Surgical Atlas of pediatric otolaryngology - part 2 pptx

Due to the lack of long-term use of middle-ear prostheses in chil-dren, autograft materials are primarily used to reconstruct the ossicularchain whenever possible.32 Sil-The most effecti

72 Surgical Atlas of Pediatric Otolaryngology

• The tympanomeatal flap is replaced A tympanostomy tube is insertedinto the tympanic membrane if eustachian tube function is still poor inorder to prevent middle-ear effusion or another portion of the tympan-

ic membrane from retracting (Figure 3–48)

• A layer of Gelfoam is placed over the tympanic membrane and graft.Two strips of Adaptic gauze impregnated with antibiotic ointment areinserted into the external canal

Myringoplasty and Tympanoplasty 73

REFERENCES

1 Saito H, Kazama Y, Yazawa Y Simple maneuver for closing traumatic eardrum perforation bymicropore strip tape patching Am J Otol 1990;11:427–30

2 Paparella MM Otologic surgery in children Otolaryngol Clin North Am 1977;10:145–51

3 Sheehy JL, Anderson RG Myringoplasty: a review of 472 cases Ann Otol Rhinol Laryngol1980;89:331–4

4 Koch WM, Friedman EM, McGill TJI, et al Tympanoplasty in children The Boston Children’sHospital Experience Arch Otolaryngol Head Neck Surg 1990;116:35–40

5 Smyth GD Tympanic reconstruction Otolaryngol Clin North Am 1972;5:111–25

6 Shih L, de Tar T, Crabtree JA Myringoplasty in children Otolaryngol Head Neck Surg1991;105:74–7

7 Tos M, Orntoft S, Stangerup SE Results of tympanoplasty in children after 15 to 27 years AnnOtol Rhinol Laryngol 2000;109:17–23

8 Vrabec JT, Deskin RW, Grady JJ Meta-analysis of pediatric tympanoplasty Arch OtolaryngolHead Neck Surg 1999;125:530–4

9 Bluestone CD, Klein JO Otitis media in infants and children WB Saunders; 2001 p 313–7

10 Potsic WP, Winawer MR, Marsh RR Tympanoplasty for the anterior-superior perforation inchildren Amer J Otol 1996;17:115–8

11 Lempert J Endaural, antauricular surgical approach to the temporal bone: principles involved

in this new approach Summary report of 1,780 cases Arch Otolaryngol Head Neck Surg1937;27:555–87

12 Blaney SPA, Tierney P, Bowder DA The surgical management of the pars tensa retraction

pock-et in the child—results following simple excision and ventilation tube insertion Int J PediatrOtorhinolaryngol 1999;50:133–7

13 Palva T, Johnsson L-G, Ramsey H Attic aeration in temporal bones from children with ring otitis media: tympanostomy tubes did not cure disease in Prussak’s Space Am J Otol2000;21:485–93

recur-14 Hasebe S, Takahashi H, Honjo I, Sudo M Organic change of effusion in the mastoid in otitismedia with effusion and its relation to attic retraction Int J Pediatr Otorhinolaryngol2000;53:17–24

15 Gerber MJ, Mason JC, Lambert PR Hearing results after primary cartilage tympanoplasty Laryngoscope 2000;110:1994–9

16 Bluestone CD Definitions, terminology, and classification In: Bluestone CD, Rosenfeld RM,editors Evidence-based otitis media Hamilton, Ontario: B C Decker Inc; 1999 p 94–6

17 Khanna SM, Tonndorf J Tympanic membrane vibration in cats studied by time-averagedholography J Acoust Soc Am 1972;51:1904–20

18 Chan KC, Sculerati N, Casselbrant ML, et al Comparison of eustachian tube function testsbetween children with cholesteatoma/retraction pocket and those with chronic otitis mediawith effusion In: Tos M, Thomsen J, Peitersen E, editors Cholesteatoma and MastoidSurgery; 1989; Amsterdam: Kugler & Ghedini; 1989 p 485–7

