable management of cholesteatoma.

The Treatment of Cholesteatomas Involving the Antrum and Mastoid Using Transcanal Underwater Endoscopic Ear Surgery

OBJECTIVE

The aim of this study was to evaluate the feasibility and safety of transcanal underwater endoscopic bone resection (TUEBR) of the external auditory canal (EAC) for the management of cholesteatoma involving the antrum and mastoid.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Pediatric and adult patients with primary cholesteatoma extending to the antrum and mastoid who underwent transcanal endoscopic ear surgery (TEES) with TUEBR between March 2016 and June 2017.

INTERVENTION

A rigid 2.7 mm diameter, 18 cm length Hopkins-rod telescope with an endoscopic sheath was inserted in the EAC and continuously perfused with saline during the dissection. TUEBR was performed to expose extensive cholesteatoma by using a high speed drill with curved burrs and a protected shaft. Next, removal of visible disease, reconstruction of the resected EAC, ossiculoplasty, and tympanoplasty were accomplished with TEES.

RESULTS

There were no intra- or postoperative severe complications such as facial palsy and inner ear injury except one patient suffering from secondary labyrinthitis. There was a negative linear relationship (r = -0.909) between the procedure time and procedure number of TUEBR. There was a weak relationship (r = 0.224) between the procedure time of TUEBR and the degree of the extension of cholesteatoma into the antrum and mastoid. There were two cases with residual cholesteatoma at 12 and 22 months follow-up postoperatively.

CONCLUSION

TUEBR is a safe and efficient technique for the resection of EAC bone and transcanal exposure of extensive cholesteatoma that would otherwise require mastoid dissection.

Lasers in Cholesteatoma Surgery: A Systematic Review

OBJECTIVES

The mainstay of cholesteatoma treatment is surgical and requires the removal of all squamous epithelium from the underlying normal structure. The application of laser technology in middle ear and mastoid surgery has shown promise in achieving both disease eradication and hearing preservation. This systematic review aims to include studies that have assessed the application of laser to the treatment of cholesteatoma and to review its outcomes in terms of disease eradication as well as hearing results.

METHOD

Two independent researchers conducted a systematic review of the literature on MEDLINE and Cochrane library, according to PRISMA guidance.

RESULT

The search resulted in 12 papers, reporting on 536 participants that fulfilled the inclusion criteria. The hearing results did not show that using laser surgery improved hearing in cholesteatoma surgery, but neither has the use of laser shown to deteriorate hearing. With regards to the prevention of residual/recurrent cholesteatoma, the current literature reports a residual/recurrent rate of 0% to 33%. The complication rate of facial palsy is 0.6%.

CONCLUSION

While there is certainly a role for future studies especially randomised large-cohort prospective comparative studies, the current literature suggests that laser may have a role in prevention or minimizing of residual cholesteatoma and generally have a safe hearing outcome profile.

The Medially-Invasive Cholesteatoma: An Aggressive Subtype of a Common Pathology

OBJECTIVE

Describe the outcomes of treatment for patients with cholesteatomas that are medially invasive to the otic capsule, petrous apex, and/or skull base.

STUDY DESIGN

Retrospective case series.

SETTING

Two tertiary care academic centers.

PATIENTS

Patients surgically managed for medially-invasive cholesteatoma at two tertiary care institutions from 2001 to 2017.

INTERVENTIONS

Surgical management of medially-invasive cholesteatomas.

MAIN OUTCOME MEASURES

The presenting symptoms, imaging, pre- and post-operative clinical course, and complications were reviewed.

RESULTS

Seven patients were identified. All patients had pre-operative radiographic evidence of invasive cholesteatoma with erosion into the otic capsule beyond just a lateral semicircular canal fistula. Five patients had a complex otologic history with multiple surgeries for recurrent cholesteatoma including three with prior canal wall down mastoidectomy surgeries. Average age at the time of surgery was 41.3 years (range 20-83). Two patients underwent a hearing preservation approach to the skull base while all others underwent a surgical approach based on the extent of the lesion. Facial nerve function was maintained at the pre-operative level in all but one patient. No patient developed cholesteatoma recurrence.

CONCLUSIONS

The medially-invasive cholesteatoma demonstrates an aggressive, endophytic growth pattern, invading into the otic capsule or through the perilabyrinthine air cells to the petrous apex. Surgical resection remains the best treatment option for medially-invasive cholesteatoma. When CSF leak is a concern, a subtotal petrosectomy with closure of the ear is often necessary.

