Treatment of sinus cholesteatoma. Long-term results and recurrence rate

We classified cholesteatomas as attic cholesteatoma, developing from Shrapnell's membrane; tensa cholesteatoma, originating in pars tensa, which is subdivided into tensa retraction cholesteatoma involving the entire pars tensa, and sinus cholesteatomas, developing from a posterosuperior retraction (perforation). From 1964 to 1980, one-stage operations were carried out on 271 ears with sinus cholesteatomas. Follow-up included 90% of the patients, and the median observation time was 9.75 years. The recurrence rate was 10%. The recurrence rate was found to be independent of the mastoidectomy type employed. The best hearing results were obtained in ears with intact ossicular chain. We conclude that, wherever possible, sinus cholesteatoma should be removed through the auditory canal without mastoidectomy just as an intact ossicular chain should be preserved. "Canal wall up" and "canal wall down" appear to be equally valuable mastoidectomy types, and both methods must be employed to obtain optimum results.     

Late results of surgery in different cholesteatoma types

Our series of 740 cholesteatomas, operated during the period 1969 to 1980, were seen at follow-up several times with a median observation period of 9.2 years (range 3-21 years). There were; 273 attic cholesteatomas with retraction (perforation) of Shrapnell's membrane; 271 sinus cholesteatomas with superioposterior retraction (perforation) of pars tensa, and 196 tensa retraction cholesteatomas extending from a retraction of the whole pars tensa. The late results were analyzed for each type separately, and compared. The recurrence rate was lowest (6.6%) in attic cholesteatoma and highest (13.3%) in tensa retraction cholesteatoma. In all three types no residual cholesteatomas were detected after the 4th postoperative year, whereas recurrent cholesteatomas occurred up to 10 years after surgery. The reoperation rate was lowest (15%) in attic cholesteatoma and almost the same (21%) in sinus and tensa retraction cholesteatoma. The hearing results were best in attic cholesteatoma and poorest in tensa retraction cholesteatoma. It is concluded that cholesteatoma surgery should be individualized and that both the canal wall up and canal wall down methods have their place in cholesteatoma surgery.     

Pathogenesis of sinus cholesteatoma

The aim of the present study was to provide evidence for the establishment of sinus cholesteatoma, defined as postero-superior pars tensa retraction extending into the posterior tympanum and tympanic sinuses. Background: There is clinical evidence for formation of a retraction, but there is a lack of explanation for the transition from a retraction pocket to an active and expanding sinus cholesteatoma. Epidemiological studies on incidence of postero-superior retractions of pars tensa and follow-up studies on patients with similar pars tensa retractions were performed. Additionally, expression of proliferation marker and analysis of basement membrane were studied in samples of sinus cholesteatoma. The prevalence of pars tensa pathology was between 9.2 and 24% of investigated ears. In children with manifest secretory otitis there were some sinus cholesteatomas and 5–6% severe retractions, some of those became pre-cholesteatomas, requiring treatment and controls. Immunohistochemistry of sinus cholesteatomas showed that proliferating keratinocytes were very often found within epithelial cones growing towards the underlying stroma. These growth cones exhibit focal discontinuities of the basement membrane especially in areas of intense subepithelial inflammation. As a possible explanation based on clinical and immunohistochemical findings, we propose a four-step concept for pathogenesis of sinus cholesteatoma combining the retraction and proliferation theory: (1) The retraction pocket stage. (2) The proliferation stage of the retraction pocket, subdivided in (a) Cone formation, (b) Cone fusion. (3) Expansion stage of attic cholesteatoma. (4) Bone resorption.     

Differences in clinical characteristics of fallopian canal dehiscence associated with pars flaccida and pars tensa cholesteatomas

This study investigated the difference in clinical characteristics of fallopian canal dehiscence associated with pars flaccida and pars tensa cholesteatomas for the purpose of increasing the preoperative detectability of dehiscence. A total of 189 ears of patients 7–80 years of age (mean 42 years) with pars flaccida cholesteatoma and 63 ears of patients 9–84 years of age (mean 50 years) with pars tensa cholesteatoma were studied. All patients had undergone prior surgical management at our institution from January 2006 to April 2012. The incidence of fallopian canal dehiscence and its location were compared between pars flaccida and pars tensa cholesteatomas. Intraoperative findings of coexistent pathologies, including destruction of the stapes superstructure, labyrinthine fistula, and dural exposure, were compared between the dehiscence and no-dehiscence groups for the two types of cholesteatomas. The incidence of dehiscence was significantly higher in patients with pars tensa cholesteatoma (55.6 %) than in patients with pars flaccida cholesteatoma (26.5 %). Dehiscence located posterior to the cochleariform process occurred slightly more frequently in patients with pars tensa cholesteatoma than in those with pars flaccida cholesteatoma. In patients with pars flaccida cholesteatoma, labyrinthine fistulas and dural exposure were significantly more frequent in the dehiscence group than in the no-dehiscence group. Fallopian canal dehiscence is more frequent in patients with pars tensa cholesteatoma than in those with pars flaccida cholesteatoma. Especially in patients with pars flaccida cholesteatoma, paying special attention to these coexisting pathologies is important to increase preoperative detectability of dehiscence.     