CH A P T E R 4

James S Batti, MD Charles D Bluestone, MD

OSSICULAR RECONSTRUCTION Etiology of Ossicular Abnormalities

Ossicular-related causes of conductive hearing loss can be congenital oracquired, and are mainly due to discontinuity or fixation:

• Ossicular discontinuity occurs in the following scenarios presented in

order of decreasing frequency: eroded incudostapedial joint, absentincus, absent incus and stapes superstructure, and absent incus andstapes including the footplate.1 Austin2 defined four groups in theabsence of an intact incus: (1) malleus handle present, stapes super-structure present, (2) malleus handle present, stapes superstructureabsent, (3) malleus handle absent, stapes superstructure present, and (4)malleus handle absent, stapes superstructure absent

• Ossicular fixation most commonly occurs when the malleus head is

anky-losed to the attic wall or when tympanosclerosis of the attic is present.Kartush3 modified Austin’s classification of ossicular defects by addingtwo other groups related to ossicular fixation: (1) ossicle head fixationwith all ossicles present, and (2) stapes fixation with all ossicles present Moretz4added still another category, nonclassifiable, to describe unusual sit-

uations requiring ossiculoplasty that are not easily included in the othercategories These include lateralized tympanic membrane and some con-genital abnormalities

This chapter reviews methods for reconstructing the ossicular chain from tympanic brane to oval window, with emphasis on specific techniques for children with ossicular fix-ation or discontinuity Information is also provided regarding outcomes and prognostic fac-tors, with the caveat that most published data relate to adults Lastly, the major reasons forfailure are discussed and the current knowledge of ossiculoplasty in children is summarized

mem-76 Surgical Atlas of Pediatric Otolaryngology

Options for Ossicular Reconstruction

The many options for ossicular chain reconstruction can be classified intothree groups:

1 Autograft prostheses include tissue harvested from the patient and used for

reconstructing the ossicular chain Examples include the patient’s ownossicles or cartilage

2 Homograft prostheses are derived from human donor tissue, screened and

treated to avoid transmission of disease, and preserved for later use.Examples include tympanic membrane, ossicles, and cartilage

3 Allograft prostheses are synthetic and biocompatible Examples include

high density polyethylene sponge (Plasti-Pore), aluminum oxide,

ceram-ic, and hydroxyapatite.5

Recommended methods of ossicular chain reconstruction are listed inTables 4–1 to 4–3 Many of the preferred methods attempt to utilize thepatient’s own tissue; however, when this is not possible, prosthetic devicescan be used depending on the remaining ossicle(s) Prosthetic devices areclassified according to the desired reconstruction:

• Incus prostheses are used when the malleus and stapes are present.

• Incus-stapes prostheses are used when the stapes footplate is present along

with an intact malleus

• Partial ossicular replacement prostheses (PORPs) are used when the stapes

superstructure is intact

• Total ossicular replacement prostheses (TORPs) are used when only the

stapes footplate is available

78 Surgical Atlas of Pediatric Otolaryngology

ADVANCEMENT FLAP Indications

• Lateralized tympanic membrane following any method of

tympanoplas-ty, but more often following the lateral graft technique (see Chapter 3

under Tympanoplasty)

Anesthetic Considerations

• In children, the procedure is performed under general anesthesia

• Local anesthetic (1% lidocaine with 1:100,000 epinephrine) is

infiltrat-ed into all four quadrants of the ear canal (6, 9, 12, and 3 o’clock) justlateral to the bony-cartilaginous junction for hemostasis and to enhancethe anesthesia

Procedure

• Coronal view demonstrating the lateralized tympanic membrane (Figure4–1)

• A transcanal incision is made just medial to the bony-cartilaginous

junc-tion (Figure 4–2A).

• The wide tympanomeatal flap is elevated (Figure 4–2B).

• The middle ear is entered by elevating the annulus (Figure 4–3A).

• The tympanomeatal flap and lateralized tympanic membrane are

elevat-ed to expose the entire middle ear space; the flap is attachelevat-ed only to the

anterior canal wall (Figure 4–3B).

