Surgical strategy for cholesteatoma in children

Surgical strategy for cholesteatoma in children.


We reviewed our experience with childhood cholesteatoma in children under the age of 16 years. Based on cumulative postoperative data and intraoperative findings(pathologic condition) we propose a modified canal-wall-up technique in conjunction with a planned, staged operation.

The goal is to eradicate cholesteatoma  from the middle ear and mastoid. It is important to fit the procedure to the pathologic condition found at surgery.

For children who have small cholesteatoma, that is localised to the meso-or epitympanum  atticotomy can be  successful, but this type of cholestatoma was very rare in our practice. This small type is to be expected at the second stage  explorative tympanotomy.

We prefer to perform mastoidectomy and middle ear surgery and to preserve the ossicular chain.

If we have to remove a part of ossicular chain, because it is damaged by the disease (ossicular erosion) or we need to have more place for the cholesteatoma eradication, we do not restore the chain  continuity at the first stage. We usually plan  a second stage explorative tympanotomy to check  the middle ear cavity, to remove residual or recurrence cholesteatoma, if there is, and restore the continuity of the ossicular chain.

However, when the cholesteatoma is ingrowing into the antrum or more, we perform an extension of the complete simple mastiodectomy (posterior tympanotomy), that allows better visualisation of the facial recess without removing the canal wall.

Canal wall down procedures are usually performed when the cholesteatoma is extensive and the complete, safety removing is uncertain.

Modified  radical mastoidectomy (this is the conservative radical operation) is a type of operation which  usually performed when a cholesteatoma can not be removed without removing the posterior canal wall, but the tympanic membrane (pars tensa) and some or all ossicles are left.

Radical mastoidectomy /radical operation when we create a common single cavity with removal the posterior ear canal wall, the eardrum, the malleus and the incus opening the epitympanum, the mastoid. Only the stapes or the footplate remains. This type of operation is only indicated when there is  extensive cholesteatoma in the middle ear and mastoid that can not be removed by a less radical procedure.

The second stage should be considered 6 months after the initial procedure, because the residual or recurrent cholesteatoma  grows more rapidly in children than in adults.

We are not agree such an opinion, that a second stage procedure may not be necessary  if the surgeon is convinced the disease was totally removed at the initial operation. Can he be so sure?

Cholesteatoma is more invasive in children than in adults

There is a higher rate of residual or recurrent cholesteatoma after intact canal wall mastoidectomy-tympanoplasty procedures in children.

Poor Eustachian tube function which would put them at risk for development of recurrent or chronic middle-ear effusion and led to development of initial cholesteatoma can recur, particulary in the posteriosuperior  or pars flaccida area.

Another aspect: second-stage procedure may not be necessary if the surgeon is convinced the disease was totally removed at the initial operation, if the tympanic membrane is translucent without evidence of progressive disease medial to the eardrum after the surgery, and if the hearing stable during the postoperative follow-up period. Has somebody another opinion?

To use needle endoscope to remove  remnant cholesteatoma, but if a small part of chol  remains somewhere in the middle ear? Has any experience in connection with this method?

Children must be observed by periodic examination for years. If severe atelectasis or retraction pocket develops,  prompt myringotomy and insertion of a tympanostomy tube are indicated.

Alternative approach for small attic cholesteatoma is atticotomy.

The recommendation is to select the operative procedure that most probably will give the best outcome for that individual child.

When tympanoplasty is performed in children at the same time that mastoidectomy is performed to eradicate a cholesteatoma, the result of the tympanoplasty  may have poor outcome.

Failures of the tympanoplasty are high negative middle-ear pressure, a retraction pocket, recurrent or chronic otitis media with effusion or recurrence of cholesteatoma.

Artificial ventilation of the middle ear must also be provided by a tympanostomy tube.

When tympanostomy is performed in children who have a defect is posterosuperior quadrant of the pars tensa , the pars flaccida or both cartilage should be placed to support the grafted tympanic membrane and thus prevent recurrence of cholesteatoma.

After radical mastoidectomy poorly functioning Eustachian tube  may have to be closed surgically to prevent the reflux of nasopharyngeal secretions resulting  inflammation and otorrhea.

Intraoperative monitoring   of the facial nerve during surgery has been advocated.

The operation must be tailored for each child.

Other factors: patient’s age, presence or absence of  otitis media, Eustachian tube function and availability of health care.

