Congenital aural cholesteatoma: results of surgery in 60 cases

Outcomes of Endoscopic Congenital Cholesteatoma Removal in South Korea

Importance

Transcanal endoscopic ear surgery (TEES) provides minimally invasive transcanal access to the middle ear and improves middle ear visibility during cholesteatoma resection. However, the literature on outcomes following TEES alone for the removal of congenital cholesteatoma (CC) is lacking and limited to small series.

Objective

To assess outcomes of TEES for CC limited to the middle ear and/or mastoid antrum and to explore the risk factors associated with recidivism (ie, recurrent and/or residual cholesteatoma).

Design, Setting, and Participants

This cohort study evaluated retrospective, multicenter data for 271 children with CC who underwent TEES at 9 tertiary referral hospitals in South Korea between January 1, 2013, and December 31, 2021, and had a follow-up of at least 6 months after surgery.

Main Outcomes and Measures

Outcomes included the incidence of residual cholesteatoma and audiometric data after TEES. A multivariable analysis using Cox proportional hazards regression models was used to assess associations between cholesteatoma characteristics and recidivism, with hazard ratios (HRs) and 95% CIs reported.

Results

Of the 271 patients (mean [SD] age, 3.5 [2.9] years; 194 [71.6%] boys, 77 [28.4%] girls), 190 had Potsic stage I CC (70.1%), 21 (7.7%) had stage II, 57 (21.0%) had stage III, and 3 (1.1%) had stage IV. Thirty-six patients (13.3%) with residual cholesteatoma were found, including 15 (7.9%) with Potsic stage I, 3 (14.3%) with stage II, and 18 (31.6%) with stage III. In the multivariable analysis, invasion of the malleus (HR, 2.257; 95% CI, 1.074-4.743) and posterosuperior quadrant location (HR, 3.078; 95% CI, 1.540-6.151) were associated with the incidence of recidivism. Overall, hearing loss (>25 dB on auditory behavioral test or >30 dB of auditory evoked responses) decreased from 24.4% to 17.7% after TEES.

Conclusions and Relevance

This cohort study involved the largest known population to date of CC removed by TEES. The findings suggest that TEES may be feasible and effective for the removal of CC limited to the middle ear and/or mastoid antrum in children.

The Endoscopic Management of Congenital Cholesteatoma

Congenital cholesteatoma is a rare, primarily pediatric disease that presents in otherwise healthy ears. Typically, this disease is found in a well-defined sac in the middle ear, making it particularly suited for removal through transcanal endoscopic ear surgery. This article reviews the ways in which endoscopy can be applied to the surgical management of congenital cholesteatoma and provides a guide based on congenital cholesteatoma stage and extent. Outcomes have shown similar rates of residual disease in total endoscopic ear surgery compared with operative microscopy.

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.

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.

Congenital Cholesteatoma in Adults-Interesting Presentations and Management

To report a series of adult patients diagnosed with congenital cholesteatoma (CC) with respect to symptoms, different varieties of presentation, surgical findings and approach used, complications and the postoperative results. A retrospective chart review of adult cases of CC who were treated in the period from January 2014-2017 was carried out in a tertiary care center. Levenson's criteria were used for diagnosis. Diagnosis was confirmed by imaging and intraoperatively. Postoperative results and complications were also analyzed. Six adult cases of CC were studied with a mean follow up of 10 months. Interesting presentations included otitis media with effusion, non-resolving facial nerve palsy, post aural discharge and meningitis. It included 3 cases of petrous apex cholesteatoma, 2 patients with cholesteatoma involving both the middle ear and mastoid and 1 patient with mastoid cholesteatoma. The operative procedures included canal wall up mastoidectomy (1 patient), atticotomy (1 patient), canal wall down mastoidectomy (1 patient), translabyrinthine and transotic excision of mass with blind sac closure (2 patients) and partial labyrinthectomy (1 patient). Complications encountered during surgery were cerebrospinal fluid leak and worsening of hearing in 2 patients and 1 patient respectively. CC can have variety of interesting presentations in adult population and they may or may not have the classical white mass behind the tympanic membrane. Appropriate individualized surgical planning and intervention gives good results.