Figure 4–1 Advancement flap

for lateralized tympanic

mem-brane Coronal view showing that

the grafted tympanic membrane

does not connect to the malleus,

which usually results in mild to

moderate conductive hearing loss.

80 Surgical Atlas of Pediatric Otolaryngology

• The tympanomeatal flap is advanced medially against the malleus, ing bare bone in the ear canal medial to the bony-cartilaginous junction(Figure 4–4)

leav-• Gelfoam is placed lateral to the flap and two strips of Adaptic (withantibiotic ointment) are inserted into the medial and lateral canal aspacking (Figure 4–5)

• An addition to the method described above is to incise part of the nomeatal flap and insert the handle of the malleus through the incision.This holds the flap against the malleus, but the incision is generally unnec-essary if the packing in the external canal rests firmly against the flap

tympa-Postoperative Care

• The packs are removed in 1 week, and the child is re-examined in about

1 month

Figure 4–4 Tympanomeatal flap

is advanced medially against the

malleus, which leaves exposed

bone in the canal wall medial to

the bony-cartilaginous junction.

Figure 4–5 Coronal view

show-ing tympanomeatal flap advanced

onto the tympanic membrane;

Gelfoam is placed lateral to the

flap and two strips of Adaptic

(with antibiotic ointment) are

inserted into the medial and

lateral ear canal.

Ossiculoplasty 81

INCUS INTERPOSITION Indications

• The most commonly encountered abnormality with the ossicular chaininvolves the incus The incus interposition procedure can be utilizedwhen there is either discontinuity or fixation involving the incudomal-leal or incudostapedial joint

Anesthetic Considerations

• The anesthesia is the same as that described for the advancement flap

Procedure

• A transcanal incision is made just medial to the bony-cartilaginous

junc-tion (see Figure 4–2A).

• The wide tympanomeatal flap is elevated (see Figure 4–2B).

• The middle ear is entered by elevating the annulus (see Figure 4–3A).

• Utilizing a right angle or curved needle, the incus is disarticulated fromany remaining attachments in the attic

• The incus is removed and sculpted (Figure 4–6A) A groove for the

malleus handle is created in the articulating surface of the incus body.The facet for the stapes is then created in the body of the incus near itsjunction with the long process

• The incus is inserted between the malleus and stapes superstructure,

completing the interposition (Figure 4–6B).

• Gelfoam is placed lateral to the flap and the ear canal is filled withantibiotic ointment

Postoperative Care

• After an initial postoperative visit, the child is followed up in 1 month

Figure 4–6 Incus interposition A, The incus is removed and sculpted B, The sculpted incus is inserted between the malleus

and head of the stapes.

82 Surgical Atlas of Pediatric Otolaryngology

PARTIAL OSSICULAR REPLACEMENT PROSTHESIS (PORP)

Indications

• Ossicular chain abnormality in which an intact stapes superstructure isbridged with a synthetic biocompatible prosthesis to the tympanicmembrane, graft, or malleus

Anesthetic Considerations

• The anesthesia is the same as that described for the advancement flap

Procedure

• A transcanal incision is made just medial to the bony-cartilaginous

junc-tion (see Figure 4–2A).

• The wide tympanomeatal flap is elevated (see Figure 4–2B).

• The middle ear is entered by elevating the annulus (see Figure 4–3A).

• The PORP is inserted on the stapes (Figure 4–7) A notch can be made

in the prosthesis to secure the PORP and accommodate the stapedialtendon

• A cartilage graft can be placed lateral to the prosthesis to aid in tion of extrusion of the prosthesis

preven-• Gelfoam is placed lateral to the flap and the ear canal is filled withantibiotic ointment

Postoperative Care

• After an initial postoperative visit, the child is followed up in 1 month

• A postoperative audiogram is obtained in 2-3 months

B A

Figure 4–7 Placement of a partial ossicular replacement prosthesis (PORP) A, Surgeon’s view of PORP in place B, Lateral

view of the PORP positioned on the stapes head.