We had a twin

Some function may be preserved


Thoughts about the basic principles of parotid surgery

Thoughts about the basic principles of parotid surgery

Do you perform subtotal parotidectomy in the event of a Warthin’s tumour?


Dr.Huszka, Janos; Dr.Pacz, Zoltan ; Dr. Balazs, Gyorgyike; Dr. Csiky Marta

Szent Istvan Hospital, ENT&Maxillofacial Surgery Dept.



The thought-provoking title of this presentation originates from a self-critical learning process of parotid surgery.

Biopsy or enucleation of the parotid tumor should not be carried out. Correct minimal treatment is parotidectomy (subtotal or total, sometimes partial). This is the basic principle of parotid operations at our ENT Department. The answer to the question proposed by the title will be yes by the end of this lecture on the bases of the following:

Papillary cystadenolymphoma or Warthin’s tumor was most frequent benign lesions (66 cases, 36%, in 185 parotid operations in last 6.5 years) at the author’s department.

A review of the scientific literature on Warthin’s tumor characteristics and treatment types will be performed.

The author analyzed  his 66 cases (62 patients) and the results were:

  • 14 patients had multifocal (2,3 or more focus) Warthin’s tumor.
  • 1 adenocarcinoma, 1 pleomorphic adenoma, 1 bening lyphoepithelial lesion was found not close connection to but in the same gland as the Warthin’s tumor.
  • It means 17 (27%) unusual cases.
  • The preoperative examinations (palpation, ultrasonography, CT, MRI, fine needle aspiration cytology) did not prove the multiple of tumor in 90% of cases.
  • Malignant transformation of the Warthin’s tumor is rare but occurs.
  • After enucleation of the tumor additional neoplasm could develop and the reoperation will be more difficult, endangering the facial nerve.
  • In the experienced hands of the operating surgeon the chance of injury of the facial nerve is minimal.
  • The interest of the patient should be above any other consideration.

Rare parotid tumor


Authors: János Huszka MD and Gábor Katona MD, PhD

Institutions: Szent István Hospital, Dept.of ORL, Head & Neck Surg. Budapest/ Hungary

Heim Pál Pediatric Hospital, Dept. ORL & Bronchology  Budapest/Hungary


Salivary gland neoplasm represent rare lesions, accounting for fewer then 5% of tumors head and neck. In the literature only a few cases of malignant parotid tumors in childhood under the age of 5 have been reported. The most frequent malignant neoplasm is mucoepiermoid carcinoma which is followed by other types of less frequently occurring malignant tumors but, because of their rarity they are at risk of misdiagnosis and subsequent mistreatment.

During the last 4-year period (1999-2003) 144 parotid operations were performed. Among the operated patients there were only 2 children. A 16-year-old girl had acinic cell carcinoma and a 2-year-old boy had a very rare parotid malignant tumor. The last mentioned case caused serious diagnostic problem to the pathologists. We will introduce this case to you in the followings.

A 2-year-old boy was referred to our department with an asymptomatic 3 cm slightly tender mass located in the right pre-and sub-auricular region, which had been discovered 6 weeks before and had had a progressive growth. Clinical examination showed a slightly mobile, painless node without any fixation to the overlying skin. We observed some palpable lymph nodes in close connection to the tumor on the neck. Facial movements were normal. The remainders of the physical examination and laboratory investigations were unremarkable. After MRI fine needle aspiration biopsy (FNA) was performed under ultrasound scan. FNA result was a rare, specific malignance tumor. Immunohistochemical reactions precluded the possibilities of lymphoma malign and ganglio-neuroblastoma and rhabdomyosarcoma, but probably it is a rhabdoid tumor.

Total parotidectomy with preservation of facial nerve and upper modified neck dissection was performed. The tumor was located in the deep lob, under the main trunk and branches of the facial nerve. The styloid-muscles near the styloid process were involved by the neoplasm and it reached to the parapharyngeal space. The involved muscles were resected. In the upper modified neck dissection we removed the upper and mid-jugular nodes, the subdigastric nodes and the upper accessory nodes. The submandibular gland, the accessory nerve, the sternocleidomastoid muscle and jugular vein were preserved. Intraoperative frozen section showed the same result as FNA, and the investigated lymph nodes did not contain any signs of malignancies.  The child had facial movement disturbance after the operation.

Before the end of our presentation we would like to show a short video about the operation.

The histological diagnosis has been difficult; we are still waiting for it. Hopefully we can discuss this interesting case with you in the congress, already knowing the exact histological diagnosis.

The child is receiving chemotherapy at present.