External auditory canal reconstruction using a novel mastoidoplasty technique during canal wall down mastoidectomy: how I do it

BACKGROUND

While mastoid obliteration techniques have received much attention in decreasing the disadvantages associated with the resultant mastoid cavity from canal wall down procedures, techniques for an anatomically normal looking ear canal reconstruction to increase the feasibility of hearing aid fitting are less commonly discussed as an alternative.

METHODS

Our mastoidoplasty technique basically utilises an inferiorly based periosteal flap with or without temporalis muscles and fascia to obliterate the epitympanum and reconstruct the external auditory canal (EAC). Stay sutures are used to keep them in place. For larger cavities, demineralized bone matrix (DBM) is used to obliterate the mastoid cavity and support the neo-EAC.

CONCLUSIONS

The concept of our mastoidoplasty potentially provides a very useful alternative in recreating a near normal ear canal anatomy avoiding cavity problems as well as facilitating hearing aid fitting with canal type hearing aids after canal wall down mastoidectomy.

Comparative Study of Various Techniques of Mastoid Obliteration following Canal Wall Down Mastoidectomy

The primary objective of mastoid obliteration is the eradication of the disease and prevention of its recurrence. We intend to evaluate the impact of mastoid obliteration using autologous materials on the achievement of a dry mastoid bowl and frequency of maintenance care and hearing outcome of the operated ear. This was a hospital-based, non - randomized, prospective study. The study was performed over a period of 2 years. The study was performed in the Department of ENT of a tertiary care teaching hospital. Patients of chronic otitis media - squamosal type underwent canal wall down mastoidectomy and patients were divided into 2 groups of obliterated and non-obliterated. The canal wall obliterated patients were further compared in 3 groups based on the technique of mastoid obliteration used - bone dust, musculo-periosteal flap and cartilage graft. 6 months post-operative mastoid cavity epithelisation based on oto-microscopy and hearing outcome based on pure tone audiometry findings were compared. Majority of patients at 6-months follow-up found that epithelization was most common status of mastoid cavity with musculoperiosteal flap and discharge was commonest with cartilage graft. Mastoid obliteration with autologous materials is a safe and effective method to achieve a dry, safe and useful ear. In this study, musculo-periosteal flap being significantly better in terms of a well epithelized cavity and hearing outcome.

Habituation of changed acoustics properties after canal wall down mastoidectomy

PURPOSE

Our objective is to evaluate the effect of habituation on the altered ear canal acoustics after canal wall down mastoidectomy.

METHODS

A total of 11 participants with single sided dry cavities and normal contralateral ear canals with normal hearing thresholds were included in the study. Filtered sound fragments were created that simulate the different acoustic properties based on the participants Real Ear to Coupler Difference (RECD) of the cavity ear and the contralateral normal ear canal. These filtered sound fragments are presented to the cavity ear canal and the contralateral normal ear canal using inserts earphones. Participants performed a subjective quality assessment of the sound fragments using paired comparison with a seven-point scale (- 3 till + 3).

RESULTS

Mean assessment of sound quality revealed the following results; naturalness of sounds of the cavity ear canal is 0.29 (± 1.41; ns) in favour of the filtered sound fragment of the normal ear canal. Mean assessment of sharpness of sounds in the cavity ear canal is 1.55 (± 1.21, p = 0.55) in favour of the filtered sound fragment of the normal ear canal. Overall preference in the cavity ear canal was in favour of the normal ear canal acoustics 0.72 (SD ± 1.54 p = 0.224).

CONCLUSIONS

Patients with cavity ear canals seem to habituate to their altered ear canal acoustics. Transforming the ear canal acoustics of the cavity ear to normal ear canal acoustics seem to sharpen the incoming sounds. Overall assessment of quality of sound of the normal ear canal acoustics is better than the cavity acoustics.

Mastoid obliteration versus canal wall down or canal wall up mastoidectomy for cholesteatoma: Systematic review and meta-analysis

BACKGROUND

There is ongoing debate over the optimal surgical approach for cholesteatoma treatment^1-5. The aim of this review was to determine whether canal-wall down with mastoid obliteration is associated with favourable outcomes compared to either canal-wall down without obliteration or canal-wall up. The primary outcome was cholesteatoma reoccurrence with secondary outcomes including otorrhoea, reoperation and patient-reported outcome measures.

METHODS

Medline, Embase, Cochrane databases and clinicaltrials.gov were searched for studies reporting outcomes of patients undergoing primary CWD-MO for cholesteatoma and directly compared with CWD and CWU mastoidectomies. Data were collated and meta-analysis performed.

