The sleeve autograft in congenital cholesteatoma

Middle ear congenital cholesteatoma: systematic review, meta-analysis and insights on its pathogenesis

PURPOSE

Congenital cholesteatoma (CC) presents as a white pearl-like lesion behind a normal tympanic membrane (TM), without a history of otorrhea, infection, perforation or previous otologic surgery. Several recent studies provided new data improving this pathology characterization. The aim of this paper is to expand the knowledge about CC and to provide new insights on its pathogenesis.

METHODS

The study consisted of two main research parts: (1) systematic review and meta-analysis; (2) medical literature review englobing anatomy, histology, embryology and congenital pathology of the ear.

RESULTS

The search strategy identified a total of 636 papers. Seventy retrospective studies were included. A total of 1497 cases were studied and the mean age was 6.58 years, with a male-female ratio of 3:1, 34% were asymptomatic, 26% had hearing loss and 2% had facial dysfunction/paralysis. The overall estimate for antero-superior quadrant involvement was 0.70 [95% confident interval (CI) 0.64-0.76], in the postero-superior quadrant was 0.60 (95% CI 0.52-0.69), in the antero-inferior quadrant was 0.32 (95% CI 0.23-0.41), in the postero-inferior quadrant was 0.38 (95% CI 0.29-0.47), in the attic was 0.53 (95% CI 0.43-0.63) and in the mastoid was 0.33 (95% CI 0.26-0.41). More advanced Potsic stages were present in older patients. The most likely inclusion place seems to be between the pars flaccida and the upper quadrants of the pars tensa.

CONCLUSIONS

During the last decades, a substantial improvement in CC diagnosis and management had been achieved. The presented mechanism seems to explain most of middle ear CC.

A Review of Twenty Congenital Cholesteatomas of the Middle Ear in Children

Cholesteatomas, arising within the middle ear space behind an intact tympanic membrane, have been detected more frequently in recent years. This article reviews 19 children (with a mean age of 4.3 years) who underwent surgery over a 7-year period for removal of cholesteatomas from behind intact tympanic membranes. Most of these children were referred by pediatricians who had detected an asymptomatic whitish middle ear mass. Many had histories of treatment for otitis media. Patients with similar histories were excluded from the series if there had been a prior perforation, myringotomy, or otologic surgery. In the series, one fourth of the children had associated congenital malformations, and there were 3 times as many boys as girls. In two thirds of the cases, the cholesteatoma was manifested as an anterior-superior middle ear mass that seemed to arise from the processus cochlearlformis, undersurface of malleus area. Many could be removed via an extended anterior tympanotomy operative approach. The results of surgery are reviewed. The possible origins of these localized cholesteatomas are considered. Are they congenital defects that arise from misplaced keratinizing epithelium? Do they arise from mesenchymal cells whose differentiation is stimulated by inflammatory changes within the middle ear?

Modified sleeve tympanotomy approach for removal of congenital cholesteatoma

OBJECTIVE

We present a technique which we have found useful for the management of congenital cholesteatoma extensively involving the middle ear.

CASE REPORT

A five-year-old boy was presented to our department for management of a white mass on the right tympanic membrane. This congenital cholesteatoma extensively occupied the tympanic cavity. It was removed through an extended tympanotomy approach using our modified sleeve technique. The conventional tympanotomy approach was extended by gently separating the tympanic annulus from its sulcus in a circular manner. The firm attachment of the tympanic membrane at the umbo was not severed, in order to avoid lateralisation of the tympanic membrane.

CONCLUSION

Although various operative techniques can be used, our modified sleeve tympanotomy approach provides a similarly sufficient and direct visualisation of the entire middle ear, with, theoretically, no possibility of lateralisation of the tympanic membrane and subsequent conductive hearing loss.

Congenital cholesteatoma clinical features and surgical results

We analyzed congenital cholesteatomas in 63 ears of 63 patients who were operated on over a 24-year period. We investigated the presenting symptoms, tympanic membrane findings, cholesteatoma morphology and location, associated anomalies of the ossicles, surgical methods, and outcome of treatment. The age of the patients ranged from 2 to 51 years (mean, 13.3 years), and the closed type of cholesteatoma and the open type were found in 57 ears and 6 ears, respectively. Seventy-three percent of the patients were 15 years or younger. Hearing loss was complained of as a presenting symptom by 60.3% of the patients. In particular, all the patients with the open type of cholesteatoma reported hearing loss as a chief complaint, and most of them had a normal tympanic membrane. Many of the cholesteatomas were located at or around the posterosuperior part of the tympanic cavity. The lesion was confined to the tympanic cavity in 26 (41.3%) ears and to the petrous apex in 1 (1.6%) ear. Advanced cholesteatoma that extended from the tympanic cavity into the mastoid antrum was seen in 35 (55.6%) ears, and multiple cholesteatoma was present in 1 (1.6%) ear. Associated anomalies of the ossicles were suspected in 8 (12.7%) of the 63 ears. Among patients with the open type of cholesteatoma, such anomalies were found in 3 (50.0%) of 6 ears. The super structure of the stapes was destroyed in 63.5% of the patients, so the columella on the foot plate method was most frequently used for ossiculoplasty, followed by the columella on the stapes method and the Wullstein type I method.

A new pathogenesis of mesotympanic (congenital) cholesteatoma

OBJECTIVES

To introduce a new, acquired pathogenetic theory of mesotympanic cholesteatoma behind an intact eardrum in children and to present some doubts on congenital pathogenesis.

