Congenital cholesteatoma of the middle ear in children: a clinical and histopathological report

Congenital cholesteatoma: what radiologists need to know

Congenital cholesteatoma is a rare, non-neoplastic lesion that causes conductive hearing loss in children. It is underrecognized and often diagnosed only when there is an established hearing deficit. In the pediatric population, hearing deficiency is particularly detrimental because it can impede speech and language development and, in turn, the social and academic well-being of affected children. Delayed diagnosis leads to advanced disease that requires more extensive surgery and a greater chance of recurrence. A need to promote awareness and recognition of this condition has been advocated by clinicians and surgeons, but no comprehensive imaging review dedicated to this entity has been performed. This review aims to discuss the diagnostic utility of high-resolution computed tomography and magnetic resonance imaging in preoperative and postoperative settings in congenital cholesteatoma. Detailed emphasis is placed on the essential preoperative computed tomography findings that facilitate individualized surgical management and prognosis in the pediatric population.

A Case of a Congenital Cholesteatoma Without Growth for a Long Term

Congenital cholesteatoma is typically an expanding cystic mass of keratinizing squamous epithelium located medial to the intact tympanic membrane in patients with no prior history of perforation, otorrhea and ear. It is generally thought to be a progressive disease and is usually surgically removed upon detection as the first-choice treatment. As such, it is rare to be observed for a long term without progression. Here we report a rare case of congenital cholesteatoma that remained in an undetectable size and did not deteriorate mild hearing loss for 12 years. A seven years old boy was referred to us with right hearing impairment. Pure-tone audiometry found conductive hearing loss with an air-bone gap of 25 dB and a high-resolution computed tomography (CT) scan found the eroded long process of incus but did not detect any soft tissue density indicating congenital cholesteatoma. He initially did not wish to undergo surgery. His hearing level and image finding remained virtually unchanged during the next 12 years of the follow-up period. Twelve years later, endoscopic ear surgery was performed, which revealed a very small cholesteatoma mass, an eroded long process of the incus and ossicular chain discontinuities. We suspect that the cholesteatoma was originally larger, partially eroded the incus, then regressed to a very small size, and remained small for at least 12 years under our observation.

Congenital cholesteatoma: Clinical features and surgical outcomes

OBJECTIVES

A typical presentation of congenital cholesteatoma (CC) is asymmetric conductive hearing loss (CHL). As CHL is usually associated with middle ear effusion, diagnosis of CC is frequently delayed. This study aimed to describe the clinical characteristics, treatment and outcomes of children with CC.

METHODS

The medical files of children diagnosed with CC at a large tertiary pediatric medical center during 2000-2019 were reviewed. The primary outcome measures were: presenting symptoms, surgical findings, stage of disease, recurrence rate and hearing outcome. Imaging findings and the size of mastoid air cells were assessed in CT scans.

RESULTS

Thirty-nine children were diagnosed with CC. The presenting symptom was unilateral CHL in 85%, with an average speech reception threshold of 41.5 ± 13.7 dB in the affected ear. The mean time from first symptoms to diagnosis was 1.3 years. The surgical approach was exploratory tympanotomy in 25% and canal wall up mastoidectomy in 69%. Seventy percent of the children presented with Potsic stage III-IV. The mean postoperative speech reception threshold was 26.4 ± 12.2 dB (P = 0.002). Recurrence of cholesteatoma occurred in 38% of the patients, mostly in stage III-IV. Mastoid air cell size was significantly smaller on the affected than the unaffected side.

CONCLUSIONS

In children with persistent unilateral or asymmetric conductive hearing loss, CC should be suspected. Late diagnosis of CC is associated with a high recurrence rate. This highlights the need to promote awareness to the disease among primary physicians in the community health care system.

The Significance of Staging in the Treatment of Congenital Cholesteatoma in Children

OBJECTIVES

To analyze the clinical characteristics of congenital cholesteatoma (CC), to explore the risk factors related to recurrence of the disease, and to clarify the importance of staging for treatment.

METHODS

A total of 87 patients were followed up for more than 5 years, who had undergone surgical procedures for CC from September 2010 to January 2017 in Beijing Children's Hospital, Capital Medical University. Patients with CC were identified in accordance with the following Levenson's criteria. The clinical characteristics of CC on different stage and risk factors related to recurrence of the disease were analyzed.

RESULTS

Canal wall up mastoidectomy and tympanoplasty (n = 45), transcanal endoscopic approach (n = 29), and canal wall down mastoidectomy and tympanoplasty (n = 13) was, respectively, performed depending on cholesteatoma extension. Between 2010 and 2013, 20.93% of patients had stage I-II disease, whereas 61.26% had stage I-II disease from 2014 to 2017. Meanwhile, the proportion with stage III-IV disease decreased from 79.07% to 38.64% between these 2 time periods. The preoperative air conduction threshold in patients with stage I, II, III, and IV was, respectively, 23.36 ± 8.20, 45.40 ± 12.82, 47.49 ± 12.03, and 50.37 ± 11.80 dB. The stage of disease was a significant risk factor regarding recurrence (P = .02). Surgery on patients with stage III-IV disease was performed with the aid of a microscope from 2010 to 2013 and with a microscope and endoscope from 2014 to 2017, which reduced the recurrence rate from 26.92% in the former period to 8.33% in the latter period.

CONCLUSION

Early detection of CC is crucial regarding the facilitation of minimally invasive surgery and reducing complication and recurrence rates. The stage of the disease is a significant risk factor regarding recurrence. The surgery shows us the possibility of reducing the recurrence rate of CC, which is performed under a microscope and an endoscope.

Clinical Characteristics and Treatment Outcomes of Congenital Cholesteatoma

OBJECTIVES

Since its introduction in 2002, the staging system for congenital cholesteatoma, as defined by Potsic, has been used widely owing to its simplicity and predictability. The aim of the present study was to analyze the clinical characteristics and surgical treatment outcomes of congenital cholesteatoma and to correlate them with postoperative recurrence.

