Both congenital and acquired cholesteatoma require surgery. The type of surgery for cholesteatoma depends on several factors, including a doctor’s results with various procedures in other patients, the patient’s age, and the extent of the cholesteatoma. Because of this, cholesteatoma surgery will always be a unique process for each child, parent and physician. The descriptions here are general. Please discuss specific questions with your otolaryngologist or otologist/neurotologist.
Surgical approach to the middle ear:
Small cholesteatomas are often described as pearl-like, and some can be removed directly through the ear canal. Going directly through the external ear canal is called transcanal or endaural; the ear drum is opened to provide access.
More commonly, a surgeon uses an approach from behind the ear, or postauricular approach. The surgeon makes an incision behind the ear, in an arc shape similar to the curve of the ear. This allows the surgeon to reach middle ear structures and the mastoid more extensively, to ensure the removal of cholesteatoma growth is complete.
Sometimes both of these approaches are used, so that the surgeon performs part of the operation(s) by going through the ear canal and another part from behind the ear.
There are many variations of procedures, but the first question here is what areas are being operated on. For most, a tympanoplasty or middle ear surgery is necessary. The term tympanoplasty is a general one for middle ear surgery.
Myringoplasty is specifically repair of the ear drum, sometimes using a skin graft surrounded by protective materials called packing (silastic sheeting). This procedure is almost always done in conjunction with a cholesteatoma removal but most surgeons use the more general term of tympanoplasty.
For cholesteatomas which extend into the mastoid, a mastoidectomy, or removal, is included.
Often these techniques are combined into what is called a tympanomastoidectomy.
Surgeries of the mastoid and middle ear may leave the external ear canal intact. This is called a canal wall up procedure (CWU); CWU procedures usually preserve as much of the middle ear structures as possible.
In other cases it may be necessary to remove/alter the external ear canal, resulting in a canal wall down surgery, often abbreviated as CWD. Many CWD procedures are characterized as a modified radical mastoidectomy, because the middle ear space is preserved. In a radical mastoidectomy, the Eustachian tube is plugged and middle ear space is not preserved.
When the ear canal is altered, it is a meatoplasty. Meatoplasty is often done in conjunction with the canal wall down procedure. This leaves the external opening to the ear enlarged.
In addition to the CWU and CWD procedures, a newer procedure called Canal Wall Window (CWW) or Canal Wall Reconstruction technique is sometimes used, particularly for children with more extensive cholesteatoma. Canal wall window attempts to preserve the canal space. The surgeon begins the procedure with a canal wall up approach. If the surgeon is unable to fully expose the cholesteatoma area, a slit or window is made in the canal wall, to provide further access. If the cholesteatoma can be sufficiently removed, the slit is later reconstructed with graft materials. If the cholesteatoma is not able to be removed, the surgeon may convert to a full canal wall down surgery during the operation.(15891650)
In canal wall reconstruction, the canal wall is taken down entirely, but then reconstructed using a graft. This procedure is also gaining popularity. A number of other hybrid approaches exist, but no single technique has emerged as a new comprehensive standard.
Other types of surgeries
Another type of surgery is confined to the upper middle ear, or the attic, space near and above the hearing bones. This is called an atticotomy. This may be used if a cholesteatoma is fairly limited to growth near the hearing bones. Atticotomy is more commonly associated with acquired cholesteatoma surgeries.
Ossiculoplasty pertains to repairing the hearing bones. If hearing bones are damaged and removed to prevent further spread of cholesteatoma, a surgical procedure to insert prosthetic devices meant to conduct sound to the cochlea is done. The inserted devices, usually made of titanium, are referred to as a PORP (partial ossicular reconstruction prosthetic) or TORP (total ossicular reconstruction prosthetic). ( 22591982)
Ossiculoplasty may be performed at the same time as a cholesteatoma removal, or it may be scheduled for a later operation when the surgeon is certain cholesteatoma has not returned in the ear. This depends on the extent of disease, type of surgical procedures used, and surgeon preferences.
Canal wall up, or canal wall down?
There is quite a bit of discussion among ear physicians around these procedures, because each carries with it some significant pros and cons. The canal wall down procedure has been performed for many decades, and was considered for a long time to be the “gold standard” in treatment. In the last 30-40 years, the canal wall up procedure has been extensively used in children with the hope of avoiding related mastoid cavity issues.
A canal wall up procedure preserves more of the natural ear structure, and as a result is said to be tied to more successful hearing outcomes, as well as requiring less maintenance. Someone with a canal wall up procedure usually does not have to take long term precautions to prevent water in the ear. For many surgeons, this is the preferred initial method, particularly in children and/or those with smaller cholesteatomas. The negative associated with this method is that cholesteatomas may be incompletely removed, and so multiple surgeries (“second look”) are used to manage regrowths. In some cases the regrowth or recurring of cholesteatoma occurs several times, at which time a surgeon may pursue a canal wall down method instead.
On the canal wall down side, the significant positive is that the technique is very effective at removal of cholesteatoma, and if regrowth occurs, it is usually more easily identified and managed. However, it is much more extensive, and typically someone with a canal wall down procedure must subsequently visit an ENT several times a year for manual ear clean outs, as the ear often loses the capability to remove wax itself. In addition, someone with a canal wall down ear must take extreme precautions concerning water in the ear to avoid infection. Finally, because this process usually removes several hearing bones, hearing outcomes are believed to be less successful.
The canal wall window technique is relatively newer, as are the canal wall reconstruction methods. These are believed to have the better hearing outcomes generally associated with a CWU procedure. It is also believed to have a return rate in between that of CWU (higher rate of returning cholesteatoma) and a CWD procedure (lower rate of return). However, surgical experience with this procedure remains somewhat limited and surgeons must identify the techniques with which they are the most familiar and successful.
Interesting discussion of this from 2010: http://www.enttoday.org/details/article/690073/The_Great_Debate_Canal-wall-up_vs__canal-wall-down_surgery_for_pediatric_cholest.html
Last updated: August 14, 2012 at 23:07 pm