Surgical planning of the treatment of cholesteatoma and postoperative follow-up

There is no single surgical treatment of choice for aural cholesteatoma. The extent of the cholesteatoma, the amount of preoperative destruction, and the size of the mastoid pneumatization should guide the surgeon in choosing the type of operation for a particular ear--which may range from a simple extraction of the cholesteatoma (delivery) all the way to a radical mastoidectomy. It is the clinical acumen that will determine the type of surgery for a given cholesteatomatous ear, algorithms being of little use in the complex situation of a pathological condition with infinite variables. However, even when the most suitable surgical modality is chosen by the best of surgeons, the operated ear will still be left with the innate cause of the cholesteatoma, namely, its physiopathologic background and its tendency to develop a negative gas balance in the middle ear. Because of this tendency to redevelop negative middle ear pressure, insertion and reinsertion of ventilation tubes are often necessary to prevent recurrent retractions and maintain aeration of the middle ear in posterior tympanotomies and modified radical mastoidectomies. Further, when the mastoid bowl is marsupialized, as in radical and modified radical mastoidectomies, the mastoid bowl is often not self-cleansing, thus periodically requiring the help of the otologist to keep it clean and dry. My study consisted of a long-term follow-up of 368 cholesteatomatous ears, which were operated on according to 6 different surgical modalities, ie, 112 radical mastoidectomies, 88 modified radicals, 72 posterior tympanotomies, 52 atticotomies, 36 deliveries, and 8 obliterations. Of the 368 ears, 11% did not require any postoperative toilet, whereas 89% required revisiting the surgeon periodically on an average of every 5 months, for cleansing of the mastoid cavity or securing the aeration of the middle ear by reinserting a ventilation tube.