© Borgis - New Medicine 2/2001, s. 11-13
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.
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