Canal wall-down procedure with soft posterior meatal wall reconstruction in acquired cholesteatoma: focus on postoperative middle ear status*

Objectives: We reviewed surgical results of canal wall-down tympanoplasty (CWDT) with soft posterior meatal wall reconstruction (SWR) for acquired cholesteatoma (AC), and identified factors associated with surgical outcomes.

Methods: Results from 119 ears with AC (pars flaccida, n?=?99; pars tensa, n?=?20) that underwent CWDT with SWR were retrospectively reviewed. We defined postoperative balloon-like retraction (PBR) with web formation, which needed reoperation to clean accumulated cerumen, as postoperative deep retraction pocket (PDRP).

Results: Residual cholesteatoma was found in 11 ears (9.2%). Seven residual cholesteatomas were treated with outpatient operation. Seven ears (5.9%) showed PDRP. A transcanal approach was applied to all PDRPs. Postoperative mastoid reaeration was observed in 57 ears (47.9%). No factors significantly associated with residual cholesteatoma or PDRP were identified. The frequency of postoperative mastoid reaeration was significantly higher among cases with young age (<50 years), stage I cholesteatoma, or type I ossiculoplasty.

Conclusion: CWDT with SWR showed low rates of residual cholesteatoma or postoperative deep retraction pocket (PDRP). Most residual cholesteatomas and PDRPs could be dealt with using a minimally invasive procedure. Young age, stage I cholesteatoma, and type I ossiculoplasty were associated with postoperative mastoid reaeration. This procedure seems fully feasible for surgical treatment of AC.     

Modified Bondy radical mastoidectomy: long-term personal experience

The 'Bondy operation', or modified Bondy radical mastoidectomy, consists of a modification of the radical procedure by which the mastoid and epitympanum are exteriorized with preservation of the pars tensa and ossicular chain. In the 10-year period from 1986 to 1996, 53 patients of the ENT Department of the University of Pisa underwent a modified Bondy radical mastoidectomy, performed with a personalized procedure; 45 of them had a follow up of at least five years. After the surgical operation, the ears were free of complications in 38 cases (84.5 per cent), while in the other seven cases residual cholesteatoma (one case), tympanic retraction (four cases) or recurrent otorrhoea and phlogosis (two cases) were observed. The post-operative hearing level was unchanged or improved in 41 patients (91 per cent) (33 subjects had an unchanged gap and eight an improved gap), and only in the remaining four cases was the gap made worse. Based on our experience, the modified Bondy radical mastoidectomy is an extremely effective operation with a clear place in modern ENT surgery. When performed on carefully selected patients, it has been proven to offer good functional and anatomical results.     

Long-term results of surgery for childhood cholesteatoma.

The study includes 54 cholesteatomatous ears in 50 children aged 16 years or less. The mean follow-up period after surgery was 7.1 years. In 26% of the ears the cholesteatoma was 'huge' involving the middle ear and the attic and filling the entire mastoid air cell system. A patient had lateral sinus thrombophlebitis. Patients with large cholesteatomas underwent canal wall down mastoidectomy with simultaneous tympanoplasty and, in most cases, cavity obliteration. Limited cholesteatomas were removed using either intact canal wall mastoidectomy or tympanotomy approach. Recurrence rate (including both residual and recurrent cholesteatomas) for the total series was 15% and 12% for the 50 cases undergoing one-stage surgery. Serviceable hearing (< or = 30 dB) was achieved in 57% of the ears. A reoperation was necessary in 26% and a third operation in 2%. At last follow-up examination, 94% of the ears had intact tympanic membranes but 4 patients (8%) suffered from cavity-related problems. Possible reasons for the disappointing results of surgical treatment for childhood cholesteatoma are discussed.     