Anesthetic Considerations

• The anesthesia is the same as that described for the advancement flap

Procedure

• A transcanal incision is made just medial to the bony-cartilaginous

junc-tion (see Figure 4–2A).

• The wide tympanomeatal flap is elevated (see Figure 4–2B).

• The middle ear is entered by elevating the annulus (see Figure 4–3A).

• The TORP is inserted on the stapes footplate (Figure 4–8)

A

Figure 4–8 Placement of a total

ossicular replacement prosthesis

(TORP) A, Surgeon’s view of

TORP in place B, Lateral view

of the TORP positioned on the

stapes footplate.

B

84 Surgical Atlas of Pediatric Otolaryngology

• A cartilage graft is placed between the TORP and tympanic membrane

to reduce the chance of extrusion (Figure 4–9)

• Gelfoam is placed lateral to the flap and the ear canal is filled withantibiotic ointment

Postoperative Care

• After an initial postoperative visit, the child is followed up in 1 month

• A postoperative audiogram is obtained in 2-3 months

Figure 4–9 Cartilage graft

between the TORP and

tympanic membrane.

Ossiculoplasty 85

OUTCOMES AND PROGNOSTIC FACTORS

Table 4–4 presents a summary of the published data on hearing level andextrusion rate outcomes for various methods of ossicular reconstruc-tion.2,5–21Several trends are apparent Successful closure of the air-bone gap

to less than 20 dB hearing level is achieved by less than 80% of authors,with TORP results being generally poorer than those for PORP or incusinterposition Furthermore, hearing results tend to worsen with time innearly all studies that reported serial outcome data This observation, com-bined with the nontrivial extrusion rates in some studies, suggests a needfor long-term follow-up of all patients after ossiculoplasty

Several prognostic factors for ossiculoplasty success have been reported.Bellucci22 noted a relationship between outcomes and middle-ear status(never infected, intermittent discharge, unremitting discharge, and cleftpalate or nasopharyngeal deformity) and Austin2 emphasized the availabil-ity of the malleus handle and stapes superstructure Black23 proposed acombined system using the acronym SPITE for preoperative predictive fac-tors of poor outcome:

(S) Surgical – complexity of surgery; necessity of scutum and drum repair(P) Prosthetic – absence of malleus or stapes; presentation of a 50 dB air-bone gap

(I) Infection – chronic otorrhea; myringitis

(T) Tissue – poor general condition of tissue, referring to extremes ofyouth (under 5 years) or advanced age (over 70 years); meatoplastyrequired; poor mucosa of the middle ear

(E) Eustachian tube dysfunction–eustachian tube dysfunction / ear effusion present; severely collapsed tympanic membrane

middle-Factors that failed to show statistically significant adverse effects in logic results included any prior failed surgery, scutum defect repair withouttympanic membrane repair, myringoplasty, and staged surgery

audio-Loss of the stapes superstructure was found by both Mills24and Smythand Patterson25to be associated with a poorer outcome in ossiculoplasty Inorder to achieve success in ossiculoplasty, Smyth and Patterson25concludedthat the average postoperative air conduction over the speech frequencies(0.5, 1.0, 2.0, and 4.0 kHz) must be < 30 dB, or the interaural differencemust be reduced to < 15 dB Fifteen dB corresponds to the cross-attenua-tion effect of the skull.26If these criteria are not met, the patient will likely

be unaware of any audiometric improvement

Reasons for Ossiculoplasty Failure

Ossiculoplasty failure may occur because of problems with the prosthesis,middle ear, or eustachian tube A common cause of ossiculoplasty failure isinadequate contact between the prosthesis and the graft, which may be caused

by sliding or reabsorption of the cartilage Additional causes of functional ure include: (1) improperly sized prosthesis (too short), (2) sliding of the pros-thesis, (3) fracture of the stapes crura, and (4) contraction and movement ofthe healing tympanic membrane Each of these results in poor contactbetween the footplate and the graft.27

fail-Ossiculoplasty 87

Middle-ear disease may also cause ossiculoplasty failure There are manyuncertainties in the hostile biological environment associated with surgeryfor chronic ear disease—mucosal disease, middle-ear adhesions, andeustachian tube dysfunction—that contribute to failure of the surgery.These abnormalities promote middle-ear effusion, retraction of the tym-panic membrane, atelectasis of the middle ear, and extrusion of the graft orprosthesis Perforation of the tympanic membrane, with or without extru-sion of the prosthesis, may also occur

