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© Borgis - New Medicine 2/2001, s. 11-13
Andrzej Makowski
Cholesteatomatous chronic otitis media in children. Results of surgical treatment
Department of Otolaryngology, Institute of the „Polish Mother” Health Centre in Łódź
Head of Department: Ass. Prof. Andrzej Makowski, MD.
Retrospective evaluation was made of the results of surgical treatment of cholesteatomatous otitis media in 51 children (F – 15, M – 36) aged from 4 to 18 years, hospitalized over the years 1976-2000 in the Department of Otolaryngology of the Institute of the „Polish Mother” Health Centre in Łódź. The extent of the cholesteatomatous process, and progression of the process of destruction of the auditory ossicles revealed in 50% of the operated ears, were estimated. Comparison was made of the cholesteatoma recurrence rates depending on the mastoidectomy technique used. With CWD procedures cholesteatoma recurrence occurred in 32.1%, and with ICW procedures in 36.3% of the operated ears. Emphasis is laid on the fact that the rate of cholesteatoma recurrence after ICW operations makes it necessary to perform a surgical revision procedure and to keep the child on a long-lasting postoperative follow-up.
Surgical treatment of chronic otitis media (c.o.m.) with subsequent hypoacusis is the subject of many publications. The objective of surgery performed on the middle ear in c.o.m. is as follows: 1/ removal of the pathologically altered mucous membrane and the middle ear bones in order to obtain a dry and safe ear; 2/ selection of an optimal surgical procedure which can protect against the recurrence of disease, and 3/ maintenance of socially serviceable hearing.
It is generally believed that cholesteatomas in children´s c.o.m. present a more aggressive development that those of adults, owing to different anatomical and physiological conditions (16, 22). The child´s temporal bone is better pneumatized making the eradication of cholesteatomatous lesions more difficult, and an impaired function of their Eustachian tube, as well as a predisposition to otitis media, secondary infections of the cholesteatoma, and recurrent cholesteatomas, due to the formation of retraction pockets are very important. Buja et al. (2) have also revealed that the keratocytes proliferation index in children is higher than that of adults.
The next subject for consideration concerns the question of what type of mastoidectomy is more beneficial in children´s cholesteatoma: an intact canal wall (ICW) procedure or a canal – wall – down (CWD) procedure, with the removal of the posterior meatal wall. Differences between CWD mastoidectomy and ICW mastoidectomy refer to the facility in eradication of pathological lesions, possibility of disease recurrences and the time needed for the postoperative healing of the ear (4, 6, 9).
Surgery for chronic otitis media with cholesteatoma using an ICW technique is diffcult, particularly with regard to exposure of the facial recess and tympanic sinus, which requires a surgical approach from the side of the external auditory meatus. Eradication of lesions from the epitympanum of the deep tympanic sinus and from the stapes is also difficult. Conservation of the posterior meatal wall predisposes to the formation of retraction pockets in the post – operative period, and to recurrent/residual cholesteatomas which appear more often with ICW than with CWD procedures. It is a principle that within a few months of an ICW mastoidectomy, a revision operation („second look”) should be performed to check the accuracy of cholesteatomatous lesion eradication.
A mastoidectomy performed with a CWD procedure allows a precise insight into the structures of the middle ear and easier eradication of cholesteatomatous lesions. However, the mastoid antrum tales long to epithelialise, and therefore infection of the postoperative cavity develops more often. After CWD operations patients require longer postoperative care, and this is why certain techniques combining ICW and CWD methods have been advocated. Cholesteatomatous lesions are eradicated after removal of the posterior meatal wall, but the procedure is finished by reconstruction of this wall. For this purpose various materials are used (fascia with cartilage palisade – Heermann (8), proplast – Johns (10), glass – ceramics –Reck (13), hydroxyapatite plates – Black (1), or the posterior meatal wall is reconstructed with soft tissue – Takahashi et al. (20).
Comparison of postoperative results obtained in c.m.o. with cholesteatoma in children using the ICW and CWD techniques has been the subject of many studies (3, 5, 7, 11, 12, 15, 17-23).
In the period 1976 to 2000, 51 children (M – 36, F – 15) aged 4-18 years with chronic cholesteatomatous otitis media were operated upon in the Department of Otolaryngology of the Institute of the „Polish Mother” Centre in Łódź. The postoperative follow-up period was from 12 months to 4 years. Mastoidectomy with the ICW procedure was performed on 31 ears, and with the CWD procedure in 30 ears. The extent of cholesteatomas in the operated ears was high, and in one half of the cases they involved the tympanic cavity and the mastoid structures (table 1).
Table 1. Location of cholesteatoma and its recurrences.
