Comparison of Totally Endoscopic Surgery versus Combined Approach Tympanomastoidectomy for Cholesteatoma in the Mastoid Antrum

By June 10, 2019

Chayaopas, Nichtima1,2; Cushing, Sharon1; Papsin, Blake1; James, Adrian1
1 Department of Otolaryngology – Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Canada;
2 Khon Kaen Ear, Hearing and Balance Research Group, Department of Otorhinolaryngology, Khon Kaen University, Thailand.

An atticoantrostomy, created with drill or curette, can provide adequate access to remove cholesteatoma from the mastoid antrum using trans-canal totally endoscopic ear surgery (TEES).  Reconstruction of the canal wall defect with tragal cartilage can maintain integrity of the canal wall. Recidivism outcomes from this approach are compared with combined approach canal wall up tympanomastoidectomy (CWU).

– Study Design:
Prospective observational comparative study
– Setting:
Tertiary referral center
– Patients:
74 ears, mean age 11.4 years (3.9 – 17.3), with intra-operative finding of cholesteatoma extending into, but not beyond, the mastoid antrum.
– Interventions:
First surgery for cholesteatoma using either TEES atticoantrostomy with cartilage reconstruction or CWU without mastoid obliteration.

– Main Outcome Measures:
Rates of residual and recurrent cholesteatoma
– Results:
Follow up of >1year was available in 11/16 TEES cases and 56/58 CWU (maximum 3.4years and 12years respectively). Of these, residual cholesteatoma was present in 1 (9%) and 11 (20%) respectively (NS, Fisher Exact Test), and recurrent disease in 4 and 11 cases respectively. Survival analysis to account for follow up duration showed recurrent cholesteatoma rates of 36% and 21% respectively (NS, Kaplan Meier Log Rank).

Antral cholesteatoma can be resected effectively with TEES atticoantrostomy with a low risk of residual cholesteatoma. Adequate reconstruction can be challenging with the smaller pediatric tragal donor site as demonstrated by the risk of recurrent cholesteatoma. Although TEES atticoantrostomy has less post-operative morbidity, early results suggest that cholesteatoma recurrence is not prevented and with longer follow up may prove to be more likely than with a conventional CWU tympanomastoidectomy, at least in children.