Abstract
To determine the impact of using otoendoscopy at the time of primary surgery of cholesteatoma in identifying hidden “cholesteatoma remnant”. Study was prospective study. Setting was University tertiary care hospital. One hundred fifty, patients diagnosed clinically and by CT as having cholesteatoma, have been operated. 64 patients operated by using canal up technique and 86 patients operated by using canal down technique. Once all visible cholesteatoma was removed with standard microscopic techniques, otoendoscopy was utilized in every patient to identify any hidden “cholesteatoma remnant”. Despite apparent total microscopic eradication of cholesteatoma of the operated cases, otoendoscopy at time of primary surgery revealed an overall incidence of hidden cholesteatoma remnants of 18%. The incidence of hidden cholesteatoma remnants identified by otoendoscopy was 23% in the canal up group and 14% in the canal down group. Otoendoscopy should be used as an adjunct with standard microscopic technique to identify hidden cholesteatoma remnants during surgery of cholesteatoma.
Keywords: Cholesteatoma, Otoendoscopy, Canal up, Canal down, Cholesteatoma remnant
Introduction
Despite advancements in surgical techniques, improved instruments and use of the microscope in surgery of cholesteatoma, the incidence of residual/recurrent cholesteatoma remains high and varies from 5.9 to 49.5% in different series [1–4]. The anterior epitympanum, retro tympanum or protympanum are the areas which are difficult to see under operating microscope and so are common sites for residual/recurrent cholesteatoma [3–5]. Although the microscope revolutionized the surgical management of ear diseases, its basic optical properties remained the same for the last 30 years. Meanwhile endoscopes with better optics and magnification with angled lenses have seen numerous applications in Otology. Endoscopic middle ear surgery can offer some advantages compared to the traditional microscopic technique, guaranteeing excellent visualization of mesotympanic structures and direct visual control of concealed areas such as sinus tympani, anterior epitympanic area, supra-tubal recess, tubal area and facial recess. Badr-Eldine and El-Messelaty reported on the value of endoscopy as an adjunct in cholesteatoma surgery and documented a reduced risk of recurrence when the endoscope was used [6, 7]. The reduction in residual disease was further confirmed by Yung [8] and Ayache [9]. Abdel Baki reported on using endoscopic techniques to evaluate disease within the sinus tympani [10]. Nowadays, it has been proven beyond doubt that endoscopes make a difference positively in surgery of cholesteatoma but the conflict is not yet enough to gain worldwide popularity. The aim of the present study is to determine the impact of using otoendoscopy in identifying hidden “cholesteatoma remnant” during the primary surgery of cholesteatoma.
Materials and Methods
One hundred fifty patients between 15 and 55 years of age, presenting with cholesteatoma, confirmed clinically and on microscopy, were included in the study. All patients have been examined and operated at Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Zagazig University Hospitals from January 2013 to January 2015.
The inclusion criteria were patients with unilateral CSOM attico-antral type with no other associated ear disease and malformation. Exclusion criteria were those patients who had undergone any surgery of the involved ear, patients with dead ear or patients referred from the Neurosurgical Department after treatment of any intracranial otogenic complication. All the patients underwent thorough ENT examination, including microscopy of the ear. Swab for culture and sensitivity of ear discharge was taken in all cases. Hearing assessment by pure tone audiometry was also conducted preoperatively. Computed tomography of the temporal bone was done routinely for all patients. According to the clinical examination, microscopic evaluation and CT findings, the patients were classified into 2 groups: group (1): 64 patients presenting with cholesteatoma and have been operated by the canal up technique and group (2): 86 patients presenting with cholesteatoma and have been operated by the canal down technique. Once all visible cholesteatoma was removed with standard microscopic techniques, otoendoscopy was utilized in every patient to identify any hidden “cholesteatoma remnant”.
Endoscopic assessment in the most notorious sites for residual cholesteatoma i.e. sinus tympani, anterior epitympanum, supra tubal recess, tubal area and facial recess was done by 4 mm Hopkins rod endoscope with 0°, 30° oto-endoscope. Any residual diseases, if present, were again cleared by angled pick. Video equipment consists of a 3-chip video camera and a monitor was used. Procedures are performed directly off the monitor and recorded.
Descriptive statistics using Microsoft,SPSS software were used in the study.
Results
The obtained results were demonstrated in the following Tables 1, 2, 3, 4, 5, 6.
Table 1.
Age and Sex
| Age group (years) | Males | Females | Total | Total | % |
|---|---|---|---|---|---|
| 15–25 | 27 | 20 | 47 | 47 | 31.3 |
| 25–35 | 20 | 18 | 38 | 38 | 25.3 |
| 35–45 | 16 | 20 | 36 | 36 | 24 |
| 45–55 | 10 | 19 | 29 | 29 | 19.4 |
| 73 | 77 | 150 | 150 | 100 |
Mean age = 37 years
Table 2.
Duration of Otorrhea
| Duration (years) | No. of patients | % |
|---|---|---|
| 1–5 | 44 | 29.3 |
| 5–10 | 40 | 26.7 |
| 10–15 | 38 | 25.3 |
| 15–20 | 28 | 18.7 |
| 150 | 100 |
Mean = 13 years
Table 3.