Multi-operated cholesteatoma: when two surgeries are not enough

PURPOSE

Most studies regarding residual and recurrent cholesteatoma focus on single relapse. This study examines patients who had to undergo at least three surgeries for complete eradication of their cholesteatoma, with the aim of bringing to light risk factors and assessing the functional impact of multiple surgeries on hearing.

METHOD

We include 27 patients who underwent 3 consecutive surgeries for cholesteatoma between 2006 and 2016. This population represented 3.1% of all cholesteatoma operated on during that same period (868 patients).

RESULTS

Cases of multi-residual and/or recurrent cholesteatoma (RRC) were significantly younger (13.1 years old), than single-RRC or cases with No-RRC (respectively, 28.0 and 38.5 years old) (p < 0.01). Furthermore, there was a significant difference in cholesteatoma location especially for combined attical and mesotympanic location between the three groups (no-RCC 26%; single-RRC 34% and multi-RRC 66%) (p < 0.01). There was also a significant difference in ossicular erosion of the malleus, incus and stapes between the three groups (p < 0.01). In our study, the type of surgery did not influence multi-RRC rates. We did not observe any significant impact on hearing between the first and third surgeries. Mean duration between the first and second surgeries was significantly shorter for multi-RRC (14.5 months SD 8.3) than for single-RRC (23.3 months SD 18.1) (p < 0.05).

CONCLUSION

Special care should be given in case of combined attical and mesotympanic extension, ossicular erosion and young children. Delaying the realization of MRI, and/or of second-look surgery, could decrease the risk of multi-RRC.

Can endoscopic ear surgery replace microscopic surgery in the treatment of acquired cholesteatoma? A contemporary review

Acquired cholesteatoma leads to significant morbidities while current surgical options remain a challenge. The principles of surgery include complete removal of disease, prevention of recurrence, and restoration of hearing function when possible. Traditionally, this has been performed using microscopes; however, a novel technique using endoscopes offers a new perspective on our understanding of anatomy, pathogenesis and surgical approaches. In recent years, various studies have demonstrated good outcomes with transcanal endoscopic ear surgery (EES) in cholesteatoma surgery. Nevertheless, the use of EES is not universal and remains controversial due to the efficacy of microscopes, specific limitations of endoscopes and the need to learn new skills. This review focuses on recent advances in EES for the treatment of acquired cholesteatoma, benefits, current challenges, and a discussion on the indications and contraindications of EES.

Improvement of otoendoscopic surgery for epitympanic cholesteatoma invading the mastoid

BACKGROUND

In recent years, the otoendoscopic surgery for epitympanic cholesteatoma has achieved great development, but it still has some disadvantages.

OBJECTIVE

This work aims to improve otoendoscopic surgery for epitympanic cholesteatoma invading the mastoid to retain the normal structure of the middle ear as much as possible.

METHODS

We classified the patients according to the lesion scope and applied different strategies of using the combination of otoendoscope and microscope. The surgery was improved and the recurrence and residual of middle ear cholesteatoma after operation were observed preliminarily.

RESULTS

Forty-six patients with middle ear cholesteatoma accepted surgical treatment, including 10 cases of independent otoendoscopic surgery, 29 cases of otoendoscope-microscope combined surgery, and seven cases of microscopic surgery assisted with an otoendoscope. All cases were treated with canal-up cholesteatoma surgery. The postoperative recurrent rate was 4/46.

CONCLUSION

We improved existing otoendoscopic surgery to reduce or avoid bony defects of the acoustic meatus, and then decreased the proportion of canal-down surgery.

Successful Posterior Canal Wall Reconstruction with Tissue-Engineered Cartilage

Difficulties are associated with reconstruction of middle ear bony structures in surgery for destructive lesions, including cholesteatoma. Although autologous cartilage appears to be the optimal choice because of its resistance to infection, the harvesting of sufficient volumes may be challenging. Therefore, regenerative medicine techniques to obtain sufficient material for reconstruction are awaited. We herein present a case of middle ear surgery for cholesteatoma with a sufficient volume of stick-shaped tissue-engineered cartilage produced from a piece of autologous auricular cartilage and autologous serum, with sufficient firmness to reconstruct bony structures. During surgery, sections of tissue-engineered cartilage were placed side by side to reconstruct the posterior canal wall. The postoperative course was uneventful. This is the first-in-human report of reconstructing middle ear bony structures with tissue-engineered cartilage. The results suggest a promising future for the satisfactory reconstruction of middle ear structures with minimal morbidity at the donor site.