MATERIALS AND METHODS

A retrospective chart review was performed for 38 patients who were diagnosed with congenital cholesteatoma and who underwent surgical resection between August 2007 and November 2014 at the Department of Otorhinolaryngology of our hospital.

RESULTS

The mean age of the patients was 7.9±8.2 years, and the number of males and females was 20 and 18, respectively. The mean follow-up period was 30±26 months. Of the 38 patients, 9 (24%) had residual or recurrent cholesteatoma during follow-up examination after primary surgery. The results showed that the size (≥4 mm) of the lesion was significantly correlated with residual or recurrent disease (p=0.026). The disease extent (single vs. multiple quadrant involvement), type (closed vs. open type), and stage; applied surgical method (with mastoidectomy vs. without mastoidectomy); and preoperative hearing level (normal vs. abnormal) were not significantly correlated with residual or recurrent disease.

CONCLUSION

The disease extent, type, and stage; applied surgical methods; and preoperative hearing level were not significantly correlated with residual or recurrent disease. The size (≥4 mm) of congenital cholesteatoma was significantly correlated with residual or recurrent disease.

Concurrent Occurrence of Congenital Ossicular Anomaly and Localized Cholesteatoma: Series of 10 Cases

OBJECTIVE

The objective of this study is to describe the clinical features, managements and outcomes of a rare coexistence of congenital ossicular anomaly and localized cholesteatoma. A literature review on these cases and each congenital disorder is also presented.

METHODS

A retrospective chart review was performed on patients diagnosed with congenital ossicular anomaly with concurrent localized cholesteatoma from 2008 to 2017. Clinical data of these patients were collected.

RESULTS

A total of 10 patients were identified. All patients presented with unilateral hearing loss. Pure-tone audiometry showed conductive hearing loss in all affected ears with an average air conduction (AC) threshold of 59 dB. High-resolution computed tomography scans of the temporal bone diagnosed ossicular anomaly for 90% (9/10); however, only 50% (5/10) had a diagnosis of localized cholesteatoma. A transcanal exploratory tympanotomy under the microscope was performed to discover whether the localized tiny-sized cholesteatoma around the ossicular chain did not have direct contact with the ossicular chain, which could be diagnosed as congenital cholesteatoma. We removed the localized cholesteatoma and reconstructed the ossicular chain in each patient. All localized cholesteatomas were found in the posterior-superior quadrant of the middle ear. Ossicular chain anomalies were associated with the incus and/or the stapes in all cases. Hearing improvement was achieved in each of the 6 patients who were followed up postoperatively, with an average AC threshold of 35 dB. The clinical features of congenital ossicular anomaly with concurrent congenital cholesteatoma were compared with those of each congenital disorder. The pathogenesis of each condition was also discussed.

CONCLUSIONS

Congenital ossicular anomaly with concurrent congenital cholesteatoma is rare. It shares similar clinical features with congenital ossicular anomaly occurring alone, therefore awareness should be raised for a possible concurrent congenital cholesteatoma which was easy to miss in the diagnosis (50%) by the radiologist. A patient's hearing level can be improved by removal of the cholesteatoma and reconstruction of the ossicular chain. Localized cholesteatoma does not usually show residuals or recurrence.

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.

Value of DW-MRI in the preoperative evaluation of congenital cholesteatoma

OBJECTIVE

This study evaluated the clinical value of diffusion-weighted magnetic resonance imaging (DW-MRI) in the diagnosis and staging of congenital cholesteatoma (CC).

PATIENTS AND METHODS

We retrospectively reviewed 24 patients with CC. All the patients underwent computed tomography (CT) and DW-MRI preoperatively; thereafter, surgery was performed. DW-MRI examination was performed with a 3 T MRI system using three-dimensional reversed fast imaging with steady-state precession and diffusion-weighted magnetic resonance sequence. The preoperative and operative CT and DW-MRI findings were compared.

RESULTS

Using DW-MRI, cholesteatoma was successfully detected in 17 (71%) of the 24 patients with CC. Among the seven patients with false-negative results, the cholesteatoma mass diameter was <5 mm in six patients and ≥5 mm in one patient. One of these patients had open type congenital cholesteatoma (OTCC). The detection rates for closed type cholesteatoma and OTCC were 85% (17/20) and 0% (0/4), respectively, using DW-MRI. Using CT and DW-MRI, the correct stage was identified in 88% (15/17) and 59% (10/17) of the patients with aeration around the CC and in 0% (0/7) and 100% (7/7) of those without aeration around the CC, respectively.

CONCLUSION

CT is the primary imaging tool for evaluating suspected CC in patients with aeration around the CC. However, CT is unreliable for the detection of the extension and staging of CC when the middle ear is filled with nonspecific imaging. DW-MRI is useful for the preoperative diagnosis and staging of CC > 5 mm in diameter with or without surrounding granulation tissue. Thus, we recommend using DW- MRI at least when CT fails to localize CC as a soft tissue mass because of non-specific tissue filling the middle ear and the mastoid.

CONGENITAL CHOLESTEATOMA OF THE TEMPORAL BONE: ISSUES ASSOCIATED WITH ITS ETIOLOGY, DIAGNOSTICS AND TREATMENT (A LITERATURE REVIEW)

This article provides a brief literature review on congenital cholesteatoma of the temporal bone. Existing theories describing the development of this pathology are analysed. The diagnostic criteria of congenital cholesteatoma are presented, along with a comparative analysis of the characteristics of various instrumental research methods used in the verification of this disease. Issues involved with the surgical management of such patients are considered.

A conclusion is made that, due to the rare occurrence of the congenital cholesteatoma of the temporal bone, diverse theories of its etiology, the lack of clear criteria for its diagnostics, this pathology requires further research to elucidate the nature of the disease and identify the risk groups of its occurrence.

Conflict of interest: the authors declare no conflict of interest.

