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