Cholesteatoma Pearls: Practical Points and Update

The European Academy of Otology and Neurotology in collaboration with the Japanese Otological Society (EAONO/JOS) recently produced a joint consensus document outlining the definitions, classification and staging of middle ear cholesteatoma. The goals were to provide terminologies in the description of cholesteatoma, classify cholesteatoma into distinct categories to facilitate the comparison of surgical outcomes and to provide a staging system that reflects the severity, difficulty of complete removal and restoration of normal function. Cholesteatoma is considered a benign, expanding and destructive epithelial lesion of the temporal bone that is the result of a multifactorial process. If undetected and left treated, cholesteatoma may lead to significant complications including hearing loss, temporal bone destruction and cranial invasion. Recent advances in imaging modalities have allowed for high sensitivity and specificity in identifying the presence of cholesteatoma. Despite these advances, deficiencies exist around the world with access to health care facilities meaning cholesteatoma remains a serious and challenging entity to manage whether found within the pediatric or adult population. Proper diagnosis and management of each form of cholesteatoma is achieved by a thorough understanding of the etiology, classification, clinical presentation and histology, thereby facilitating prevention, early detection and appropriate treatment.

Association Between Middle Ear Cholesteatoma and Chronic Rhinosinusitis

Importance

Chronic rhinosinusitis (CRS) can cause an obstruction of the tubal orifice and thereby compromise ventilation of the middle ear. The resulting negative pressure in the middle ear may, in turn, lead to the formation of an eardrum retraction pocket and subsequent acquired cholesteatoma. This study hypothesizes that CRS may increase the risk of cholesteatoma.

Objective

To evaluate the risk of cholesteatoma in patients with CRS.

Design, Setting, and Participants

This study used a nationwide, population-based claims database to test the hypothesis that CRS may increase the risk of cholesteatoma. The Longitudinal Health Insurance Database of Taiwan was used to compile data from (1) 12 670 patients with newly diagnosed CRS between January 1, 1997, and December 31, 2002, and (2) a comparison cohort of 63 350 matched individuals without CRS, resulting in a CRS vs control ratio of 1:5. Data analysis was performed from June 1 to October 27, 2015. Each patient was followed up for 8 years to identify those in whom cholesteatoma subsequently developed. The Kaplan-Meier method was used to determine the cholesteatoma-free survival rate, and the log-rank test was used to compare survival curves. Cox proportional hazards regression models were used to compute the 8-year hazard ratios (HRs).

Main Outcomes and Measures

Diagnosis of cholesteatoma.

Results

Among the 76 020 patients enrolled in this study, 35 220 (46.3%) were female; mean (SD) age was 27.57 (22.03) years. A total of 209 patients developed cholesteatoma, 66 (101 084 person-years) individuals from the CRS cohort and 143 (506 540 person-years) from the comparison cohort were diagnosed with cholesteatoma during the 8-year follow-up period. The incidence of cholesteatoma per 1000 person-years was more than twice as high among patients with CRS (0.65; 95% CI, 0.50-0.81 person-years) than among those without CRS (0.28; 95% CI, 0.24-0.33). The absolute difference in the incidence density between CRS and non-CRS group was 0.37 (95% CI, 0.21-0.53) per 1000 patient-years. After adjusting for potential confounders, patients with CRS had a 69% increased risk of cholesteatoma within 8 years, compared with those without CRS (HR, 1.69; 95% CI, 1.23-2.32). Patients with CRS presented a significantly lower 8-year cholesteatoma-free survival rate than did those in the comparison group. The absolute difference in the 8-year cholesteatoma-free survival rate between the CRS and non-CRS groups was 0.0029 (95% CI, 0.0016-0.0043).

Conclusions and Relevance

This is the first large-scale study, to date, to demonstrate a prospective link between CRS and the subsequent development of cholesteatoma within a follow-up period of 8 years. The purpose of the study was to draw attention to the possibility of development of cholesteatoma among patients with CRS. Because that possibility exists, clinicians should keep this association in mind as well as the importance of a thorough head and neck examination.

Increased risk of cholesteatoma among patients with allergic rhinitis: A nationwide investigation

OBJECTIVES

No large population-based studies have reported on the risk of cholesteatoma developing after allergic rhinitis (AR). This study used a nationwide population-based claims database to investigate the hypothesis that AR may increase the risk of cholesteatoma.

STUDY DESIGN

Retrospective cohort study.

METHODS

Data from Taiwan's Longitudinal Health Insurance Database were analyzed to compile the following: 1) 15,953 patients newly diagnosed with AR between 1997 and 2000, and 2) a comparison cohort of 63,812 matched non-AR enrollees (with a ratio of 1 to 4). Each patient was followed for 10 years to identify cases in which cholesteatoma subsequently developed. The Kaplan-Meier method was used to determine the cholesteatoma-free survival rate, and the log-rank test was used to compare survival curves. Cox proportional hazard regressions were performed to compute adjusted hazard ratios (HRs).