Is transcanal tympanoplasty an appropriate surgical treatment for congenital middle ear cholesteatoma with ossicular involvement?

OBJECTIVES

The aims of this study are to analyze the clinical characteristics of congenital middle ear cholesteatoma (CMC), to evaluate the treatment results according to the types of surgical approach, and to suggest the appropriate surgical treatment option in each stage.

METHODS

One hundred fifteen children (≤15 years old) with surgically confirmed CMC, who underwent surgery at a tertiary hospital during 1994-2012 and were followed up more than 2 years, were enrolled in this study. CMC was classified into four stages by the staging system proposed by Potsic. Clinical characteristics of CMC were analyzed and its association with the rate of residual disease was evaluated.

RESULTS

Based on the location of the lesion, posterior-origin CMCs were detected significantly later (5.5 years old, P = 0.018) and more likely to be in the Stage 3 or 4 (P < 0.001). Residual CMCs were observed in 10 out of 115 cases (8.7%) and were more frequent in the Stage 3 or 4 patients (P = 0.007). However, the rate of the residual disease was not statistically different between anterior- and posterior-origin CMCs (P = 0.101). All 58 cases of CMC in the Stage 1 or 2 were successfully removed by transcanal tympanoplasty with only one residual case (1.7%). In the Stage 3 cases, transcanal tympanoplasty was conducted in 24 out of 29 patients, and the residual disease rate was 12.5% (3 out of 24).

CONCLUSIONS

The early stages of CMC were likely to be diagnosed at younger age, and the early diagnosis seemed to show better surgical outcomes with less invasive techniques. Transcanal tympanoplasty can be an effective surgical option for CMCs in the Stage 3.

Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Objectives

As endoscopic instrumentation, techniques and knowledges have significantly improved recently, endoscopic ear surgery has become increasingly popular. Transcanal endoscopic ear surgery (TEES) can provide better visualization of hidden areas in the middle ear cavity during congenital cholesteatoma removal. We aimed to describe outcomes for TEES for congenital cholesteatoma in a pediatric population.

Methods

Twenty-five children (age, 17 months to 9 years) with congenital cholesteatoma confined to the middle ear underwent TEES by an experienced surgeon; 13 children had been classified as Potsic stage I, seven as stage II, and five as stage III. The mean follow-up period was 24 months. Recurrence of congenital cholesteatoma and surgical complication was observed.

Results

Congenital cholesteatoma can be removed successfully via transcanal endoscopic approach in all patients, and no surgical complications occurred; only one patient with a stage II cholesteatoma showed recurrence during the follow-up visit, and the patient underwent revision surgery. The other patients underwent one-stage operations and showed no cholesteatoma recurrence at their last visits. Two patients underwent second-stage ossicular reconstruction.

Conclusion

Although the follow-up period and number of patients were limited, pediatric congenital cholesteatoma limited to the middle ear cavity could be safely and effectively removed using TEES.

Bilateral congenital cholesteatoma: A case report and review of the literature

OBJECTIVES

Congenital cholesteatoma (CC) occurs less commonly than acquired cholesteatoma (AC), and bilateral CC (BCC) is even more rare with only 38 such cases having been reported in the past 42 years. Because of the rarity of this condition, providers confronted with cases of BCC may find it difficult to treat while balancing complete removal of disease, optimal hearing outcomes, and minimized surgical burden in the pediatric patient. This review alerts physicians that BCC occurs, highlights past presentations and management strategies, describes the considerations in treatment and offers an algorithm helpful in the management of BCC.

METHODS

Review of a single case with extensive review of published reports from 1975 to 2017 pertaining to management of BCC.

RESULTS

A five-year-old boy presented with bilateral congenital cholesteatoma. Tympanomastoidectomy was performed to remove cholesteatoma in the left ear then in the right ear months later. Ossicular chain reconstruction was deferred in both cases. Second look procedures revealed persistent cholesteatoma in both ears. In the descriptions of the 38 published BCC cases, the extent and location of the CC varied widely as did the approach to management. In the 18 cases that had descriptions of surgical management, four had second look procedures. In the 16 reports that described extent of cholesteatoma, 12 had the first of two or more operations on the ear with more extensive cholesteatoma.

CONCLUSIONS

Risks are increased for recidivism/recurrence and hearing impairment in children with BCC compared to children with unilateral CC. We present a novel algorithm for management of BCC that recommends surgery for cholesteatoma removal first in the more severely affected ear and delayed OCR for both ears. Simultaneous surgery may be considered in certain cases.

Lateral Skull Base Approaches in Pediatric Skull Base Surgery

Lateral skull base pathology is rare in children. Awareness of the potential for lateral skull base lesions in children is imperative for timely identification and appropriate management. Some of the common presentations and pathologies shall be presented, as well as a variety of approaches that may be utilized to access the lateral skull base in the pediatric patient. Although the lateral skull base approaches utilized in adults may also be considered for management of pediatric lesions, some special considerations given the small developing anatomy need to be kept in mind.

Cholesteatoma behind an intact tympanic membrane in adult life: congenital or acquired?

Background:

Congenital cholesteatoma occurring behind the tympanic membrane is typically located in the anterior middle ear.

Objective:

To investigate the location, clinical features and treatment of cholesteatomas located behind an intact tympanic membrane in adults.

Methods:

Review of a series of 265 consecutive, new, adult cases of previously untreated cholesteatoma seen by the author over a 22-year period.

Results:

Seventeen (6 per cent) cases were located behind an intact tympanic membrane without any evidence of a retraction pocket of the attic or pars tensa. Ten (59 per cent) of these patients had undergone previous ear surgery and therefore the disease could reasonably be considered to be iatrogenic. The most common presentation was conductive deafness with no other symptoms (71 per cent). In all of the cases, the disease was located in the posterior half of the middle-ear space. The most common surgical management was simple excision of the disease via a tympanotomy. Two cases (12 per cent) developed residual disease.

Conclusion:

The majority of the cases in this series were likely to be acquired cholesteatomas. This type of disease often presents with conductive hearing loss alone.

