Portuguese Version

Year:  2001  Vol. 67   Ed. 2 - (1º)

Artigos Originais

Pages: 142 to 146

Efficacy of Surgical Treatment of the Chronic Otitis Media with Cholesteatoma.

Author(s): Oswaldo L. M. Cruz*,
Cristiane A. Kasse**,
Fernando D. Leonhardt***.

Keywords: chronic otitis media, cholesteatoma, mastoidectomy, canal wall down technique, canal wall up technique

Abstract:
Objective: Evaluate the results of surgical treatment for chronic otitis media with cholesteatoma. Canal wall down and intac canal wall procedure with tympanoplasty was performed. Study design: Retrospective chart review. Material and method: Data were analyzed from 36 patients (39 ears) available for clinical and audiometric studies with a minimum follow-up of 18 months. Sixteen cases (41,02%) underwent intact canal wall surgery with tympanoplasty, and 58,98% (N=23) underwent canal wall down surgery with reconstruction of the conductive system. Results: The recurrence rate of cholesteatoma was 12,5% (N=2) on intact canal wall procedure and 4,34% (N=1) on canal wall down. A safe and dry middle ear was achieved in 75,0% (N=12) of intact canal wall procedure and in 78,26% (N=18) of canal wall procedure. Regarding the functional hearing results, the intact canal wall group maintained the same level of pre-operative SRT. A slight increase on post-operative SRT level was observed on the canal wall down group (4 dB). Conclusion: For patients with cholesteatomatous chronic otitis media either intact canal wall mastoidectomy with tympanoplasty or canal wall down with reconstruction of conductive system showed satisfactory results regarding the control of the cholesteatoma, once observing strict criteria for the indication of each technique. Better functional results could be expected with intact canal wall procedures.

INTRODUCTION

Cholesteatoma was the term initially used by the German anatomist Johannes Muffler, in 1838, to describe a pearled laminated tumor formed by fat and cholesterol crystals dispersed into polyedr is cells. Later, Friedmann8 defined it as a cystic formation recovered by stratified squamous epithelium that lied on a fibrous stroma of variable thickness, which could maintain elements of its original lining. Schuknecht 14 described it as a accumulation of exfoliated keratin inside the middle ear, or any other pneumatized are of temporal bone, arising from the keratinized squamous epithelium.

Thanks to a better understanding of its histopathological structure, the name cholesteatoma has been questioned from an etymological viewpoint: it does not really have cholesterol crystals (chole-) inside it, it does not have fat (-stea-) and its tumor nature is controversial (-oma). One less discussed term that is rarely used is keratoma, as introduced by Schuknecht 14. From a histopathological standpoint, cholesteatoma associated with chronic otitis media may be defined as a destructive lesion, which contains fibroblasts, keratinocytes and inflammatory cells, affecting the eardrum, mastoid process or both 6.

As to its origin, cholesteatomas may be classified into two categories - congenital and acquired. Congenital cholesteatoma are defined, according to Derlacki and Clemis 5, as epithelial tissue debris behind an intact tympanic membrane and with no history of previous infections. Levenson et all ¹°. changed this definition when they acknowledged the congenital origin in some selected cases with positive history of otitis. Nevertheless, they arise from epithelial debris left behind by the auditory cleft because of alterations during embryonic development. Other temporal bony regions may also have congenital cholesteatomas.

Acquired cholesteatomas are divided into two subgroups: primary cases, which develop from the retraction of tympanic membrane, with no compulsory association with repetitive infections, but with some occasional infectious outbreaks from the cholesteatomatous sac. Secondary, formed by the migration of epithelium from the auditory external canal, through marginal perforations of the tympanic membrane caused by middle ear chronic infection, or squamous metaplasia of respiratory epithelium of auditory cleft induced by chronic inflammation.

The clinical presentation of cholesteatomatous chronic otitis media depends on the extension and the etiological aspect of the disease. In case of lesions that have arisen from the tympanic retraction, they may be left unnoticed for a long period of time, until they become more extensive and symptomatic. In secondary cholesteatoma, repetitive infectious episodes are predominant. Once established, they normally cause hearing loss and otorrhea.

In some occasions, intratemporal or intracranial complications may occur and be associated with otalgia, vertigo, sensorineural hearing loss and headache.