Average of air-bone gap on pure tone audiometry in speech frequencies in dB
| Air-bone gap (dB) | No. of patients | % |
|---|---|---|
| 10–20 | 12 | 8 |
| 20–30 | 54 | 36 |
| 30–40 | 39 | 26 |
| 40–50 | 45 | 30 |
| 150 | 100 |
Mean = 33 dB
Table 4.
Sites of cholesteatoma
| Site | No. of patients | % |
|---|---|---|
| Posterosuperior | 78 | 52 |
| Attic | 67 | 44.7 |
| Cholesteatoma with central perforation | 5 | 3.3 |
| 150 | 100 |
Table 5.
Incidence of residual cholesteatoma discovered by otoendoscopy
| Canal up = 64 pt. | Canal down = 86 pt. | Total = 150 pt. | |||
|---|---|---|---|---|---|
| No. patients with residual cholesteatoma discovered by otoendoscopy | % | No. patients with residual cholesteatoma discovered by otoendoscopy | % | No. patients with residual cholesteatoma discovered by otoendoscopy | % |
| 15 | 23.38 | 12 | 13.95 | 27 | 18 |
Table 6.
Incidence of residual cholesteatoma in hidden areas discovered by otoendoscopy in 27 patients
| Sites of residual disease | Number of sites | % of total |
|---|---|---|
| Sinus tympani | 24 | 88.9 |
| Facial recess | 15 | 49.3 |
| Anterior epitympanum | 5 | 18.5 |
| Supratubal recess | 5 | 18.5 |
| Tubal area | 4 | 14.8 |
| Hypotympanum | 4 | 14.8 |
Discussion
The main treatment options for cholesteatoma are two microscopic surgical procedures: the canal wall-down (CWD) and the canal wall-up (CWU) mastoidectomy with tympanoplasty. The intact canal wall approach has traditionally been favored for its simpler postoperative care and maintenance [11]. Moreover, by preserving the anatomy of the middle ear, the cavity is permitted to get wet and, thereby, does not limit patients in future activities [12]. However, many surgeons have noted high rates of recurrent and residual disease using this approach. Because of these disadvantages, others prefer to remove the posterior canal in their treatment of cholesteatoma [3, 13]. The removal of the posterior canal does not always ensure complete visualization of sinus tympani that often remain hidden from surgical view. Other hidden areas that are not completely visualized by the surgical microscope and may be the cause of residual cholesteatoma are the facial recess, anterior epitympanum, and hypotympaum. Sanna et al. [14] 20 evaluated 222 cases of cholesteatomas operated with their modified Bondy’s technique. They reported a pearl-like residual cholesteatoma in 7.4% of ears, while no recurrence was discovered over a mean follow-up of 7.8 years. Haginomori et al. [3] performed 85 canal wall-down tympanoplasties and observed 18 (21%) residual cholesteatomas after 1 year at second-look. Gaillardin et al. [2] after a mean follow-up of 48 months, found a rate of residual disease of 25% cholesteatomas in 113 ears operated with a closed canal wall-up mastoidectomy with tympanoplasty. Mishiro et al. [15] described recurrent cholesteatoma in 19.4% of ears treated with closed mastoidectomy with tympanoplasty.
Endoscopic assistance may further fix the option of recurrences and residual disease typically associated with these 2 approaches. In our study of 150 patients of cholesteatoma, after finishing the drill work under the microscope, every patient underwent a complementary endoscopy with 4 mm 0° and 30° telescope (Hopkins rod). We looked for the presence or absence of cholesteatoma in sinus tympani, facial recess, anterior epitympanum and hypotympanum. Otoendoscopy at time of primary surgery revealed an overall incidence of hidden cholesteatoma remnants of 18%. The incidence of hidden cholesteatoma remnants identified by otoendoscopy was 23.38% in the canal up group and 13.95% in the canal down group (Table 5).
Badr-Eldine reported on the value of otoendoscopy as an adjunct in cholesteatoma surgery and documented a reduced risk of recurrence when the endoscope was used [16]. Pressutt et al. [17] had noticed 37% incidence of residual cholesteatoma with otoendoscope after microscopical work in his series. El-Meselaty et al. [7] in his series on use of otoendoscopy in canal wall down and canal wall up procedures after drill work under microscope, noticed 30% incidence of residual cholesteatoma in canal wall down procedures and 50% incidence of residual cholesteatoma in canal wall up procedures.
The commonest site of residual cholesteatoma in our series was sinus tympani (88.9%) followed by facial recess (49.3%), anterior epitympanum (18.5%) and supratympanic recess (18.5%). Ayubi et al. [18] found that the most common site cholesteatoma was sinus tympani (83.3%) followed by anterior epitympanum (50%) and protympanum (16.67%). Ayeche et al. [19] in a similar study noticed 76% incidence of residual cholesteatoma in sinus tympani and 44% in anterior epitympanum. The sinus tympani was also the most common site of residual cholesteatoma in a series of Presutt et al. [20]. The reason for such a high incidence of recurrent/residual disease in sinus tympanum is that it is one of the most difficult areas to see by microscope.
Conclusion
Otoendoscopy should be utilized as an adjunct with standard microscopic technique to identify hidden cholesteatoma remnants during surgery of cholesteatoma.
Abbreviations
- CSOM
Chronic suppurative otitis media
- CWD
Canal wall-down
- CWU
Canal wall-up
Compliance with Ethical Standards
Conflict of interest
None.
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