Retrograde approach and soft wall reconstruction in surgery for congenital cholesteatoma

CONCLUSIONS

A retrograde approach and soft wall reconstruction is thought to be an effective surgical approach for patients with good eustachian tube function and good mastoid development such as in congenital cholesteatoma.

OBJECTIVE

To analyze the usefulness of a retrograde approach and soft wall reconstructive surgical treatment for congenital cholesteatoma.

METHODS

Data from 24 patients (25 ears in total) who underwent surgical intervention for congenital cholesteatoma at Kanazawa University Hospital between January 2001 and July 2011 were retrospectively reviewed. We had used a retrograde approach for congenital cholesteatomas in which bone is removed as necessary in a retrograde manner from the external auditory canal side. The extent of bone removal was determined according to the location of the cholesteatoma. The posterior walls of the external auditory canals were reconstructed with soft tissue using temporal fascia.

RESULTS

Good preoperative mastoid development was identified in 83% of the patients. Postoperative recurrence was seen in 1 of 25 ears. Analysis of pre- and postoperative hearing ability showed significant improvement in both pure tone audiogram air conduction and pure tone audiogram air-bone gaps.

Acquired cholesteatoma in children following congenital cholesteatoma surgery

OBJECTIVES

To determine the incidence of severe atelectatic otitis media and acquired cholesteatoma (AC) in children treated for congenital cholesteatoma (CC).

METHODS

Retrospective chart review of 15 children who underwent primary surgery for CC over a 15 year period by a single surgeon.

RESULTS

The mean postoperative follow up was 3.1 years. Significant tympanic retraction occurred in 6 children, included a retraction pocket that required T-tube insertion (3), and AC requiring tympanomastoid surgery (3). There was no complication related to retraction pocket in 9 children however 2 developed residual disease. In comparing the two groups, those with and without subsequent significant tympanic retraction, both groups had similar gender, age, extent of CC (median Potsic grade of 2), bone erosion, and surgical technique. Differences were noted in air-bone gap at presentation (PTA 32.4 and 17.25), otitis media with effusion in the contralateral ear (3/6 and 1/9), smaller mastoid volume ratio compared with the contralateral ear (0.74 and 1.21), and longer average timing for second surgery (14.8 months and 8 months).

CONCLUSIONS

Acquired middle ear disease, including cholesteatoma, can follow surgical removal of CC, and long term follow up of all patients is required. Factors at initial evaluation indicative of risk of AC include a significant air-bone gap, otitis media with effusion in the contralateral ear and a smaller mastoid cavity ratio. The use of composite grafts at the time of CC surgery should be considered. Additionally, our findings suggest that the mastoid volume plays a causative role in the development of AC.

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.

Congenital Cholesteatoma of the Mastoid Temporal Bone

OBJECTIVE

Congenital mastoid cholesteatomas are rare lesions of the temporal bone. The clinical presentation of these lesions is variable, making them difficult to identify preoperatively. We evaluated our series of mastoid congenital cholesteatomas (CCs) in an effort to better define the clinical presentation, imaging characteristics, and surgical challenges specific to this lesion.

STUDY DESIGN

Retrospective chart and radiologic study review.

METHODS

The medical records of patients with the diagnosis of mastoid CC on radiologic imaging over a 15-year period were reviewed. All had surgical and pathologic confirmation. Eight patients underwent preoperative computed tomography (CT). Six also underwent magnetic resonance (MR) scanning. Demographic information, clinical presentation, imaging results, and operative findings were recorded.

