Residual Disease After Transcanal Totally Endoscopic Surgery versus Post-auricular Surgery for Meso- and Epitympanic Cholesteatoma in Children

By June 7, 2019

Dixon, Peter1; James, Adrian2
1 Department of Otolaryngology Head & Neck Surgery and Institute of Health Policy, Management & Evaluation, Univerity of Toronto, Toronto, ON, Canada;
2 Department of Otolaryngology Head & Neck Surgery, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Trans-canal totally endoscopic ear surgery (TEES) improves visibility of the tympanic cavity during cholesteatoma resection, but does not readily permit two-handed surgery as is possible with a post-auricular (PA) approach and operating microscope. Visibility or two-handed access may influence risk of incomplete surgical clearance leading to residual cholesteatoma. This study compares rates of residual cholesteatoma after TEES and PA for initial resection of disease limited to the meso- and/or epitympanum.

– Study Design: Prospective observational cohort
– Setting: Tertiary referral center
– Patients: 177 ears, median age 10 years (range 2-16), cholesteatoma limited to meso- and/or epitympanum, and at least one of 2-year follow-up, post-operative MRI, or second look surgery
– Interventions: TEES versus PA microscope approach with or without endoscope as an adjunct

– Main Outcome Measure: Residual cholesteatoma
– Results: Residual was detected in 4/65 (6.2%) of the TEES group and 12/112 (10.7%) of the PA group (NS, Fisher’s Exact). No difference in rate of second look surgery was detected between TEES (27, 41.5%) and PA (49, 43.8%) groups (NS, X2). Date of surgery was strongly associated with proportion of TEES cases, which increased linearly from 3% in 2011 to 93% in 2016 (R2 = 0.84, p=0.004).

There was no apparent advantage of the two-handed PA microscope approach as compared to TEES with respect to rate of complete surgical clearance of cholesteatoma limited to the meso- and/or epitympanum. Allocation to TEES was strongly associated with year of surgery, suggesting that learned surgical proficiency and comfort were primary determinants of surgical approach allocation rather than complexity of resection.