Post-operative vestibular and equilibrium evaluation in patients with cholesteatoma-induced labyrinthine fistulas

OBJECTIVE

This study aimed to compare the pre- and post-operative vestibular and equilibrium functions of patients with cholesteatoma-induced labyrinthine fistulas who underwent different management methods.

METHODS

Data from 49 patients with cholesteatoma-induced labyrinthine fistulas who underwent one of three surgical procedures were retrospectively analysed. The three management options were fistula repair, obliteration and canal occlusion.

RESULTS

Patients underwent fistula repair (n = 8), canal occlusion (n = 18) or obliteration procedures (n = 23). Patients in the fistula repair and canal occlusion groups suffered from post-operative vertigo and imbalance, which persisted for longer than in those in the obliteration group. Despite receiving different management strategies, all patients achieved complete recovery of equilibrium functions through persistent efforts in rehabilitation exercises.

CONCLUSION

Complete removal of the cholesteatoma matrix overlying the fistula is reliable for preventing iatrogenic hearing deterioration due to unremitting labyrinthitis. Thus, among the three fistula treatments, obliteration is the optimal method for preserving post-operative vestibular functions.

Presentation, Management, and Hearing Outcomes of Labyrinthine Fistula Secondary to Cholesteatoma: A Systematic Review and Meta-analysis

OBJECTIVE

The current study systematically reviewed the literature to compare auditory outcomes of patients treated for labyrinthine fistula (LF) based on characteristics of disease and surgical management.

DATABASES REVIEWED

PubMed, Scopus, Web of Science.

METHODS

Original series (at least five cases) published from 2000 reporting management and hearing results of LF secondary to cholesteatoma were included. Proportion and odds-ratio (OR) meta-analyses were conducted through inverse variance random-effects models based on logit transformation.

RESULTS

The prevalence of LF is estimated to be 7% (95% confidence interval [CI], 5-9%). Fistulae involving the lateral semicircular canal (90%; 95% CI, 87-93%) and larger than 2 mm (53%; 95% CI, 43-64%) were common, whereas membranous involvement was less frequent (20%; 95% CI, 12-30%). Complete removal of the cholesteatoma matrix overlying the LF was mostly applied. Bone conduction (BC) preservation was frequently achieved (81%; 95% CI, 76-85%); new-onset postoperative anacusis was rarely reported (5%; 95% CI, 4-8%). A higher chance of BC preservation was associated with sparing the perilymphatic space (OR, 4.67; 95% CI, 1.26-17.37) or membranous labyrinth (OR, 4.56; 95% CI, 2.33-8.93), exclusive lateral semicircular canal involvement (OR, 3.52; 95% CI, 1.32-9.38), smaller size (<2 mm; OR, 3.03; 95% CI, 1.24-7.40), and intravenous steroid infusion (OR, 7.87; 95% CI, 2.34-26.42).

CONCLUSION

LF occurs in a significant proportion of patients with cholesteatoma. In the past two decades, complete removal of the cholesteatoma matrix followed by immediate sealing has been favored, supported by the high proportion of BC preservation. Hearing preservation depends primarily on characteristics of the LF, and specific surgical strategies should be pursued. Intraoperative and postoperative intravenous steroid infusion is recommended.

Analysis of postoperative effects of different semicircular canal surgical technique in patients with labyrinthine fistulas

Objective

Different semicircular canal surgery techniques have been used to treat patients with labyrinthine fistulas caused by middle ear cholesteatoma. This study evaluated postoperative hearing and vestibular function after various semicircular canal surgeries.

Materials and methods

In group 1, from January 2008 to December 2014, 29 patients with middle ear cholesteatoma complicated by labyrinthine fistulas were treated with surgery involving covering the fistulas with simple fascia. In group 2, from January 2015 to October 2021, 36 patients with middle ear cholesteatoma complicated by labyrinthine fistulas were included. Cholesteatomas on the surface of type I labyrinthine fistulas were cleaned using the “under water technique” and capped with a “sandwich” composed of fascia, bone meal, and fascia. Cholesteatomas on the surface of type II and III fistulas were cleaned using the “under water technique,” and the labyrinthine fistula was plugged with a “pie” composed of fascia, bone meal, and fascia, and then covered with bone wax.

Results

Some patients with labyrinthine fistulas in group 1 exhibited symptoms of vertigo after surgery. In group 2 Patients with type II labyrinthine fistulas experienced short-term vertigo after semicircular canal occlusion, but no cases of vertigo were reported during long-term follow-up. “sandwich.” In patients with type II labyrinthine fistulas, the semicircular canal occlusion influenced postoperative hearing improvement. However, postoperative patient hearing was still superior to preoperative hearing.

Conclusion

The surface of type I labyrinthine fistulas should be capped by a “sandwich” composed of fascia, bone meal, and fascia. Type II and III labyrinthine fistulas should be plugged with a “pie” composed of fascia, bone meal, and fascia, covered with bone wax.

Clinical efficacy of the 'sandwich technique' in repairing cholesteatoma with labyrinthine fistula

BACKGROUND

Labyrinthine fistula is the most common complication of middle ear cholesteatoma.