Eustachian tube dysfunction is also a common cause of tympanic brane perforation and prosthesis extrusion, because of graft retraction andincreased tension against the prosthesis Sustained tension may break theprosthesis, or result in partial or complete extrusion One proposed method

mem-to decrease failure is mem-to cut the tensor tympani tendon during ossicularreconstruction This may flatten and slightly lateralize the tympanic mem-brane, thereby facilitating placement of the prosthesis and decreasing thetendency of the tympanic membrane to medialize in patients witheustachian tube dysfunction.16

RECOMMENDATIONS FOR OSSICULOPLASTY IN

CHILDREN

Few studies of ossicular reconstruction in children have been reported verstein et al28reported 18 cases using Plasti-Pore PORPs and TORPs, butobtained poor results with a 44% failure rate and 17% extrusion rate Con-versely, Sheehy29and Kessler et al30reported using PORPs and TORPs inchildren with success rates similar to those in adults In Kessler’s study, forexample, the mean patient age was 9.8 years and hearing results of an air-bone gap < 20 dB were noted in 54% of cases with an extrusion rate of13% Tos and Lau31evaluated autografts and homografts in children andfound 58% had hearing results of an air-bone gap < 20 dB which remainedstable Due to the lack of long-term use of middle-ear prostheses in chil-dren, autograft materials are primarily used to reconstruct the ossicularchain whenever possible.32

Sil-The most effective method of managing ossicular chain abnormalities isdisease prevention, ie, tympanic membrane retraction treated with place-ment of a ventilation tube, cartilage graft, or both (see Chapters 1 and 3).The hesitancy to perform ossiculoplasty in children is primarily related toeustachian tube dysfunction with difficulty in controlling middle-ear diseaseand cholesteatoma With some reported failure rates higher in children than

in adults, many argue that ossicular reconstruction should be be poned.10The principles of successful tympanoplasty, however, are similar foradults and children Once the child’s ear is made safe and stable, ossicularreconstruction is the next goal and completes the restoration of normal mid-dle-ear function Some claim that children differ only in that they may bemore likely to require postsurgical tympanostomy tube insertion to main-tain a stable ear.31,33

post-Despite a paucity of studies that have evaluated short- and long-termoutcomes of ossiculoplasty in children, the surgeon must have some guide-lines for procedure timing A useful rule of thumb is that eustachian tubefunction may be considered adequate for ossiculoplasty when there has

88 Surgical Atlas of Pediatric Otolaryngology

been no otitis media (in an ear with an intact tympanic membrane) for atleast four consecutive seasons (12 months) This should minimize the inci-dence of postoperative atelectasis or middle-ear effusion, which can result

in failure or extrusion Similarly, ossicular reconstruction in children whohave had a cholesteatoma removed from the middle ear is usually withhelduntil the middle ear is found to be free of disease (eg, at the time of “sec-ond look” tympanotomy), because residual or recurrent cholesteatoma atthe site of the reconstruction will usually result in failure of the graft orprosthesis Nonetheless, the timing and treatment option chosen should beindividualized for each child

REFERENCES

1 Hough J Incudostapedial joint separation: etiology, treatment and significances Laryngoscope1959;69:644–53

2 Austin DF Ossicular reconstruction Otolaryngol Clin North Am 1972;5:145–60

3 Kartush JM Ossicular chain reconstruction: capitulum to malleus Otolaryngol Clin North Am1994;27:689–715

4 Moretz WH Jr Ossiculoplasty with an intact stapes: superstructure versus footplate prosthesisplacement Laryngoscope 1998;108:1–12