A comparison of cartilage palisades and fascia in tympanoplasty after surgery for sinus or tensa retraction cholesteatoma in children.

OBJECTIVE: To compare cartilage palisades with fascia grafting in reconstruction of the eardrum after surgery for sinus or tensa retraction cholesteatoma in children, with respect to postoperative drum retraction and perforation, cholesteatoma recurrence, and hearing. MATERIAL: From March 1995 to October 2000, a total of 64 children, aged 5 to 15 years, underwent surgery for either sinus or tensa retraction cholesteatoma. The eardrum was reconstructed using cartilage palisades in 32 children and fascia or perichondrium in 32 children. Postoperatively, the patients were seen as out-patients and were recently reevaluated by otomicroscopy and audiometry. MAIN OUTCOME MEASURES: Postoperative drum retraction and perforation, cholesteatoma recurrence, and hearing (pure tone average, speech reception threshold, and air-bone gap). RESULTS: All patients in the palisade group and all but one patient in the fascia group attended the follow-up examination. In the palisade group, the mean follow-up period was 37 months (range, 3-65 mo) and in the fascia group 52 months (range, 17-75 mo).Two (6%) retractions and no perforations were found in the palisade group, versus 12 (36%) retractions and 4 perforations (12%) in the fascia group at follow-up (both significant differences). No cholesteatoma recurrence occurred. Late hearing results in sinus cholesteatomas were significantly better in the palisade group. CONCLUSIONS: The comparison of fascia and cartilage palisade grafting for drum reconstruction after tensa cholesteatoma surgery in children indicates that the palisade technique may be superior in respect to prevention of drum retraction and perforation. Further, in sinus cholesteatoma surgery, the long-term hearing results are better when grafting cartilage palisades.     

Cholesteatoma in children--the experience at The Red Cross War Memorial Children's Hospital in South Africa 1988-1996.

This review of experience with cholesteatoma in children, describes the presentation and features of the disease from a tertiary institution in a 'developing country'. A total of 24 out of 96 cholesteatomas in 81 children (M:F = 44:37) aged 2-12 years initially presented with mastoiditis, with intracranial complications in seven children. Three of the cholesteatomas were congenital, 56 arose from retraction pockets-11 pars flaccida, 45 pars tensa 21 were associated with either a central perforation or total atelectasis and one originated at a ventilation tube site. Open cavity surgery was undertaken in all cases-atticotomy in 14, open mastoid cavity in 82 ears. It was not always possible to preserve reasonably normal pre-operative hearing nor was it possible to improve hearing loss. Twenty-six out of 81 children did not return for follow-up. Even with open cavity surgery, recurrence of cholesteatoma occurred. Late diagnosis, extensive disease, a high rate of complications and poor follow-up are the features of this disease in 'developing' countries.     

Expression patterns of cytokeratins in retraction pocket cholesteatomas

OBJECTIVES: To investigate the patterns of cytokeratin (CK) expression in retraction pocket cholesteatoma. STUDY DESIGN: An animal model study. METHODS: Retraction pocket cholesteatomas were induced by electrocautery of the eustachian tube orifice in 24 mongolian gerbils. They were divided into normal and cholesteatoma groups of clinical stages I to IV. The antibodies to pan-cytokeratin CK 1/10, CK 5/6, CK 4, and CK 13/16 were used for immunohistochemical staining. The intensity of staining in each group as measured with densitometry was compared regarding anatomical sites and clinical stages. RESULTS: In retraction pocket cholesteatoma, CK expression was altered only at focal sites such as the pars tensa of the tympanic membrane. The change of CK expression was observed only at certain stages of cholesteatoma formation. In keratinocytes from cholesteatomas, CK 13/16 was overexpressed compared with control specimens, indicating hyperproliferation. The site with the most prominent change in retraction pocket cholesteatoma was somewhat different from that in canal ligation cholesteatoma in a previous study. CONCLUSIONS: The results suggested that aural cholesteatoma is a disease with a spectrum of pathological conditions and that the transmigration and hyperproliferation process of squamous epithelium occurs in areas adjacent to the cholesteatoma.     