Location of cholesteatomas Number of cholesteatomas/ /Number of recurrences
Attic 5
Attic + Antrum 3
Attic + Tympanic cavity + Mastoid process 18/5
Attic + Tympanic cavity 3
Attic + Mastoid process 3/1
Antrum + Tympanic cavity 4/2
Tympanic cavity 25/6
The progression of a cholesteatomatous destructive process in the operated ears is shown by the condition of the auditory ossicles. Destruction of the long processus of the incus was found in 29 ears (47.5%), and destruction of the stapes suprastructure in 23 ears (37.5%). In 6 cases the cholesteatoma destroyed the osseous wall of the facial nerve canal, in 7 ears destruction of the osseous wall of the sigmoid sinus and of the antrum tegmentum with exposure of the dura mater was observed, and in one patient thrombotic inflammation of the sigmoid sinus developed.
After the first operation on the middle ear residual cholesteatomas appeared in 21 ears – they were situated 13 times in the tympanic cavity (in the attic, tympanic sinus and facial recess) and 3 times in the tympanic cavity and antrum. In five cases the cholesteatomas had considerable proportions, involving all structures of the middle ear, in patients treated in another centre or in those who did not submit to periodic check – ups in the postoperative period.
In 28 ears mastoidectomy was performed with the „wall down” technique, and residual cholesteatomas were found in 9 cases (32.1%). In 33 ears operated on with the „wall up” technique cholesteatoma recurrences were noted in 12 cases (36.3%). A total of 34.4% of recurrences of cholesteatomatous lesions were revealed in the operated ears. Of 28 operations with the ICW technique, 6 required a second operation with removal of the posterior meatal wall. For eradication of a cholesteatoma after a first surgical procedure using the CWD technique, two patients required a twice – repeated operation and one had to have surgery three times. Postoperative cholesteatomas which occurred in the children´s ears were residual in character, and in only 3 cases could be classified as recurrent after myringoplasty or due to the formation of retraction pockets.
The results of surgical treatment for cholesteatomatous chronic otitis media in children still remain the subject of many studies. Consideration has been given in analyses to the relationship between the type of mastoidectomy, with a preserved or removed posterior wall of the external auditory meatus, and cholesteatoma recurrences and the state of hearing (3 – 23). In view of the fact that the occurrence rate of recurrent residual cholesteatomas is twice as high after operations in children as compared with operations in adults, the larger extent of cholesteatomas observed in children, and the more frequent infections of cholesteatomas with persistant inflammatory processes, it is recommended that operations in children be performed by stages – Sheehy (17). During the first stage attemps should be made to eradicate inflammatory and cholesteatomatous processes, and during the second stage – after checking the efficiency of the eradication – the sound – conduction system should be reconstructed. Although mastoidectomy with a preserved wall of the external auditory meatus may yield good results (6,15,20), operation with the CWD technique is preferable on account of the lower number of cholesteatoma recurrences resulting from it. Mastoidectomy performed with the CWD technique is also recommended in children with only one hearing ear, in those encumbered with the risk of anaesthetic complications, and in those who cannot be expected to co – operate in the postoperative period. Operations with the CWD technique are recommended in cases with a small mastoid process, with a low – positioned tegmentum and an anteroposition sigmoid sinus, and in the presence of a fistula in the lateral semicircular canal. A decision about removal of the posterior meatal wall is usually made during the operative procedure.
A review of the literature has shown that the cholesteatoma recurrence index in children after mastoidectomies varies from 7.8 to 57% – averaging 30% (7, 17, 23). With the use of the ICW technique cholesteatoma recurrences were from 6 to 40% (17, 21), and with a CWD technique they were half as frequent, from 2 to 20% (14,15). Only Tos and Lau (21) did not observe a difference in the rate of cholesteatoma recurrence depending on the type of mastoidectomy. In our own material the number of postoperative cholesteatoma recurrences after mastoidectomies of the CWD type amounted to 32.1%, and after those of the ICW type 36.3%. This agrees with average values in the literature. One must agree with those authors who draw attention to the fact that the index of postoperative cholesteatoma recurrences rises with large cholesteatomas, up to 63% – Stangerup (19), and in ears in which destruction of the auditory ossicles has occurred. According to Fisch (15), the most common sites of recurrence of inflammatory and cholesteatomatous processes are, in sequence: epitympanic – 89%, extralabyrinthine – 58%, extrafacial – 29%, and the region outside the sigmoid sinus – 16%. One of the factors conducive to postoperative recurrences of cholesteatoma in children is dysfunction of the Eustachian tube (14). It is recommended, in order to improve the function of the tube and prevent accretion of the tympanic membrane to the promontorium, that during operation silicone strips or ventilating tubes be inserted into the tympanic cavity and tympanic membrane (6, 9, 19). Recurrent postoperative cholesteatomas in chronic otitis media are more common in younger children than in older ones (19). We found that small children with large cholesteatomas, bad ventilation of the middle ear and resorption of the auditory ossicles constitute a group at particular risk of cholesteatoma recurrence after operation, and they should be kept under observation and control for a period of years, postoperation. The recurrence rate of inflammatory processes and of cholesteatoma after operation also depends, apart from the above – mentioned factors, on the skill of the surgeon performing the operative procedure. This is why surgery on cholesteatomatous chronic otitis media in children should be performed only by experienced otosurgeons.
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New Medicine 2/2001
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