Otorrhea is not normally abundant, but it has a foul smell and does not respond to treatment. Hearing loss is almost always present at diagnosis and it is directly related to the degree of destruction of the tympanic-ossicle chain and labyrinthic impairment. However, the cholesteatomatous mass per se may play the role of sound conductor, masking ossicle chain destruction. Bleeding, a symptom that is relatively common, may occur from granulation tissues that occupy the middle ear or are exteriorized on the external auditory canal (EAC) as polyps. Otalgia is not very frequent, but if present, it may represent reactivation of a stable cholesteatoma, infection of EAC skin, or presence of complications such as mastoiditis or extradural abscess. Vertigo and sensorineural loss may originate from a labyrinthic fistula caused by erosion of bone labyrinth, or passage of toxins from the middle ear into the internal ear, providing serous labyrinthitis. Sudden headache in patients with active cholesteatomatous chronic otitis media may show intracranial complications.

The most efficient treatment for cholesteatomatous chronic otitis media (CCOM) is surgery, using mastoidectomy. For two centuries now, the procedure has focused on the eradication of the disease, with no special attention given to the functional portion of the middle ear. Radical mastoidectomy, a term introduced by Von Bergman²° in 1889, advocated total cleaning of mastoid, including the destruction of posterior and superior wall of EAC, in order to eradicate the affection and to exteriorize the tympanic cavity and the mastoid, enabling direct visual control of any cases of recurrence or the manipulation of the cavity. Standardization of the technique was proposed by Zaufal²² and Stacke 16. Concerns regarding hearing were present only at the end of the 19th century and beginning of 20th century, generating modifications in the radical classic mastoidectomy. Initially proposed by Jansen in 1893², and consolidated in 1910, after the publication by Bondy¹ that described the preservation of the tense portion of the tympanic membrane and the ossicle chain, it produced functional satisfactory results. At the beginning of the 50's, Wüllstein²¹ and Zöllner 23 introduced tympanoplasty with reconstruction of tympanicossicle system, even in cases of chronic otitis. At the end of the 50's, House Ear Clinic, in Los Angeles, started to use mastoidectomy with preservation of the posterior wall of EAC, the so called close or wall up technique, that is still in use, has motivated the discussion about the efficacy of wall down x wall up techniques. We believe that it is due to the fact that the choice of surgical technique for treatment of CCOM is based on complex criteria. There is no consensus as to the best surgical procedure. Extension of cholesteatoma, conditions of middle ear mucosa, tympanic membrane, upossicle chain, the role of Eustachian tube and the functional status of the inner ear, should all be taken into consideration.

Based on all these reasons, we thought that it would be convenient to conduct a review of outcomes of people who dedicated to the treatment of this complex entity, in order to contribute to the definition of the best therapeutic strategy.

The purpose of the study was to assess outcomes of canal wall up and wall down mastoidectomy in 39 cases of CCOM using a retrospective analysis.

MATERIAL AND METHOD

We included in the present study 39 ears (36 patients) submitted to canal wall up and wall down mastoidectomies between 1990 and 1999. Surgeries had been performed by the same surgeon, following always the same standardization and the same criteria for selection of one or the other technique. Indication for wall up technique was given in cases restricted to attic and aditus of antrum, especially those encapsulated, with the remaining middle ear mucosa and tympanic ostium of the Eustachian tube in good shape. In cholesteatomas that extended beyond the aditus, such as the involvement of supra-tubarian recess, extensive impairment of facial recess and tympanic sinus, associated with bad conditions of the rest of the middle ear mucosa and presence of granulation tissue or cholesterol granuloma, plus non-functional auditory tube, wall down mastoidectomy was selected. All patients that had previously undergone surgery in other services and had recurrence of cholesteatoma or complications were selected for wall down technique. Surgical techniques employed have already been described in details'. In all cases, we decided to include the functional portion of the procedure during the first surgery, in both techniques.

Out of 39 cases included, 35.89% (N=14) were female and 64.11% (N=25) were male subjects. Ages ranged from 2.5 to 67 years, and 41.02% of the patients were children (ages up to 12 years; N=16), and 58.98% (N=23) were adults, mean age of 24.8 years. The time between clinical diagnosis and surgery varied from one month to 30 years, mean of 6.16 years.

Among the patients, 30.76% (N=12) had been operated previously in other services, as follows: 8.33 % (N=1) to place short-term ventilation tubes, 8.33 % (N=1) for tympanoplasty, and 83.33% (N=10) for mastoidectomy Out of these total, 40% (N=4) had been operated on more that once - one case had been submitted to four previous surgeries and the others to two previous surgeries.

Patients were divided into two different groups - one formed by patients submitted to canal wall up mastoidectomy, totaling 41.02% (N=16) of the cases; and the other formed by subjects submitted to canal wall down mastoidectomy, amounting to 58.98% (N=23) of the cases. Follow-up took place for a minimal of 18 months up to 10 years. We observed recurrence of disease, relapse of cholesteatoma, complications, functional outcome, pre and post-op speech reception threshold (SRT), and the need for further surgical interventions in one and the other group.