Surgical strategy for cholesteatoma in children

OBJECTIVE: We reviewed our experience with childhood cholesteatoma in children under 15 years old. Based on cumulative postoperative data, we propose a modified canal-wall-up technique in conjunction with a planned, staged operation. METHODS: From 1982 to 1997, 56 children with cholesteatoma (58 ears, total) underwent surgery in our department. In the early period (1982-1990), canal wall-down mastoidectomy was performed in 52% (21 of 40 ears), and canal wall-up mastoidectomy in 48% (the remaining 19 ears). In the late period (1991-1997), 18 ears with cholesteatoma underwent surgery. The canal-wall up mastoidectomy was performed in 89% (16 ears), and canal-wall-down mastoidectomy in the remaining 11% (two ears). RESULTS: In the early period (1982-1990), cholesteatoma recurred more frequently in the canal-wall-up mastoidectomy group than in the canal-wall down mastoidectomy group (53 vs. 14%). Other postoperative complications, such as erosion of the mastoid cavity, otorrhea, and perforation of the eardrum, occurred more frequently in the canal-wall-down mastoidectomy group than in the canal-wall-up mastoidectomy group. In the late period (1991-1997), in the canal-wall-up mastoidectomy group, ten ears underwent one-stage surgery. Planned staged tympanoplasty was completed in six ears. After one-stage surgery, four of ten ears experienced residual cholesteatoma. Two of the recurrent ears had undergone planned staged tympanoplasty. As revealed by postoperative computed tomography (CT) images, 12 of 15 ears had aeration in the attic and antrum as well as in the tympanic cavity. In these cases, no attic retraction pocket formation was observed. CONCLUSION: Our strategy for pediatric cholesteatoma in the future is to use canal-wall-up mastoidectomy when possible. If aeration in the attic and antrum is observed by preoperative CT-scan image and no erosion in the malleus and incus exists, the one-stage surgery will be chosen. If no aeration is observed by CT-scan and/or erosion exists in the surgical findings, planned staged tympanoplasty will be necessary. This strategy allows a high incidence of aeration of the attic and antrum, and prevents the formation of the attic retraction pocket while enabling the early detection of residual cholesteatoma by means of CT.     

Retrograde mastoidectomy with canal wall reconstruction: a follow-up report.

OBJECTIVE: To evaluate long-term results of retrograde mastoidectomy with canal wall reconstruction as a single-stage technique for cholesteatoma removal. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Forty-six patients, representing 50 ears (20 pediatric and 30 adult), who had undergone surgery for cholesteatoma removal with said technique and had an average follow-up of 7.8 years. INTERVENTIONS: Temporary removal of the upper canal wall, in association with a retrograde-type mastoidectomy, for full exposure and extirpation of the disease, followed by reconstruction of the canal defect using cymba cartilage. MAIN OUTCOME MEASURES: Preoperative and short- and long-term postoperative audiogram, obtained as four-frequency pure-tone average air-bone gap. Complications, including presence of recurrent or residual cholesteatoma, need for tube insertion, perforation, and poor hearing requiring revision surgery, were also reported and correlated with the patient's tobacco use. RESULTS: The average preoperative, short-term postoperative, and long-term postoperative pure-tone average air-bone gap was 25.6+/-11.2 dB, 11.0+/-5.7 dB, and 12.4+/-6.4 dB, respectively. There were significant differences between the pre- and postoperative values (p < 0.5), but there was no significant difference between short- and long-term hearing results. Recurrent cholesteatomas were seen in eight ears (16%); pressure-equalizing tube insertion was performed postoperatively in nine ears (18%); a perforation was seen in one ear (2%); and two ears (4%) had poor hearing results requiring second-look surgery. The long-term complication rate of smokers was 79% (15 of 19), compared with 16% (5 of 31) for nonsmokers. CONCLUSION: This single-stage technique for cholesteatoma removal and canal wall reconstruction showed acceptable long-term results, but tobacco use was associated with a higher long-term complication rate.     

Combined Heermann and Tos (CHAT) technique in cholesteatoma surgery: surgical technique and preliminary results