Clinical Aspects and Surgical Outcomes of Congenital Cholesteatoma in 93 Children: Increasing Trends of Congenital Cholesteatoma from 1997 through 2012

BACKGROUND AND OBJECTIVES

The recent increase in the reported incidence of congenital cholesteatoma (CC) may be secondary to the widespread use of otoendoscopy as well as an increased awareness of these lesions among primary care physicians. However, little research about CC has been conducted in a large group of patients. This study aimed to analyze the clinical characteristics of CC including the annual number of patients, symptoms, age at diagnosis, stage and type of disease, surgical techniques, recurrence, and postoperative complications.

SUBJECTS AND METHODS

Retrospective chart review was performed for patients who met the inclusion criteria between January 1997 and June 2012.

RESULTS

Ninety-three patients underwent surgery for CC. The age at operation ranged from 12 months to 17 years (mean age, 6.1 years). The number of patients was less than 4 per year until 2005, but increased to more than 10 per year since 2008. CC was most commonly reported as an incidental finding (58.1%). The operative procedures included the transcanal myringotomy approach (46.2%), canal wall up mastoidectomy (37.6%), tympanoplasty (8.6%), and canal wall down mastoidectomy (7.5%). The recurrence rate was 20.4% and the complication rate was 12.9%. No patients with stage I CC had complications.

CONCLUSIONS

This study showed that the incidence of CC has recently increased notably. Most patients with stage I and II CC were completely cured by transtympanic surgery, and complication and recurrence rates increased according to the extent of disease. Early detection of CC is important to facilitate minimally invasive surgery and to reduce complication and recurrence rates.

Minimally invasive transcanal myringotomy for pediatric early stage congenital cholesteatoma

OBJECTIVE

Recently, minimally invasive transcanal myringotomy (MITM), which is a useful surgical technique for early stage congenital cholesteatoma (CC) in children, was introduced. The purpose of this study is to evaluate the short-term surgical results of MITM in pediatric early stage CC.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 24 patients who underwent MITM between January 2013 and October 2015.

RESULTS

The patients' ages ranged from 1 to 16 years (mean, 2.6 years). There were 17 male and 7 female patients. The right side (n = 13) was affected twice as often as the left side (n = 11). The most common site was the anterosuperior quadrant (15 cases). The diameter of the CC on axial computed tomography images ranged from 2.8 to 5.7 mm (mean, 3.9 mm). CCs were graded according to Potsic's system: 18 cases were classified as stage I, 3 case as stage II, and 3 cases as stage III. AllCCs except 1 were closed type. In21 patients, the tympanic membrane closed naturally without recurrence. Three patients showed small persistent dry perforation. Natural closure occurred in these patients, who were treated with paper patches.

CONCLUSION

MITM is a simple, effective technique for removing an early stage CC from the middle ear, and it can minimize operative time, length of hospitalization, and postoperative morbidity.

Congenital Cholesteatoma

Congenital cholesteatoma is one of the more common causes of the onset of childhood conductive hearing loss unrelated to middle ear effusion. If undiagnosed, the disease can progress to irreversibly destroy the conductive hearing architecture, as well as the surrounding skull base of the lateral temporal bone. When diagnosed early, the growth can be removed and the conductive hearing mechanism preserved in the vast majority of patients. Because most children are asymptomatic, the burden falls on primary care providers to perform pneumatic otoscopy and visualize all quadrants of the tympanic membrane even in young children who frequently resist attempts to conduct a thorough examination to rule out suspicious lesions. [Pediatr Ann. 2016;45(5):e167-e170.].

Expression of Apoptotic vs Antiapoptotic Proteins in Middle Ear Cholesteatoma

Objectives

To explore the role of antiapoptotic and apoptotic processes in the development of cholesteatoma by investigating the expression of an antiapoptotic (c-FLIP) and apoptotic (p53) protein relative to the expression of a proliferation marker (Ki-67).

Study Design

Basic science study.

Setting

Tertiary referral center.

Subjects and Methods

An immunohistochemical investigation was performed on 35 cholesteatoma specimens (21 acquired, 14 congenital) and 10 normal retroauricular skins to evaluate the expression of c-FLIP, p53, and Ki-67. The expression rate of each marker was measured to assess the difference between retroauricular skin and cholesteatoma, as well as between congenital and acquired cholesteatoma.

Results

c-FLIP expression was significantly higher in the cholesteatoma specimens than in retroauricular skin ( P < .05), while the expression of p53 did not significantly differ between the two. Ki-67 expression in cholesteatoma was significantly higher than in retroauricular skin ( P < .001). The c-FLIP expression rate was positively correlated with that of Ki-67 ( r = 0.47, P = .001), and there was no significant correlation between the expression level of p53 and that of Ki-67 ( r = 0.152, P = .319). In addition, no differences in c-FLIP, p53, and Ki-67 expression rates were evident between congenital and acquired cholesteatoma.

Conclusions

The upregulation of c-FLIP together with unchanged p53 suggests an altered equilibrium between apoptosis and antiapoptosis, favoring antiapoptosis, and may play a role in the pathogenesis of cholesteatoma.