AIMS/OBJECTIVES

To explore the postoperative hearing changes and surgical results of repairing middle ear cholesteatoma with labyrinthine fistula using the 'sandwich technique'.

MATERIALS AND METHODS

We retrospectively studied the clinical data of 36 patients (36 ears) who underwent surgical treatment for cholesteatoma with labyrinthine fistula. All patients were treated by completely removing the cholesteatoma matrix and repairing the fistula using the 'sandwich technique'. The hearing, clinical features, radiological data, intraoperative findings, and surgical results were respectively analyzed.

RESULTS

Most labyrinthine fistulas were located in the lateral semicircular canal (94%). Fifty percent of fistulas were of medium size. Based on Dornhoffer classification, 17 cases of labyrinthine fistulas were classified as I. In 34 patients, the average bone conduction threshold improved or did not change after surgery. Two patients had preoperative facial paralysis. During follow-up (3-60 months), all patients had no postoperative vertigo symptoms and disease recurrence.

CONCLUSIONS

Following the removal of the cholesteatoma matrix, the fistula is repaired using the "sandwich technique", which preserves or increases hearing and achieves an anti-vertiginous effect.

SIGNIFICANCE

This finding suggests that, 'sandwich technique' is a feasible procedure to treat cholesteatoma with labyrinthine fistula.

[A case of hearing preservation during surgical treatment of distributed fistula labyrinth in a patient with chronic purulent means otitis and cholesteatoma]

The article provides a brief overview of the epidemiology, diagnosis, clinical manifestations and surgical methods of treatment of labyrinthine fistulas (LF) in patients with chronic suppurative otitis media (CSOM) with cholesteatoma. The efficacy of various LF treatment techniques, their complications, and the principles of prevention of cochleovestibular disorders during surgical treatment are described. The prognostic criteria for the deterioration of bone conduction thresholds during LF surgery, which include a large LF size, the opening of the membranous labyrinth, and the extent of damage to the structures of the inner ear, are presented. A clinical case of surgical treatment of widespread LF in CSOM with cholesteatoma is presented, which proves the possibility of preserving the auditory and vestibular functions while observing the stages of sanitation, manipulations on the LF and obliteration of semicircular canals defects with auto tissues. Combined surgery of such a plan must certainly be accompanied by local instillation of solutions of hormonal preparations in case of a deficiency of perilymphatic fluid in the labyrinth and postoperative antibacterial and hormonal therapy.

Surgical treatment of cholesteatomatous labyrinthine fistula by hydrodissection

Middle ear cholesteatoma is a destructive lesion that can potentially erode the bone. Cholesteatoma is a clinical diagnosis in the vast majority of cases. Patients must be systematically investigated for the presence of signs suggestive of complications, the most common of which is labyrinthine fistula. However, the clinical features of labyrinthine fistula are inconstant and the fistula sign may sometimes be negative. CT scan of the petrous temporal bone is performed systematically to specify the site and extension of the cholesteatoma, and to assess the extent of osteolysis that can result in exposure of the membranous labyrinth. Surgical treatment has three main objectives: complete resection of the cholesteatoma, which is the only way to avoid residual cholesteatoma, prevention of recurrence by an adapted, preferably one-step, technique, and restoration of good quality hearing. Hydrodissection of the cholesteatoma matrix in the presence of labyrinthine fistula is a simple technique that can achieve the three main general objectives of cholesteatoma surgery.

Imaging Analysis for Cholesteatoma Extension to the Perilymphatic Space in Labyrinth Fistulae

OBJECTIVES/HYPOTHESIS

Disturbed perilymph behind a labyrinth fistula can lead to hearing deterioration; thus, delicate manipulation is required during surgery for cholesteatomatous fistulae with matrix extension to the perilymphatic space (EPS). However, it remains challenging to identify the EPS preoperatively. This study aimed to evaluate the diagnostic value of computed tomography (CT) for preoperative prediction of the EPS of cholesteatomatous fistulae.

STUDY DESIGN

Retrospective study.

METHODS

We included serial high-resolution CT images showing a cholesteatomatous bone defect in the lateral semicircular canal (LSC) requiring mastoidectomy. CT and intraoperative findings were analyzed retrospectively. Using axial CT planes, we evaluated the length and angle between the margins of bone defects. Receiver operating characteristic (ROC) curves were constructed to determine the cutoff points.

RESULTS

We extracted data from 30 bone defects, of which six (20.0%) showed EPS intraoperatively. Bone defects with EPS (n = 6) had significantly greater length and angle values than those without EPS (n = 24) (P < .001 for both, Wilcoxon rank sum test). For length and angle, the area under the curve was 0.944 (95% confidence interval [CI]: 0.858-1.000) and 0.951 (95% CI: 0.875-1.000), respectively, according to the ROC analysis, and the optimal cutoff values were 3.65 mm and 71.6°, respectively, with 100% sensitivity and 91.67% specificity for both.

CONCLUSIONS

Results demonstrated that a length >3.65 mm and an angle >71.6° for LSC bone defects on axial CT images are reliable diagnostic markers of EPS. Preoperative high-resolution CT analysis can provide surgeons with a more conscientious preparation for handling deeper labyrinth fistulae.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1301-E1307, 2021.