RESULTS

Among the 79,765 patients enrolled in this study, 45 (159,364 person-years) from the AR cohort and 88 (638,130 person-years) from the comparison cohort were diagnosed with cholesteatoma during the follow-up period (incidence rates 0.28 and 0.14 of 1,000 person-years, respectively). Patients with AR were more likely to develop cholesteatoma compared to those without AR (adjusted HR 1.57, 95% confidence interval = 1.05-2.34, P < 0.05). Patients with AR presented a significantly lower 10-year cholesteatoma-free survival rate than did those in the comparison group (log-rank, P < 0.001).

CONCLUSION

This is the first study to demonstrate a link between AR and the development of cholesteatoma. We suggest that clinicians keep this association in mind and carefully investigate the possibility of development of cholesteatoma among patients with AR.

LEVEL OF EVIDENCE

3b. Laryngoscope, 128:547-553, 2018.

TREM-2 promotes acquired cholesteatoma-induced bone destruction by modulating TLR4 signaling pathway and osteoclasts activation

Triggering receptor expressed on myeloid cells (TREM) has been broadly studied in inflammatory disease. However, the expression and function of TREM-2 remain undiscovered in acquired cholesteatoma. The expression of TREM-2 was significantly higher in human acquired cholesteatoma than in normal skin from the external auditory canal, and its expression level was positively correlated with the severity of bone destruction. Furthermore, TREM-2 was mainly expressed on dendritic cells (DCs). In human acquired cholesteatoma, the expression of proinflammatory cytokines (IL-1β, TNF-α and IL-6) and matrix metalloproteinases (MMP-2, MMP-8 and MMP-9) were up-regulated, and their expression levels were positively correlated with TREM-2 expression. Osteoclasts were activated in human acquired cholesteatoma. In an animal model, TREM-2 was up-regulated in mice with experimentally acquired cholesteatoma. TREM-2 deficiency impaired the maturation of experimentally acquired cholesteatoma and protected against bone destruction induced by experimentally acquired cholesteatoma. Additional data showed that TREM-2 up-regulated IL-1β and IL-6 expression via TLR4 instead of the TLR2 signaling pathway and promoted MMP-2 and MMP-8 secretion and osteoclast activation in experimentally acquired cholesteatoma. Therefore, TREM-2 might enhance acquired cholesteatoma-induced bone destruction by amplifying the inflammatory response via TLR4 signaling pathways and promoting MMP secretion and osteoclast activation.

Depression and cholesteatoma: Preliminary findings from a nationwide population-based retrospective cohort study

OBJECTIVE

To estimate the risk of developing depressive disorder (DD) following diagnosis with cholesteatoma.

METHODS

In the study, we analyzed data from the Longitudinal Health Insurance Database of Taiwan. A total of 599 patients newly diagnosed with cholesteatoma between 1997 and 2007 were included with a comparison cohort of 2995 matched non-cholesteatoma enrollees. Each patient was followed for 3 years to identify the subsequent development of DD. Cox proportional hazard regression analysis was performed to compute adjusted 3-year hazard ratios.

RESULTS

The incidence of DD per thousand person-years was approximately twice as high among patients with cholesteatoma (11.32) as among those without cholesteatoma (5.85). After adjusting for potential confounders, patients with cholesteatoma were 1.99 times (95% CI=1.18-3.34, P=0.010) more likely to suffer from DD within 3 years compared to those without cholesteatoma.

CONCLUSIONS

This is the first study to demonstrate a link between cholesteatoma and subsequent DD within a three-year followup. We suggest that clinicians keep this critical but neglected issue in mind and carefully investigate the possibility of subsequent psychological problems among cholesteatoma patients.

Updates and knowledge gaps in cholesteatoma research

The existence of acquired cholesteatoma has been recognized for more than three centuries; however, the nature of the disorder has yet to be determined. Without timely detection and intervention, cholesteatomas can become dangerously large and invade intratemporal structures, resulting in numerous intra- and extracranial complications. Due to its aggressive growth, invasive nature, and the potentially fatal consequences of intracranial complications, acquired cholesteatoma remains a cause of morbidity and death for those who lack access to advanced medical care. Currently, no viable nonsurgical therapies are available. Developing an effective management strategy for this disorder will require a comprehensive understanding of past progress and recent advances. This paper presents a brief review of background issues related to acquired middle ear cholesteatoma and deals with practical considerations regarding the history and etymology of the disorder. We also consider issues related to the classification, epidemiology, histopathology, clinical presentation, and complications of acquired cholesteatoma and examine current diagnosis and management strategies in detail.