Management of Early Cholesteatoma

Abstract

Chronic otitis media with cholosteatoma had been one of the most prevalent forms of otological disease. However, recently, the incidence of chronic otitis media have decreased owing to better economic status and health care. Thus, cases of middle ear surgery have also decreased relatively in number. So it seems that otologists nowadays should be engaged in revision surgery of the middle ear and management of early cholesteatoma. While the incidence of extensive or complicated cholesteatoma has dramatically decreased for last decades, the early staged or less extensive cholesteatoma and retraction pockets are more frequently found. Especially localized adhesive otitis media, usually posterior tympanic membrane, is one of the most difficult dilemmas for the otologist. There are several controversial issues for managing patients with early cholesteatoma：1) conservative care or surgical treatment 2) techniques of surgery 3) whether or not mastoidectomy. So surgery for early cholesteatoma is thought to be reconstructive rather than destructive and it can be a prophylactic operation. I proposed a strategy for the management of early cholesteatoma which was based on safe marsupialization of retraction pocket or cholesteatoma, preservation of the mucosa, adequate ventilation, and prevention of retraction pocket. In case of attic retraction pocket or cholesteatoma, atticotomy with scutumplasty was made. On the other hand, the procedure to remove posterior annular bone and posterior scutum to allow access tympanic sinus and posterior attic space designated as posterior sinusectomy with reconstruction were applied to sinus retraction pocket or cholesteatoma. Early tensa retraction cholesteatoma would be managed as the combination of atticotomy and posterior sinusectomy. So I preferred the term “atticosinoplasty” which includes attic reconstruction with scutumplasty after atticotomy and posterior sinusectomy. If the disease seems to extend to mastoid, endoscopes were introduced transmeatally. If cholesteatoma occupies in mastoid, complete mastoidectomy is made, and sometimes mastoid cavity is obliterated to eliminate the cavity problems. During the last 7 years, I managed surgically 208 cases of attic or sinus cholesteatoma, so-called early cholesteatoma, among which there were 45 cases of atticosinoplasty. I analysed 45 cases with atticosinoplasty with special reference to period of postoperative care and hearing result , as compared to cases with mastoid obliteration and open cavity mastoidectomy. In conclusion, I personally think that middle ear cholesteatoma has a possibility of different clinical entity rather than a kind of chronic otitis media, eustachion tube dysfunction can not be always a prerequisite of middle ear cholesteatoma but it can be a secondary phenomenon, and finally surgury for early cholesteatoma is reconstructive rather than destructive ant it can be a prophylactic operation.