The combined Heermann and Tos (CHAT) technique is the combination of Heermann's 'cartilage palisade tympanoplasty' and Tos's 'modified combined approach tympanoplasty = modified intact canal wall mastoidectomy'. The first author (Cem Uzun) performed the CHAT technique as a one-stage operation in 15 ears of 15 patients with cholesteatoma. Two patients (one with a follow up of less than six months and one who did not show up at the final re-evaluation) were excluded from the study. Median age in the remaining 13 patients was 37 years (range: 14-57 years). Cholesteatoma type was attic, sinus (Tos tensa type 1) and tensa retraction (Tos tensa type 2) in six, five and two ears, respectively. Cholesteatoma stage was Saleh and Mills stage 1, 2, 3, 4 and 5 in one, three, four, four and one ear, respectively. The eustachian tube was not involved with cholesteatoma in any ear. After drilling of the superoposterior bony annulus, transcanal atticotomy with preservation of thin bridge and cortical mastoidectomy with intact canal wall, the cholesteatoma was removed, and the eardrum and atticotomy were reconstructed with palisades of auricular cartilage. Type I tympanoplasty was performed in two ears, type II in nine ears and type III (stapes absent) in two ears, with either autologous incus (eight cases), cortical bone (two) or auricular cartilage (one). No complication occurred before, during or after surgery. Oto-microscopy and audiometry were done before and at a median of 13 months after surgery (mean 14 months, range 7-30 months). There was no sign of residual or recurrent cholesteatoma in any patient during the follow-up period. At the final examination, all ears were dry and had an intact eardrum except one with a small, central hole, which had been seen since the early post-operative period. Clean and stable attic retraction with a wide access was observed in two ears. Post-operative hearing at the final evaluation was better (change > 10 dB) than the pre-operative one in nine ears and did not change in the remaining four. Pre- and post-operative mean hearing values were, pure-tone average 47 and 35 dB (p = 0.01) and air-bone gap 30 and 20 dB (p = 0.02), respectively. With the CHAT technique, cholesteatoma can be completely and safely removed from the middle ear, and a durable and resistant reconstruction of the middle ear with reasonable hearing can be achieved. However, a further study should analyse long-term results of a larger patient group.     

Anterior epitympanic recess--CT assessment

Aeration of the middle ear is the prerequisite of it proper function. It is also necessary for successful surgical reconstruction in cases of chronic otitis media. The anterior epitympanic recess (AER) has attracted the attention in recent years as possible additional route of ventilation. The preoperative axial CT scans of the temporal bones were compared with the operative findings in retrospective analysis of cases operated because of cholesteatoma. 25 ears with perforation in pars tensa and 29 ears with the perforation in pars flaccida were analysed as well as 34 healthy ears. In 1/2 of healthy ears AER consisted of a single cell and in 1/3 of multiple small cells. The structure of the AER was much more difficult to assess in cholesteatoma ears but still it was possible in more than 1/2 of them, and it did not differ significantly from healthy ears. In the majority of ears with attic cholesteatoma the structure of AER was not identified because of cholesteatoma involvement of this area. Aeration of the AER in cases of pars tensa cholesteatoma when the tympanic isthmus was closed suggests the presence of additional route of ventilation through anterior attic.     

canal wall reconstruction mastoidectomy

Objective To investigate the advantages of canal wall reconstruction(CWR) mastoidectomy, a single-stage technique for cholesteatoma removal and posterior external canal wall reconstruction, over the open and closed procedures in terms of cholesteatoma recurrence. Methods: Between June 2002 and December 2005, 38 patients (40 ears) with cholesteatoma were admited to Sun Yat-Sen Memorial Hospital and received surgical treatments. Of these patients, 25 were male with ages ranging between 11 and 60 years(mean = 31.6 years) and 13 were female with ages ranging between 20 and 65 years (mean = 38.8 years). Canal wall reconstruction(CWR)mastoidectomy was performed in 31 ears and canal wall down(CWD) mastoidectomy in 9 ears. Concha cartilage was used for ear canal wall reconstruction in 22 of the 31 CWR procedures and cortical mastoid bone was used in the remaining 9 cases. Results At 0.5 to 4 years follow up, all but one patients remained free of signs of cholesteatoma recurrence, i.e., no retraction pocket or cholesteatoma matrix. One patient, a smoker, needed revision surgery due to cholesteatoma recurrence 1.5 year after the initial operation. The recurrence rate was therefore 3.2% (1/31). Cholesteatoma recurrence was monitored using postoperative CT scans whenever possible. In the case that needed a revision procedure, a retraction pocket was identified by otoendoscopy in the pars flacida area that eventually evolved into a cholesteatoma. A pocket extending to the epitympanum filled with cholesteatoma matrix was confirmed during the revision operation, A decision to perform a modified mastoidectomy was made as the patient refused to quit smoking. The mean air-bone gap in pure tone threshold was 45 dB before surgery and 25 dB after(p < 0.05). There was no difference between using concha cartilage and cortical mastoid bone for the reconstruction regarding air-bone gap improvement, CT findings and otoendoscopic results. Conclusion CWR mastoidectomy can be used for most patients with acquired middle ear cholesteatoma, including children. The CWR technique provides improved exposure of the middle ear, especially the anterior epitympanum, without creating a mastoid bowl and reduces the incidence of residual and recurrent disease, including cholesteatoma and otorrhea.     