STUDY DESIGN

Literature review.

METHODS

The incidence and origination of mesotympanic cholesteatoma in children were thoroughly analyzed in the world literature and correlated to the histopathological studies on human middle ear epithelia and to epidemiological studies on secretory otitis, tubal occlusion, and acute suppurative otitis media.

RESULTS

The new, acquired theory is based on the fact that that the place of origin of the anterosuperior mesotympanic cholesteatoma is the area of the malleus handle and malleus neck, and of the posterosuperior cholesteatoma, the long process of the incus. During the common pathological conditions there is a great risk of retractions and adhesions of the eardrum to these ossicles. After subsequent loosening of the retracted eardrum some cells of the keratinized squamous epithelium may be left behind and become included into the tympanic cavity, eventually causing an inclusion cholesteatoma. Four basic mechanisms of inclusions are proposed and the presence of great dynamics in middle ear disease in children, with high incidence of tubal dysfunction, retractions, secretory otitis, and acute suppurative otitis, is documented, making the acquired pathogenesis probable. The place of origin does not fit with the congenital pathogenesis of epithelial formation localized on the lateral wall of the eustachian tube close to the annulus. The origination around the malleus and incus fits better with the proposed acquired pathogenesis.

CONCLUSIONS

There are no definitive proofs for the acquired pathogenesis of the mesotympanic cholesteatoma, nor is there experimental research to prove or disprove it. Mesotympanic cholesteatoma, congenital cholesteatoma, acquired pathogenesis of mesotympanic cholesteatoma, cholesteatoma in children, cholesteatoma behind intact eardrum.

Congenital cholesteatoma

Since the late 1970s, the author has had the opportunity to prospectively study, document, and surgically manage 40 cases of congenital cholesteatoma. All cases met strict criteria for inclusion in the study, all were surgically and pathologically confirmed, and were definitively followed. During that same period, 38 cases were managed by other members of the otolaryngology department. It is the purpose of this thesis to critically study this personal and institutional experience, and to validate the rationale for early diagnosis and prompt and effective surgical intervention.

Primary cholesteatoma of the mastoid presenting as cervical abscess

Primary cholesteatoma has been described in a number of sites within the temporal bone. We report an unusual case of primary cholesteatoma, confined to the mastoid, presenting with Bezold's abscess of the anterior cervical triangle, in an otherwise asymptomatic elderly man with normal hearing.

Origin of congenital cholesteatoma from a normally occurring epidermoid rest in the developing middle ear

The sites of involvement of congenital cholesteatoma, a lesion which has recently become more frequently recognized, are reviewed from literature sources. There is a propensity for its occurrence, especially when small, in the anterior superior part of the middle ear. The same situation is the precise location of an epidermoid cell rest, the epidermoid formation (EF). This is seen in most fetal ears at the junction of the Eustachian tube with the middle ear near the anterior limb of the tympanic ring, until 33 weeks gestation, when it disappears. Its origin is traced to early fetal life from the ectoderm of the first branchial groove. In embryonic and early in fetal life it seems to act as an organizer in the development of the tympanic membrane and middle ear. It is likely that congenital cholesteatoma is derived from the EF by its continued growth instead of regression. Congenital cholesteatomas show a thinner and flatter matrix than acquired cholesteatomas, probably because the former are most frequently 'closed' and therefore subject to pressure effects from the keratin within the cyst. 'Open' forms also occur in smaller numbers. It is possible that a screening program for congenital cholesteatoma in infants might reduce the incidence of the severe, extended form of the disease.

Double intratemporal congenital cholesteatomas combined with ossicular anomalies

A 15-year-old patient had unilateral double congenital cholesteatomas, one isolated to the mastoid and the other located in the petrous pyramid. The presenting symptoms were facial palsy and a conductive hearing loss on the affected side. The case is interesting, not only in that there were two isolated cholesteatomas in the same temporal bone, but also because of the combination of ossicular anomalies. The unusually early detection and surgical intervention in this instance suggest that similar cases of multicentric cholesteatomas may have occurred, but may have been concealed because of the later detection and possible linkage of the cholesteatomas. I would therefore emphasize Sheehy's recommendation that temporal bone radiography never be omitted where idiopathic facial nerve palsy exists.

A review of twenty congenital cholesteatomas of the middle ear in children

Cholesteatomas, arising within the middle ear space behind an intact tympanic membrane, have been detected more frequently in recent years. This article reviews 19 children (with a mean age of 4.3 years) who underwent surgery over a 7-year period for removal of cholesteatomas from behind intact tympanic membranes. Most of these children were referred by pediatricians who had detected an asymptomatic whitish middle ear mass. Many had histories of treatment for otitis media. Patients with similar histories were excluded from the series if there had been a prior perforation, myringotomy, or otologic surgery. In the series, one fourth of the children had associated congenital malformations, and there were 3 times as many boys as girls. In two thirds of the cases, the cholesteatoma was manifested as an anterior-superior middle ear mass that seemed to arise from the processus cochleariformis, undersurface of malleus area. Many could be removed via an extended anterior tympanotomy operative approach. The results of surgery are reviewed. The possible origins of these localized cholesteatomas are considered. Are they congenital defects that arise from misplaced keratinizing epithelium? Do they arise from mesenchymal cells whose differentiation is stimulated by inflammatory changes within the middle ear?