RESULTS

2379 patients were included from 12 studies that met the inclusion criteria. CWD-MO was found to be associated with significantly less risk of recurrence when compared to CWU (OR = 0.330 (95 % CI 0.191-0.570, p < 0.001). When compared to CWD, CWD-MO was associate with significantly lower incidence of persistent otorrhoea (OR 0.405 (95 % CI 0.232-0.706, p < 0.001) while the rates of recurrence were comparable (OR: 1.231 [95 % CI: 0.550-2.757] p = 0.613). Otorrhoea rates between CWD-MO and CWU were equivalent as was reoperation. Quality of life and hearing outcomes were variably reported.

CONCLUSIONS

This systematic review demonstrates that CWD-MO technique achieves lower recurrence rates comparable to CWD approaches and superior to CWU, while offering improved long-term control of otorrhoea. The final procedural choice should be decided based on surgeon experience, skill set and individual patient factors. To address the risk of selection bias, a randomised controlled trial is needed to answer this important research question.

Prevalence and surgical management of cholesteatoma in Down Syndrome children

OBJECTIVE

The objective was to report the outcomes of surgical management of cholesteatoma in Down Syndrome (DS) children and to determine the prevalence of cholesteatoma in DS children at three academic tertiary care centers.

METHODS

A retrospective chart review was performed of all DS children diagnosed with cholesteatoma from three tertiary care academic centers. Demographic data, comorbidities, imaging findings, surgical management, and pre- and postoperative pure tone averages were collected.

RESULTS

The prevalence of cholesteatoma in DS patients at these three institutions was calculated to be 8/802 (0.998%), 4/448 (0.893%), and 4/1016 (0.394%), with an average prevalence of 0.762%. Of the 16 patients with cholesteatoma identified, the average age of diagnosis was 10.8 years, and 5/16 (31%) had at least three sets of pressure equalizing tubes (PETs) placed. Of the 13 patients with preoperative CTs, 4/13 (30.8%) had blunting of the scutum, 4/13 (30.8%) had tegmen involvement, 1/13 (7.7%) had erosion of the semicircular canal, 2/13 had facial nerve dehiscence, and 7/13 (53.8%) had ossicular chain erosion. For surgical management, disease control was attained in 4/16 children with tympanoplasty only and canal wall up (CWU) tympanomastoidectomy in 11/16 patients. Available pre- and postoperative audiograms were evaluated; however, there was insufficient audiological data to contribute to outcomes.

CONCLUSION

Cholesteatoma occurs in nearly 1% of DS patients, and the disease tends to be advanced with tegmen involvement in nearly a third of patients, and ossicular erosion seen in more than half the patients. A CWU procedure can be successful in managing DS patients with cholesteatoma when consistent long term follow-up is planned. Close monitoring and a high index of suspicion for cholesteatoma are essential to prevent delays in diagnosis and treatment of DS patients with a history of multiple sets of PET placement.

Surgical treatment of external auditory canal cholesteatoma in congenital malformation of the ear: A case series

Background

External auditory canal (EAC) cholesteatoma is a lesion lined with stratified squamous epithelium containing proliferative keratin with bony erosion in EAC which can spread to the tympanic cavity, mastoid, and surrounding organ. External cholesteatoma can occur in patients with congenital abnormalities such as congenital aural atresia (CAA).

Method

This case series was reported using the 2020 PROCESS Guideline. The design of this study used a retrospective study during the 2015–2020 period.

Result

3 participants aged 10.67 ± 2.31 years with CAA had other complaints of ear infections. All participants experienced sensorineural hearing loss with an average threshold of 59.33 ± 36.68 dB and suspicious cholesteatoma from a CT scan. Canal wall down, meatoplasty, and/or canaloplasty were performed based on the findings.

Conclusion

Surgical procedure in CAA with cholesteatoma aimed on preventing further complications and recurrence.

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Congenital aural atresia (CAA) is a condition where the patent external auditory canal is not formed.

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Canaloplasty and meatoplasty is the management of congenital aural atresia (CAA).

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Canal wall down effective management of CAA with grade IV.

Facial nerve course in the temporal bone: Anatomical relationship between the tympanic and mastoid portions for safe ear surgery

OBJECTIVE

Avoidance of iatrogenic injury to the facial nerve is crucial during ear surgery. The anatomical relationship between the tympanic portion of the facial canal (FC) and the mastoid portion of the facial nerve was analyzed using multi-slice computed tomography (CT) scans to avoid iatrogenic facial nerve injury.

METHODS

In total, 364 ears of 351 patients who underwent CT scans were enrolled. The 364 ears were divided into two groups: 281 ears with middle ear inflammation (MEI) and 83 ears without middle ear inflammation (non-MEI). The anatomical relationship between the tympanic portion of the FC and mastoid portion of the facial nerve was analyzed on multi-slice CT images. The ears were categorized into three subgroups based on the course of the mastoid portion of the facial nerve to the tympanic portion of the FC: ("lateral running course", LRC), "on the tympanic line course" (OL), and "medial running course" (MRC). The proportions of ears in each subgroup were compared between the MEI and non-MEI groups.