Middle-ear cholesteatoma in children--an Indian perspective

A study of the clinical presentation of acquired aural cholesteatoma in 51 Indian children is presented. An attempt has been made to assess the impact of this chronic ear disease in terms of the morbidity it incurs upon the paediatric population. The preponderance of bilateral presentation in cholesteatomatous otitis media (24.5 per cent) and the associated sensorineural or mixed hearing loss (in 25.4 per cent of the ears) is emphasized, to reflect the alarming audiological disability in the afflicted child. An attempt has been made to correlate the otoscopic profile with the extent of disease, osteitic damage and co-existing complications. It was noted that, in Indian children, mesotympanic choleasteatoma was more often associated with large defects of the pars tensa (viz. marginal, subtotal and total perforations--54.4 per cent) than with postero-superior retraction pockets (37.2 per cent) or purely attic defects (7.8 per cent). Further analysis revealed this common otoscopic presentation to be a more active process, occurring in predominantly cellular mastoids and associated with extensive disease. Based on this study, a more aggressive canal down tympanomastoid approach is advocated for children presenting with this otoscopic profile.     

Cholesteatoma in children

Of 325 previously untreated cholesteatomas, 109 were found to be in children 13 years old and younger--however, these 109 ears were not found to consist of one clinical entity. Sixty-three of the 109 ears presented a marginal perforation or a retraction pocket, at the level of Shrapnell's membrane or beyond the postero-superior quadrant. In this group the cholesteatoma was distributed mainly in the attic and mastoid and was associated with a non-cellular mastoid. A second group comprising 31 ears presented with cholesteatoma behind an intact drum and were considered to be primary cholesteatomas. These were distributed mostly in the tympanic cavity as cystic epidermoid formations--their mastoid was usually pneumatized. Eight cholesteatomas were related to a central perforation. These ears presented features very similar to the primary cholesteatomas i.e., a pneumatized mastoid and tympanic cavity distribution. The similar features of this group make us think that they may have also originated as primary cholesteatomas which eventually perforated and bring the percentage of primary cholesteatomas in children to 38.3%. Seven of the 109 ears with cholesteatoma were of an indeterminate character.     

Pathology of the ossicular chain in various chronic middle ear diseases.

In a collection of 1,100 operated ears, 426 of which had cholesteatoma and 674 had not, the various defects of the ossicular chain are described and related to the nature of the disease and the site of perforation. The analysis showed marked differences between the various diseases and in the frequency of the individual ossicular defects or combinations of defects. Defects of the head of the malleus and of the body of the incus were found exclusively in chiolesteatomas, most often those affecting the attic. Isolated defects of the malleus handle were most common in cholesteatoma of the parts tensa and in total perforations. Defects of the long process of the incus occurred in 74--88 per cent of cholesteatomatous diseases, defects of the stapedial arch in 47 per cent of ears with sinus cholesteatoma. In granulating otitis without cholesteatoma and in sequelae to otitis there was less ossicular pathology, and 57 per cent of these ears had an intact ossicular chain. Total or posterior perforations were associated with pathology of the ossicles more often than inferior or anterior perforations. All cases with destruction of the body of the incus and the head of the malleus showed squamous epithelium in close relation to the ossicular defect, indicating a marked--presumably enzymatic--influence by the squamous epithelium upon the bone resorption.     

Attic cholesteatoma. Recurrence rate related to observation time

Two hundred twenty-four ears with attic cholesteatomas, subjected to one-stage surgery between 1965 and 1978, were reevaluated several times, most recently in 1980/81 at a median observation time of 8 years (range, 3 to 16 years) and in 1985/86 at a median observation time of 11 years (range, 3 to 21 years). The recurrence rate was related to length of observation time. Up to and including the follow-up examination in 1980, the rate of residual cholesteatoma in the tympanic cavity was 1.3% and 0.9% in the attic. The incidence of recurrent cholesteatoma in the attic or the cavity was 1.8%. The total recurrence rate was 4.0%. At follow-up in 1985/86, the total recurrence rate had increased to 6.3%, comprising residual cholesteatoma in the tympanic cavity in 1.8% and in the attic in 0.9% and recurrent cholesteatoma in 3.6%. A total of 133 patients had a modified canal wall up mastoidectomy, whereas 91 patients had canal wall down mastoidectomy with obliteration. With regard to the total results of surgery, no significant differences could be demonstrated between the two methods, and we conclude that canal wall up mastoidectomy can be performed in one stage.