Comparative analysis of the expression of E-cadherin, β-catenin, and β1 integrin in congenital and acquired cholesteatoma

E-cadherin, β-catenin, and β1 integrin are important cell adhesion molecules to maintain epithelial structure and function. We investigated the expression of these cell adhesion molecules in cholesteatomas to understand the role of cell-cell and cell-extracellular matrix interaction in cholesteatomas. An immunohistochemical investigation was carried out on 35 cholesteatoma tissue samples (14 congenital, 21 acquired cholesteatomas) and 10 normal retroauricular skin (RAS) tissues which are obtained during middle ear surgery. The expression rate was measured to find out differences between retroauricular skin and cholesteatoma, as well as between congenital and acquired cholesteatoma. E-cadherin expression rate was significantly lower in the cholesteatoma (spinous layer 88.7 ± 17.9 %, granular layer 54.6 ± 22.6 %) than in the RAS (100 %, 74.4 ± 7.4 %) and in the acquired (83.3 ± 19.4 %, 48.1 ± 22.9 %) than in the congenital (96.7 ± 12.0 %, 64.4 ± 18.8 %). β-catenin expression rate was significantly lower in the cholesteatoma (spinous layer 84.1 ± 17.2 %, granular layer 28.7 ± 30.8 %) than in the RAS (100 %, 75.9 ± 6.1 %) and in the acquired (78.1 ± 17.0 %, 17.1 ± 22.3 %) than in the congenital (93.2 ± 13.5 %, 46.1 ± 34.2 %). The expression pattern of β-catenin is similar to that of E-cadherin. In β1 integrin, there was no significant difference of the expression rate between RAS and cholesteatoma, as well as between congenital and acquired cholesteatoma. In conclusion, the expression of E-cadherin and β-catenin is reduced in cholesteatoma, and the reduction is more pronounced in acquired cholesteatoma than in congenital cholesteatoma. Acquired cholesteatomas showed more aggressive characteristics than congenital cholesteatomas in terms of cell-cell adhesion.

The difference in congenital cholesteatoma CT findings based on the type of mass

OBJECTIVE

A retrospective assessment of differences in congenital cholesteatoma CT findings with a focus on type of cholesteatoma mass.

MATERIALS AND METHODS

The medical records and CT images of 14 patients with congenital cholesteatomas in the middle ear who underwent surgery at our institution between January 2009 and July 2014 were reviewed. Cholesteatomas were classified as closed type, open type, or mixed type based on intraoperative findings. The CT findings including cholesteatoma size, location, and shape were retrospectively reviewed.

RESULTS

Eight patients had closed type cholesteatomas, four had mixed type, and two had open type. The mean size of all cholesteatomas was 5.1mm. None of the cholesteatoma types indicated a tendency towards a certain location. The round shape was observed more frequently in closed type cholesteatomas than in other types (closed: 5/8; mixed: 1/4; open: 0/2). Two large closed type cholseteatomas and two mixed type cholesteatomas exhibited a constricted shape. Both of the open type cholesteatomas displayed an irregular shape.

CONCLUSION

Small closed type congenital cholesteatomas were typically observed as round shaped lesions, but large closed type cholesteatomas and other type cholesteatomas tended to display shapes other than round.

Open vs closed type congenital cholesteatoma of the middle ear: two distinct entities or two aspects of the same phenomenon?

OBJECTIVE

The clinical features and surgical results of "closed type" versus "open type" congenital cholesteatoma were compared in order to analyse the differences between the two forms; whether the morphology of the disease may have a role in the staging systems has been also evaluated.

PATIENTS AND METHODS

We reviewed retrospectively 95 patients (96 ears) who underwent surgery for congenital cholesteatoma over a 15-year period focusing on the clinical differences between open and closed type congenital cholesteatoma.

RESULTS

Seventy-one patients (74%) had a closed-type and 25 (26%) an open type congenital cholesteatoma. Our study confirmed the higher prevalence of the closed type, as well as, a younger age at initial diagnosis compared with the open type congenital cholesteatoma. Other differences between the two forms were: modality of diagnosis (pathognomonic otoscopy in 100% of the closed type and in 40% of the open type), positive history for otitis media with effusion (51.4% in closed type vs 20% in open type), involvement of the tympanic membrane quadrants (anterior quadrants were more frequently involved in the closed forms, whereas posterior quadrants were more frequently involved in the open forms), disease extension and aggressiveness. A residual cholesteatoma was found in 6 out of the 71 patients (8.4%) with a closed type congenital cholesteatoma and in 10 out of the 25 patients (40%) with an open type congenital cholesteatoma. After adjusting for potential confounders, open-type congenital cholesteatoma was significantly associated with residual cholesteatoma compared to the closed-type (odds ratio [OR] 7.39, 95% confidence interval [CI] 1.10-49.77, p=0.03).

CONCLUSION

This study confirmed that the open congenital cholesteatoma has global clinical features that are uniquely different from the classical closed form. These differences could reflect a distinct pathogenesis, but there is no proof of this to date. The classification of the congenital cholesteatoma could be further refined by adding the morphologic type of the disease.

Congenital middle ear cholesteatoma: experience from 26 surgical cases

OBJECTIVES

We analyzed the clinical features and surgical techniques used in cases of childhood congenital cholesteatoma of the middle ear.

METHODS

We studied 26 patients (26 ears) who underwent surgery for congenital cholesteatoma between January 1998 and December 2009, focusing on the location and type of cholesteatoma, the surgical procedures involved, and the results obtained. Patients with prior otologic procedures were excluded. A 4-stage system was used to grade the cholesteatomas.

RESULTS

The frequency of posterior-quadrant involvement and open-type cholesteatomas increased in the more advanced stages. Second-look operations were performed in 60% of stage III and 75% of stage IV cases; and residual cholesteatomas were found in 20% of stage III and 75% of stage IV cases. Of the cases evaluated both before and after the operation, 100% of stage I and II cases, 86% of stage III cases, and 50% of stage IV cases showed improvement in hearing function.

CONCLUSIONS

The staging system is relatively simple, while accurately reflecting clinical results. However, there are many differences between the anterior and posterior types of congenital cholesteatomas in surgical approach and postoperative progression that are not reflected in the classification systems and require further study. In addition, we reviewed the surgical procedures involved in anterior-quadrant cases, and propose a modified surgical procedure.

Congenital cholesteatoma in identical twins

OBJECTIVE

We present an extremely rare case of congenital cholesteatoma in identical twins.

METHOD

Case report of congenital cholesteatoma in identical twins, and a literature review, are presented.

RESULTS

Both cases presented to the ENT out-patient clinic, but with different clinical pictures. Both were managed surgically.