RESULTS

Nine patients with the diagnosis of mastoid CC satisfying the inclusion criteria were found. Clinical findings were variable, with the most common presentation being an incidental finding. Imaging findings were more uniform. All CT scans demonstrated an expansile, well-circumscribed mass centered within the mastoid portion of the temporal bone. All MR scans showed a well-circumscribed mass with high intensity on T2-weighted images with precontrasted T1 sequences showing the lesion to be isointense or slightly hyperintense to cerebrospinal fluid (CSF). Operative findings included lateral mastoid cortex erosion, sigmoid sinus exposure, ossicular destruction, facial nerve exposure, and associated postauricular abscess. Management of these lesions is reviewed.

CONCLUSION

Congenital mastoid cholesteatomas have a variable and nonspecific clinical presentation. Surgical challenges arise from the indolent nature of this clinical entity, which belies the extent of otologic involvement. Imaging with CT and magnetic resonance imaging are diagnostic, defines the extent of these lesions, and facilitates preoperative surgical planning.

Congenital Cholesteatoma: Risk Factors for Residual Disease and Retraction Pockets-A Report on 117 Cases

OBJECTIVES

To define predictors of residuals and retraction pockets (RP) in children operated on for congenital cholesteatoma (CC).

DESIGN AND SETTING

Retrospective review (1996-2005), academic center.

PATIENTS

One hundred seventeen patients treated for CC corresponding to modified Derlacki's criteria were included (median age, 6.5 yr). No case of RP at time of diagnosis, with a mean follow-up of 2.5 years after last surgery.

MAIN OUTCOME MEASURES

Clinical and surgical data influencing outcome. Multivariate analysis.

RESULTS

Two groups were defined after CC removal: group I (12 cases), no second look required and no case of subsequent re-intervention; group II (105 cases), planned second look always performed (mean delay, 12.1 mo), no difference of sex ratio (M/F = 2). Group I patients were younger than in group II (3.3 vs. 5.9 yr, P < .001). All of them had a normal contralateral eardrum and a disclosure of CC by routine examination (vs. 19% in group II, P < .001). In group I, the mass occupied one or two anterior quadrants (41.6% and 58.4%, respectively) versus more than two quadrants in 46.6% in group II. Residuals and RP rates were 41% and 15%, respectively (only in group II). Predictors for residuals were atticotomy (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.3-6.7) and destruction of stapes (OR 4.3, 95% CI 1.7-10.5). Predictors for RP were eustachian tube extension (OR 6.8, 95% CI 1.7-26.8) and nonreconstructed atticotomy (OR 5.9, 95% CI 1.1-30.9).

CONCLUSIONS

Young children with small CC had no recurrences. Residuals were more frequent in case of atticotomy and stapes destruction. RP occurred especially in cases of eustachian tube extension and if cartilage tympanoplasty was not performed. Tympanic and canal wall reinforcement should be considered in extensive CC.

Congenital cholesteatoma: theories, facts, and 53 patients

Congenital cholesteatoma has a different pathophysiology than acquired cholesteatoma in that these patients rarely have eustachian tube dysfunction. This likely accounts for their reasonable preoperative hearing and their lack of complications or recurrences postoperatively. The most important factor is early detection. Treatment remains surgical removal.

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.

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.

Congenital cholesteatomas in the tympanic membrane

The etiology of congenital middle ear (ME) cholesteatomas is unclear. One etiologic possibility of ME cholesteatoma may be progression of a congenital tympanic membrane (TM) cholesteatoma. We recently have encountered three cases of congenital tympanic membrane cholesteatoma. Each child, ages 1, 3, and 14 years, presented with cholesteatoma of the tympanic membrane extending into the middle ear. These children have not had previous otologic surgery including myringotomy, nor had they had repeated middle ear infections, perforation, or trauma. Neither the 3-year-old nor 14-year-old child complained of hearing loss. Audiograms demonstrated only a mild conductive loss. Each child underwent excision with tympanoplasty. Although the middle ear component of the cholesteatoma was always more extensive than the pearl seen, the point of attachment was the TM and not the middle ear. This demonstrates one possible source for congenital cholesteatomas.