RESULTS

Overall, 15% of ears were categorized as LRC, 30% were OL, and 55% were MRC. In the MEI group, the proportions of LRC, OL, and MRC ears were 17%, 32%, and 51%, respectively, whereas they were 7%, 24%, and 69% in the non-MEI group. The proportion of LRC ears in the MEI group was significantly higher than that in the non-MEI group.

CONCLUSIONS

Especially in patients with MEI, a more LRC for the facial nerve increases the risk of facial nerve injury during posterior tympanotomy or canal wall down mastoidectomy. The course of the facial nerve in the temporal bone should be evaluated before surgery on multi-slice CT images.

Does canal wall down mastoidectomy benefit syndromic children with congenital aural stenosis?

OBJECTIVES

To determine whether a canal wall down mastoidectomy can provide long-term benefit for children with aural stenosis.

METHODS

Retrospective case series of children with congenital aural stenosis having undergone a canal wall down mastoidectomy over a twelve-year period at a tertiary children's hospital.

RESULTS

Data from thirteen children who underwent a total of twenty canal wall down mastoidectomies for aural stenosis were reviewed. The mean age at surgery was 7.1 years (range, 3.3-12.3 years). All patients had genetic syndromes including Trisomy 21 (n = 7), Trisomy 21 and Pierre Robin sequence (n = 1), Angelmann (n = 1), Cri-du-chat (n = 1), Branchio-oto-renal syndrome (n = 1), Spina bifida (n = 1) and Nager syndrome (n = 1). Seven (54%) children underwent bilateral canal wall down mastoidectomies. All thirteen ears that could not be visualized preoperatively had improved ease of office examination following surgery. Only one patient required revision surgery and all canals were patent at the last clinic visit. The mean follow-up was 4.9 years. There were no cases of facial nerve injury or cerebrospinal fluid leak.

CONCLUSION

Syndromic children with congenital aural stenosis with poorly pneumatized mastoids may benefit from canal wall down mastoidectomy to improve ease of office examinations.

Health-related quality of life measurement after cholesteatoma surgery: comparison of three different surgical techniques

The objective of this study was to compare health-related quality of life (HRQOL) after sequential cholesteatoma surgery including exclusively transcanal technique (ETC), combined transcanal transmastoidal technique (TCM) and canal wall down surgery with obliteration (CWD). It was a clinical case study conducted in a tertiary referral center. 97 patients at least 12 months after cholesteatoma surgery were included. Interventions included sequential cholesteatoma surgery with ETC, TCM or CWD; ossiculoplasty with partial and total ossicular replacement prostheses. HRQOL assessed by Chronic Otitis Media Outcome Test 15 including an overall score and three subscores ('ear symptoms', 'hearing function' and 'mental health') as well as a general evaluation of HRQOL and the frequency of physician consultations, audiometric outcome related to HRQOL were the main outcome measures. Patients, who had undergone sequential cholesteatoma surgery, showed moderate restrictions in HRQOL postoperatively. Stratified for the three surgical techniques, patients receiving ETC tended to report lower restrictions in HRQOL. The ETC group offered a significantly lower value in the subscore 'ear symptoms'. The 'hearing function' was attributed to be the most restriction criteria for all techniques. The overall score and all subscores correlated moderately with the postoperative air conduction threshold. The strongest correlation coefficient was achieved for the subscore 'hearing function' (r(s) = 0.49, p < 0.001). Sequential cholesteatoma surgery offers acceptable moderate restrictions in HRQOL postoperatively. Patients receiving canal wall down surgery with obliteration showed equivalent limitations in HRQOL compared to closed techniques (ETC, TCM). The postoperative air conduction threshold was shown not to be a sufficient indicator for HRQOL. Therefore, disease-specific validated and reliable measuring instruments for HRQOL should be transferred from clinical research to clinical practice to provide an individualized postoperative assessment after cholesteatoma surgery.

Canal wall reconstruction and preservation in the surgical management of cholesteatoma in children with Down's syndrome

INTRODUCTION

Down's syndrome is associated with poor Eustachian tube function, and an increased incidence of cholesteatoma. The only previously published case series suggests that 'canal wall preserving' procedures are only rarely suitable for the management of cholesteatoma in this population.

METHODS

We conducted a retrospective review of the hospital's clinical records database to identify patients with Down's syndrome and cholesteatoma. These patients' notes were then reviewed.

RESULTS

We identified nine patients with Down's syndrome who had undergone surgical management of cholesteatoma over a twelve year period. Three patients had bilateral disease, meaning twelve ears were treated. Seven ears were initially treated with 'canal wall down' procedures. Four out of five of the remaining ears were successfully treated using 'canal wall preservation' or 'canal wall reconstruction', with one ear requiring subsequent conversion to a 'canal wall down' approach.

CONCLUSION

Canal wall preservation/reconstruction is feasible in patients with Down's syndrome, even when cholesteatoma extends into the mastoid.