CONCLUSION

Congenital cholesteatoma presents as a whitish mass in the middle ear, with an intact tympanic membrane. It is a rare entity comprising between 3.7 and 24 per cent of total cholesteatoma cases. The key to its diagnosis is the absence of previous ear infection, ear surgery and local trauma. To our best knowledge, this paper represents the first report in the world literature of congenital cholesteatoma in identical twins.

Congenital cholesteatoma: clinical features and growth patterns

OBJECTIVE

The clinical features and patterns of growth, relative to age, were examined in patients with congenital cholesteatoma to investigate disease progression and site of origin.

PATIENTS AND METHODS

We retrospectively reviewed 72 children younger than 15 years with intraoperatively confirmed congenital cholesteatoma diagnosed using the inclusion criteria of Levenson et al. Patient demographics, history, and otoscopic and operative findings were evaluated. Correlation between mass volumetric and operation age was analyzed in patients with closed-type masses. Parameters of disease extent of middle ear quadrant, ossicular erosion, attic involvement, invasion of the mastoid cavity, and type of mass were assessed relative to age at operation.

RESULTS

Mean patient age was 63.1 months (range, 20-179 months), with 51 patients (70.8%) being asymptomatic and diagnosed incidentally. Nineteen patients (26.4%) had closed-type cystic masses, and 53 (73.6%) had open-type lesions. The volume of closed-type masses was linearly correlated with age at operation. Logistic regression showed that increased age at operation was associated with a lower proportion of anterosuperior quadrant lesions, resulting in uncertainty about the site of origin. The possibility of open-type masses also increased according to age at operation.

CONCLUSION

Congenital cholesteatoma shows growth and extension over time. Early detection and intervention are necessary to avoid advanced disease.

Open-type congenital cholesteatoma: differential diagnosis for conductive hearing loss with a normal tympanic membrane

CONCLUSION

In patients with progressive conductive hearing loss and a normal tympanic membrane (TM), and with soft tissue density in the middle ear cavity (MEC) on temporal bone computed tomography (TBCT) scan, open-type congenital cholesteatoma (OCC) should be highly suspected and a proper surgical plan that includes mastoid exploration and second-stage operation is required.

OBJECTIVE

The clinical presentation of OCC is very similar to congenital ossicular anomaly (COA) presenting with a conductive hearing loss with intact TM. Therefore, it is challenging to make a correct preoperative diagnosis in patients with OCC. We evaluated the clinical characteristics of OCC compared with those of COA to find diagnostic clues useful in diagnosis of OCC.

METHODS

The medical records of 12 patients with surgically proven OCC and 14 patients with surgically proven COA were reviewed for demographic data, otologic history, preoperative TBCT findings, intraoperative findings, and pre- and postoperative audiologic data.

RESULTS

There was no difference between OCC and COA based on demographic data, preoperative hearing, and ossicular status on TBCT. However, the presence of progressive hearing loss, soft tissue density in the MEC on TBCT scan, and the need for mastoid surgery and second-stage operation were significantly more frequent in OCC patients.

Stage progression of congenital cholesteatoma in children

This study aimed to investigate the most prevalent stage in each age-group of children with congenital cholesteatoma (CC) and verify the correlation between the stage and the age of the patients for the type of CC ("closed" keratotic cyst and "open" infiltrative types). Patients diagnosed with CC between 2004 and 2009 (n = 156; 116 boys and 40 girls; mean age, 5 years and 5 months; range, 12 months-16 years and 7 months) were enrolled retrospectively. Assessment of stage and type of CC was performed with preoperative high-resolution temporal bone computed tomography and intraoperative findings. The stage of CC was determined using Potsic's staging system classified into four stages according to ossicular involvement and mastoid extension. The patients consisted of groups divided on the basis of a 2-year interval. The prevalence of stage I began to decline from the age-group of 1-2 years. In contrast, the prevalence of stages III increased from the age-group of 3-4 years and that of stage IV from the age-group 5-6 years. The prevalence of "open" infiltrative type CC increased from approximately the age of 7 years, thus showing some correlation with age but not with stage. The prevalence of CC with the advanced stage increased since the age of 2 years. Therefore, the importance of early diagnosis and treatment of CC should be more emphasized.

Clinical experience of 71 cases of congenital middle ear cholesteatoma

CONCLUSIONS

As congenital middle ear cholesteatoma (CMC) is a different disease entity from acquired cholesteatoma, early diagnosis is important for good treatment results. Preoperative computed tomography (CT) imaging is a useful modality for both evaluation of the extent of the disease and selection of appropriate surgical methods. Some modification should be considered based on the findings of the actual operative field for complete removal of CMC.

OBJECTIVES

To present the results of surgical treatment of 71 cases of CMC and investigate the applicability of preoperative CT for the treatment of CMC.

PATIENTS AND METHODS

A retrospective study over an 11-year period was performed. The presenting symptoms, tympanic membrane findings, surgical findings, methods, and results were investigated retrospectively.

RESULTS

CMC was found incidentally in 38 cases (53.5%). A whitish mass medial to the tympanic membrane was observed in 62 cases (87%). Postoperative air-bone gap changes were not statistically significant. There was no predominance of localized lesions of the middle ear. The recurrence rate was 9.9% (seven cases), and higher in open type. Staging by CT and surgical staging matched in 70.4%. Positive predictive value for mastoid involvement of CT staging was 72.7%, with sensitivity and specificity of 68.6% and 87.5%, respectively.

Mastoid subperiosteal abscess as a first sign of unnoticed cholesteatoma in children

AIM

To present children who underwent mastoidectomy for congenital cholesteatoma presented as a subperiosteal abscess.

RESULTS

All seven children (age range 7-14 years, six boys) presented with retroauricular swelling, erythema and fluctuation in the mastoid area, and one child also had a mastoid-cutaneous fistula. Five children had otorrhoea, while the other two had normal-appearing tympanic membranes. None of the children had a history of middle ear disease. Four children were treated with antibiotics for a recent episode of otitis media prior to admission. The main findings at surgery were pus, granulations and erosion of the mastoid cortex. Pseudomonas aeruginosa and Proteus sp. were isolated from the abscess in two patients, and the other five cultures were negative. All the patients demonstrated some degree of hearing impairment after surgery.