RESULTS

When analyzed regardless of the surgical technique used, the 39 operated cases did not present significant alterations concerning functional outcomes, comparing pre and post-op SRT. The levels of pre-op SRT varied from 15 to 70 dB, mean of 41.36 dB, and post-op SRT values ranged from 5 to 85 dB, mean of 45.69 dB. Post-op SRT was lower or equal to 30 dB in 25.64% (N=10) and higher than 30 dB in 74.36% (N=29) of the cases.

When analyzed individually, the group of patients submitted to wall down technique had pre-op SRT mean of 50.41 dB and post-op mean of 54.47 dB, whereas the group submitted to wall up technique had SRT mean of 30.5 dB and 29 dB, respectively.
As a whole, the most common post-op complications were: granulation tissue in 23.07% (N=9) of the cases, resolving spontaneously or requiring ambulatory cauterization; retraction of tympanic membrane graft in 12.82% (N=5); final perforation of tympanic membrane with dry ear in 5.12% (N=2); dehiscence of tympanic tegument in 2.56% (N=1); mild stenosis on the external third of EAC in 2.56% (N=1); mastoid abscess in 2.56%(N=1); acoustic trauma, with high frequency (4, 6 and 8 kHz) sensorineural loss in 5.12% (N=2) of the cases.

The most frequent complications in patients submitted to wall down mastoidectomy were granulation tissue in 30.4% (N=7), clinically controlled in 21.7% (N=5) but with 8.69% (N=2) of the cases that required review because of granulation caused by foreign body granuloma of hydroxyapatite; graft retraction in 8.69% (N=2); high frequency sensorineural loss in 8.69% (N=2); dehiscence of tympanic tegument in 4.34% (N=1); narrowing of contralateral opening in 4.34% (N=1); perforation of tympanic membrane flap in 4.34% (N=1).

In the wall up technique, the most common ones were graft retraction in 18.75% (N=3), recurrence of cholesteatoma in 12.5 % (N=2), and in one case it happened nine years after the first surgery and presented as a mastoid abscess; eczema of external auditory canal in 6.25% (N=1); granulation tissue in 6.25% (N=1), controlled in the outpatient unit; tympanic perforation in 6.25% (N=1); narrowing of the external third of the EAC in 6.25% (N=1).

Twenty-six point eight percent (26.08%) of the cases submitted to the wall down technique required a new surgery (N=6), whereas 37.5% (N=6) of the cases of wall procedure needed it. The surgical findings of reintervention for the first group were hydroxyapatite granuloma in two cases, dehiscence of tympanic tegument in one case, recurrence of cholesteatoma in one case, narrowing of contralateral opening in one case, perforation of graft in one case. In the wall up technique, the findings were chronic noncholesteatomatous inflammatory process in one case, hydroxyapatite in one case, recurrence of cholesteatoma in two cases - one of them had mastoid abscess with recurrence of the disease nine years after the first surgery, tympanic perforation in one case and review because of cicatricial blockade in the external 1/3 of EAC one year after surgery

As to eradication of the disease, it was achieved in 95.65% (N=22) of the cases submitted to canal wall down mastoidectomy and in 87.5% (N=14) of the cases operated with canal wall up technique in the first intervention. The disease was eradicated in all cases after the second intervention.

DISCUSSION

Treatment of cholesteatomatous chronic otitis media is primarily surgical and its main purpose is to eradicate all affected tissue, providing a dry and safe middle ear, that is to say, free of infection and complications. However, the need for careful and prolonged post-op follow-up is always stressed, because of the significant rate of recurrence. Maintenance or recovery of hearing is considered secondary goals, but they should be necessarily considered when choosing the surgical technique. Thanks to the improvement in eradicating the cholesteatoma, recovery of hearing started to play a key role in the final assessment of surgical outcomes.

Therefore, cholesteatomatous otitis media surgical approaches have changed a lot since radical classic mastoidectomy, which was considered the only possible way to treat cholesteatoma in previous centuries, resulting in hearing sacrifice inherent to the technique. Since the 50's, thanks to the techniques introduced by Wüllstein and Zöllner 21,23 the reconstruction of tympanic-ossicle system started to be emphasized, resulting in the development of tympanomastoidectomy. Canal wall down tympanomastoidectomy started to be largely used. However, due to difficulties of
post-op management because of the resulting large cavities, associated with the description by Jansen in 1978, it enabled the development of wall up tympanomastoidectomy (intact posterior wall with opening of facial recess). The possibility of preservation of anatomy of the middle ear and better auditory gain attracted otologists. Since then, the discussion about the use of one or the other surgical technique has taken the center stage in otolopy and no consensus has vet been reached. Recently, reconstruction of columella system and reduction of surgical cavity at wall down mastoidectomy produced very satisfactory outcomes, and consequently hearing sacrifice is no longer a limiting factor to the use of the procedure.

