Experience with cholesteatoma behind an intact tympanic membrane in children

Acquired Cholesteatomas Behind Intact Tympanic Membranes of Adults: A Series of 13 Cases

Background and Objective: Acquired cholesteatomas behind intact tympanic membrane (ITMC) are rarely encountered in adults in the otology clinic, and the clinical and imaging features of ITMC in adults remain unclear to date. ITMC patients are commonly overlooked because of the absence of both a typical retraction pocket and a tympanic membrane (TM) perforation. The objective of this study was to describe clinical features, pathogenesis, and surgical outcomes in a series of adult patients with acquired ITMC. Materials and Methods: The clinical records of 13 adult patients diagnosed with ITMC were retrospectively reviewed. ITMC were classified into those associated with otitis media with effusion (OME; Group A) and histories of previous perforations (Group B). Results: A total of 13 cases with unilaterally acquired ITMC were included, of which 10 (76.9%) were in Group A and 3 (23.1%) were in Group B. All Group A patients exhibited white masses behind intact TMs, in the anterosuperior quadrants of 6 and the posterior upper quadrants of 4. In Group B patients, white masses in the middle ear were lacking. The TMs were atrophic and white myringosclerotic plaques were evident. The cholesteatomas were confined to the antrum and aditus ad antrum in 2 Group B patients but extended to the epitympanum in 1. All 10 Group A patients had extensive cholesteatomas but intact (noneroded) malleoli. Conclusions: An acquired ITMC should be suspected if symptoms worsen or new symptoms develop in adults with OME or a history of perforation, although the TM is intact with or without pars flaccida retraction, computed tomography/magnetic resonance imaging should be performed. Canal wall up mastoidectomy combined with ventilation tube insertion effectively treated ITMC associated with OME.

Congenital cholesteatoma clinical and surgical management

OBJECTIVES

Congenital cholesteatoma (CC) is accompanied by hearing loss and an intact tympanic membrane. However, the hearing loss is usually associated with otitis media, and the diagnosis of CC is frequently delayed in patients with an intact tympanic membrane. This study aimed to describe the clinical characteristics, management and outcomes of patients with CC.

METHODS

We reviewed patients with cholesteatoma from January 2011 to May 2020 and selected those meeting the congenital cholesteatoma criteria. The primary outcome measures included presenting symptoms, surgical findings, stage of disease, recurrence rate and hearing outcomes.

RESULTS

We reviewed 1646 medical files of cholesteatoma patients and identified 18 patients with congenital cholesteatoma, the mean age at operation was 8.13 ± 1.36 years (range 3-18). The unilateral hearing loss included moderate 13 patients (72.2%), severe 4 patients (22.2%), and slight 1 (5.6%). There were 14 cases of conductive hearing loss (77.8%) and 4 cases of mixed hearing loss (22.2%). The mean course of disease was 1.41 ± 0.05 years (range 0.4-3). The surgical management was oto-endoscope exploratory tympanotomy in 1（5.6%）, canal wall up mastoidectomy in 12 (66.7%) and canal wall down in 5 (27.8%), with 17 (94.4%) ossicular replacements. Seventeen (94.4%) patients presented with Potsic stage III-IV. Recurrence occurred in 5.6% of patients in stage III and 11.1% of patients in stage IV. After surgery, patients achieved normal voice tone hearing.

CONCLUSIONS

To diagnose it early, congenital cholesteatoma should be considered as a possible aetiology for hearing loss patients with an intact tympanic membrane. In our study, most patients were diagnosed at III and IV stage. This highlights the need to promote awareness of the disease among primary physicians in the community healthcare system. Surgical management with removal of the cholesteatoma and reconstruction of the tympanum and ossicular chain is an effective treatment.

Clinical Findings of Cholesteatoma Behind an Intact Tympanic Membrane in Adults

OBJECTIVE

The aim of this study was to describe the clinical features and surgical results in a series of adult intact tympanic membrane cholesteatoma (ITMC).

MATERIALS AND METHODS

The author retrospectively analyzed 17 adult patients diagnosed with ITMC who underwent surgery. The author investigated the demographic data, presenting symptoms, endoscopic findings, disease location, surgical technique, post-operative complications, and outcomes.

RESULTS

Diagnosis was made based on a white mass behind an intact tympanic membrane in 14 cases and on explorative surgery and CT in the remaining 3 patients. ITMC presented as a cystic lesion with a complete capsule. ITMCs were removed through an endoscopic endaural approach combined with cartilage myringoplasty in 14 cases and intact canal wall mastoidectomy was performed in 3 cases. No recurrent cholesteatoma or iatrogenic sensorineural hearing loss was observed during the follow-up period. The mean ABG was 17.7 ± 2.7 dB perioperatively and 10.2 ± 1.3 dB postoperatively.

CONCLUSIONS

Intact tympanic membrane cholesteatoma in adults may have both congenital and acquired origins, but it is not possible to differentiate between a slow growing acquired or indolent congenital cholesteatoma. ITMC typically presents as a cystic lesion with a complete capsule that can be treated successfully via an endoscopic tympanotomy approach, but in a minority of cases a more extensive mastoidectomy may be required.