CONCLUSION

Surgical eradication of a mastoid SA in older children is essential as it may be the first indication of an underlying CC.

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.

Locations of congenital cholesteatoma in the middle ear in Japanese patients

OBJECTIVES

To present clinical features of congenital cholesteatoma treated in our institute and to investigate the locations of congenital cholesteatoma in the middle ear of Japanese patients to verify its pathogeneses.

PATIENTS AND METHODS

A retrospective chart review of patients in our institute and a review of articles on congenital cholesteatoma reported by Japanese researchers. Charts of the 25 patients with congenital cholesteatoma treated in our institute were reviewed regarding symptoms, locations of cholesteatoma in the middle ear, and ossicular anomalies. The same points were investigated in the 71 cases in the Japanese literature.

RESULTS

Unlike Westerners, more than half of the Japanese cases had posterior-type cholesteatomas, any parts of which did not exist anteriorly beyond the handle of the malleus. Congenital ossicular anomalies, absence of the long process of the incus, and/or the superior structure of the stapes were seen with a high rate in the Japanese patients.

CONCLUSIONS

These two findings of the posterior location of cholesteatomas in the middle ear and the high incidence of congenital ossicular anomalies in the Japanese patients suggested that there should be some racial difference in pathogenesis of congenital cholesteatoma. The pathogenesis of congenital cholesteatoma cannot be adequately explained by only one theory alone. It is more appropriate to explain the pathogenesis by using an aggregation of theories.

Etiopathogenesis of cholesteatoma

Cholesteatoma is a destructive lesion of the temporal bone that gradually expands and causes complications by erosion of the adjacent bony structures. Bone resorption can result in destruction of the ossicular chain and otic capsule with consecutive hearing loss, vestibular dysfunction, facial paralysis and intracranial complications. Surgery is the only treatment of choice. The etiopathogenesis of cholesteatoma, however, is still controversial. This review was designed to understand the reasons for these disparities and to reduce or eliminate them. Future studies focused on developmental, epidemiological, hormonal and genetic factors as well as on treatment are likely to contribute to further understanding of cholesteatoma pathogenesis.

Congenital middle ear cholesteatoma: need for early recognition--role of computed tomography scan

BACKGROUND

Congenital cholesteatoma (CC) of middle ear is a rare entity that may go undiagnosed for years. Patients with CC who are diagnosed at a later stage of disease have poor outcome. There is controversy regarding the best way to delineate CC preoperatively. More specifically, the need to obtain preoperative computed tomography (CT) scan in all cases of CC is debated.

OBJECTIVES

This study was conducted to determine factors that may influence the outcome of surgery in CC as well as the value of obtaining preoperative CT scan in CC.

METHOD

A retrospective chart review of all patients with a diagnosis of middle ear cholesteatoma operated on between 1994 and 2000 was carried out. Patients with CC were identified using the criteria proposed by Levenson and Parisier.

RESULTS

Thirty-five patients with CC were identified. In 30 (86%) patients, the diagnosis was made during ear examination and the remaining five (14%) patients were diagnosed during myringotomies. Preoperative CT scans were available in 17 patients. The findings on CT scans were classified into four categories based on the ossicular chain and mastoid septae status as well as the presence or absence of middle ear and mastoid opacification. Intraoperatively, 22 (63%) patients were found to have extensive cholesteatomas with or without extension beyond the mesotympanum. Eleven of these 22 patients had ossicular chain erosion and five were later found to have recidivism. Preoperative CT scan accurately predicted the extent of the cholesteatoma seen during surgery in 14/17 (82%) and ossicular chain status in 15/17 (88%), while micro-otoscopy predicted the extent of the existing pathology in only 10/35 (29%). Intraoperative location and size of CC influenced the type of surgical approach, status of ossicular chain, postoperative hearing level and rate of recidivism.

CONCLUSIONS

Children still present with late stage CC. Micro-otoscopy is insufficient to clearly delineate the extension of CC. Preoperative CT scan is essential in defining the extent of existing pathology. The intraoperative CC size and location influence the outcome of surgery. Early surgical intervention and long-term follow-up are essential.

Congenital middle ear cholesteatomas in children: our experience in 34 cases

OBJECTIVES

To evaluate clinical data, extensions, residual disease rate, and functional results in cases of congenital cholesteatoma in pediatric patients compared with cases of acquired forms.

STUDY DESIGN AND SETTING

In a retrospective study conducted at a single tertiary care center over a decade, 34 congenital cholesteatomas (mean patient age, 6.6 years) isolated from a series of 215 cholesteatomas in children were treated surgically and followed up for an average of 83 months. Surgical treatment consisted of the closed technique (CT), open technique tympanoplasty in CT [TOT], radical mastoidectomy (RM), or Rambo's technique. The main outcome measures were surgical findings, residual lesion rate, and hearing assessment.

RESULTS

The first surgical procedure was CT in 85.3%, TOT in 8.8%, RM in 2.9%, and Rambo's technique in 2.9% of patients. Two, 3, and 4 operations were necessary in 76.5%, 11.4%, and 11.4% of children, respectively. Residual lesions were observed in 34.6% of those multi-operated patients (7 CT and 2 TOT), 24.1% in those treated with CT, and 29.2% in those treated with CT with a planned second look. Mean postoperative pure tone average and air-bone gap were 26 and 21 dB, respectively. A speech reception threshold of less than 30 dB HL was achieved in 66% of patients. A total of 26 ossiculoplasties had to be performed (8 partial and 18 total); the mean postoperative air-bone gap was lower after the former (15 dB) than after the latter (22 dB). A high-frequency pure-tone hearing loss of more than 10 dB was uncommon (5.8%). Unsurprisingly, the residual lesion rate seems to be higher for congenital than for acquired cholesteatomas, but hearing results are significantly better.