In our opinion, canal wall up mastoidectomy may be used to treat CCOM, especially in cases of secondary cholesteatoma acquired after the retraction of the flaccid portion of the tympanic membrane, restricted to the attic and showing good general mucosal conditions of middle ear and mastoid; however, it still requires a very strict post-op follow-up. In stable cases, once the ear is kept infection-free and with general good otoscopic aspect, we do not believe that a second surgical look should necessarily be performed, as suggested by some authors. Clinical observation, associated with imaging control, should be enough to guide for the appearance of recurrence and the need for re-intervention.

In cholesteatomas that extend beyond the limits of the attic, reaching the antrum or the region of the anterior attic and supra-tubarian recess, or when associated with important alterations of residual mucosa, such as granulation tissue, cholesterol granuloma and hyperplasia, it is preferable to employ canal wall down mastoidectomy with, reconstruction of sound conducting system and reduction of surgical cavity, if necessary. Reduction of cavity, with occlusion of the tip of the mastoid and sinus-dural angle with hydroxyapatite, decreases the need for post-op maintenance and offers better esthetic and technical results at meatoplasty. Functional reconstruction of the tympanicossicle system should be conducted whenever there is cochlear reserve compatible with improvement in hearing.

In our study, functional outcome was considered reasonable for both techniques. Generally speaking, the mean levels of SRT pre-operatively were maintained and 25.64% (N=10) of the cases presented SRT < 30dB and 74.36% (N=29) presented SRT>30dB. With the wall up technique, we obtained improvement in the mean post-op SRT. We should point out that the cases selected for the wall down technique had clearly poorer pre-op hearing, which may suggest more difficulty to reconstruct middle ear and justify less satisfactory results. According to the literature, the most frequently used index to compare results is air-bone difference; it should be below 30dB in order to be considered a satisfactory functional outcome13,15,19. Nevertheless, reduction of gap may not express, in fact, the functional outcome, since gap may disappear because of the presence of a sensorineural loss (drop of bone thresholds). Therefore, we prefer SRT because, in our opinion, it reflects better what the social hearing capacity really is.

The rate of recurrence of cholesteatoma was considered very satisfactory, reaching 12.5% (N=2) in the wall up technique and 4.34% (N=1) in the wall down technique. According to the literature, the same rate has ranged from 5% to 40% with the wall up technique and between 2% and 21% with the wall down procedure11,12,15,17,19.

The rate of dry ears obtained after the first intervention was 75.0 % (N=12) for the wall up technique and 78.62 % (N=18) for the wall down technique, and all cases that required re-intervention obtained resolution. The same rate ranged in the literature from 90 to 96% with the wall up technique 7, 9, 18, 19 and from 79 to 95% with the wall down technique 7, 9, 19. In order to obtain a dry ear it is essential to have a very careful immediate post-operative process. The control of formation of granulation tissue and cicatricial stenosis may be reached with ambulatory interventions at this phase.

CONCLUSION

Surgical treatment of cholesteatomatous chronic otitis media through mastoidectomies may provide efficient rates for the control of diseases and dry ears, provided that we comply with the strict criteria of indication of one or the other technique. Wall up mastoidectomy has shown better functional outcomes, although it presented higher recurrence of cholesteatoma (12.5%) when compared with the wall down technique (4.25%).

REFERENCES

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* Professor of the Discipline of Pediatric Otorhinolaryngology at Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP - EPM). Full Professor at FMUSE
** Postgraduate studies (Master degree) under course at the Discipline of Otorhinolaryngology, Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP - EPM).
*** Resident Physician of the Discipline of Otorhinolaryngology at Universidade Federal de Sao Paulo - Escola Paulista de Medicina (UNIFESP - EPM).
Study conducted at the Discipline of Otorhinolaryngology, Sector of Otology at Universidade Federal de São Paulo - Escola Paulista de Medicina.
Study presented at 35° Congresso Brasileiro de Otorrinolaringologia, awarded with a special citation.
Address for correspondence: Fernando Danelon Leonhardt - Rua Bandeira Paulista, 142 - Apto. 22 - 04532-000 São Paulo /SP - Tel: (55 11) 3068-0103. E-mail: fernandodanelon@uol.com.br
Article submitted on August 15. 2000. Article accepted on October 20, 2000.

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