CONCLUSION

In most cases, staged CT appears to be the best technique to treat these lesions, which often develop in a well-pneumatized mastoid.

The clinical evaluations of pathophysiology for congenital middle ear cholesteatoma

PURPOSE

Congenital middle ear cholesteatoma (CMEC) is less common than the acquired variety. Many theories have been put forward to explain the pathophysiology of CMEC; however, none of them have been convincingly proven thus far. This clinical study was performed to analyze the case reviews; assess the characteristic features of CMEC, and evaluate the correlation between those features and the pathophysiology of CMEC.

METHODS

The medical records of patients who underwent otologic procedures at the hospitals of the Catholic University, Seoul, Korea, from January 1993 to November 1998 have been reviewed.

RESULTS

Of the 14 patients, 3 had cystic lesions isolated to the anterosuperior quadrant of the mesotympanum. The lesions were easy to remove and did not affect the patients' hearing. Eleven patients had more extensive disease with posterior mesotympanum involvement; the lesions were large, were often too extensive to indicate a formative site, and caused ossicular damage.

CONCLUSION

CMEC manifests in 2 distinctive forms according to the formation site. This distinctive formation site suggests that the pathophysiology of posterior lesions may be different from that of anterior ones. For early diagnosis of CMEC, a screening program should be established for children to prevent more extensive disease.

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.

The epidermoid formation and its affinity to congenital cholesteatoma

The epidermoid formation was reinvestigated in stained step sections of foetal and neonatal temporal bones to assess its relationship to congenital cholesteatoma. Epidermoid formations were found in 88 of 211 temporal bones (42%) at from 12 weeks gestation to 6 months post-partum. The site was usually near the roof of the anterolateral epitympanum at an average of 389 microns anterior to the anterior edge of the tympanic membrane. Seven epidermoid formations however, were sited on the medial anterosuperior tympanic membrane surface. The mean surface diameter of epidermoid formations was 242 microns. Some were greater than 1500 microns, which approaches the size of small congenital cholesteatomas. They are often in proximity to a developmental epithelial fold which could close off to produce a cyst. These features support the concept that the epidermoid formation is a precursor of the small anterosuperior congenital cholesteatoma.

Mastoid pneumatization in children with congenital cholesteatoma: an aspect of the formation of open-type and closed-type cholesteatoma

OBJECTIVES

To clarify mastoid pneumatization in children with congenital cholesteatoma and compare their clinical characteristics.

STUDY DESIGN

The mastoid pneumatization of 34 children with congenital middle ear cholesteatoma, of 34 age-matched children with unilateral acquired cholesteatoma, and of 17 age-matched control children without middle ear diseases was studied.

METHODS

The sizes of the mastoid cells were measured from 1.5-mm sliced semiaxial sections of a temporal bone computed tomography scan. The sum of the two areas from the two images, one showing the lateral semicircular canal and the other, 3 mm below this, was defined as the area of the pneumatized mastoid cells.

RESULTS

The mastoid cells in ears of children with congenital cholesteatoma were poorly pneumatized compared with those of control children without middle ear diseases, but were better pneumatized compared with those of children with acquired cholesteatoma. In children with congenital cholesteatoma, the degree of pneumatization in the cholesteatoma side was significantly poorer than that in the opposite side. A well-pneumatized mastoid was seen in ears with no episode of otitis media, in ears with the open-type cholesteatoma, and in ears with ossicular anomalies.

CONCLUSIONS

The presence of cholesteatoma matrix accelerates the inflammatory response when middle ear infections occur, and this probably leads to the suppression of mastoid pneumatization. The authors also propose the hypothesis that cholesteatoma in most congenital cases is the open type, and that middle ear inflammation may contribute to the formation of cystic and closed-type cholesteatoma.

Cholesteatoma in children

Cholesteatoma in children falls into two main categories: congenital and acquired. Though they present in different ways, both are potentially destructive lesions that are managed surgically. The goals of treatment are to eradicate keratinizing squamous epithelium from the temporal bone and to preserve or restore hearing. These children need to be followed closely by the pediatric otolaryngologist to prevent and control recurrent disease.

Bilateral congenital cholesteatoma

We report a case of bilateral congenital cholesteatoma in a 6-year-old boy. Cholesteatoma was present in both ears around the tympanic isthmus (the only open passage from the tympanic cavity to the attic), extending to behind the horizontal portion of the facial nerve. This patient underwent a total of three canal wall up operations on each side to remove the cholesteatoma completely and improve hearing. This case fulfills the criteria proposed by Derlacki and Clemis in 1965. Bilateral congenital cholesteatoma is a rare condition, but the incidence of congenital cholesteatoma in children has increased recently for the following reasons: Reassessment of the criteria, the introduction of computed tomography, and increased awareness of congenital cholesteatoma. When operating on patients with bilateral cholesteatoma, the best method for preservation of hearing should be chosen. We discuss these problems in the present report.

Congenital aural cholesteatoma: results of surgery in 60 cases

From 1978 to 1993, 59 patients (60 ears) with congenital middle ear cholesteatoma were treated at the House Ear Clinic. The median patient age at presentation was 5 years, and the period of postoperative follow-up was 4.8 years. An intact canal wall was maintained in 58 of 60 cases and a closed middle ear space in all cases. In 12 operations, lateral graft tympanoplasty eradicated the cholesteatoma in one stage; 32 patients required a second-stage surgery to rule out recurrence, and the remaining 16 cases required three or more operations to eradicate disease and reconstruct the hearing mechanism. Thirty-five (63%) of 56 patients had a postoperative air-conduction threshold pure-tone average (PTA) within 10 dB of the best bone-conduction PTA; 91% were within 20 dB. Average speech reception threshold improved from 32 dB hearing level (HL) preoperatively to 20 dB HL postoperatively.

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.