5 Chole RA, Skarada DJ Middle ear reconstructive techniques Otolaryngol Clin North Am1999;32:489–503

6 Nikolaou A, Bourikas Z, Maltas V, Aidonis A Ossiculoplasty with the use of autografts and thetic prosthetic materials : a comparison of results in 165 cases J Laryngol Otol 1992;106:692–4

syn-7 Jackson CG, Glasscock ME III, Nissen AJ, et al Ossicular chain reconstruction: the TORP andPORP in chronic ear disease Laryngoscope 1983;93:981–8

8 Grote J Reconstruction of the middle ear with hydroxyapatite implants: long-term results AnnOtol Rhinol Laryngol 1990;144 Suppl:12–6

9 Wehrs RE Incus interposition and ossiculoplasty with hydroxyapatite prostheses OtolaryngolClin NA 1994;27:677–88

10 Schwetschenau EL, Isaacson G Ossiculoplasty in young children with the Applebaum ostapedial joint prosthesis Laryngoscope 1999;109:1621–5

incud-11 Colletti V, Fiorino FG, Sittoni, V Minisculptured ossicle grafts versus implants: long-termresults Am J Otol 1987;8:553–9

12 Bayazit Y, Goksu N, Beder L Functional results of Plasti-Pore prostheses for middle-ear lar chain reconstruction Laryngoscope 1999;109:709–11

ossicu-13 Goldenberg RA Hydroxylapatite ossicular replacement prostheses: preliminary results goscope 1990;100:693–700

Laryn-14 Brackmann DE, Sheehy JL, Luxford WM TORPs and PORPs in tympanoplasty: a review of

1042 operations Otolaryngol Head Neck Surg 1984;92:32–7

15 Smyth GD Five year report on partial ossicular replacement prostheses and total ossicularreplacement prostheses Otolaryngol Head Neck Surg 1982;90:343–6

16 Slater PW, Rizer FM, Schuring AG, Lippy WH Practical use of total and partial ossicularreplacement prostheses in ossiculoplasty Laryngoscope 1997;107:1193–8

22 Bellucci RJ Dual classification of tympanoplasty Laryngoscope 1973;83:1754–8.

23 Black B Ossiculoplasty prognosis: the SPITE method of assessment Am J Otol1992;13:544–51

24 Mills RP The influence of pathological and technical variables on hearing results in plasty Clin Otolaryngol Allied Sciences 1993;18:202–5

ossiculo-25 Smyth GD, Patterson CG Results of middle ear reconstruction: do patients and surgeons agree?

Am J Otol 1985;6:276–9

26 Browning G Clinical Otology and Audiology London, England: Butterworths; 1986

27 Sellari-Franceschini S, Piragine F, Bruschini P, Berrettini S TORPS and PORPS: causes of ure Am J Otol 1987;8:551–2

fail-28 Silverstein H, McDaniel AB, Lichtenstein R A comparison of PORP, TORP, and incus graft for ossicular reconstruction in chronic ear surgery Laryngoscope 1986;96:159–65

homo-29 Sheehy JL Cholesteatoma surgery in children Am J Otol 1985;6:170–2

30 Kessler A, Potsic WP, Marsh RR Total and partial ossicular replacement prostheses in children.Otolaryngol Head Neck Surg 1994;110:302–3

31 Tos M, Lau T Stability of tympanoplasty in children Otolaryngol Clin N Am 1989;22:15–28

32 Bluestone CD, Stool SE, Kenna M Pediatric Otolaryngology 3rded Philadelphia: WB ders; 1996

Saun-33 Chandrasekhar SS, House JW, Devgan U Pediatric tympanoplasty A 10 year experience ArchOtolaryngol Head Neck Surg 1995;121:873–8

indica-There are three traditional procedures:

1 Simple (cortical, complete) mastoidectomy

2 Modified radical mastoidectomy

3 Radical mastoidectomy

A fourth procedure, tympanomastoidectomy, combines the simple

mas-toidectomy with a middle-ear procedure, maintaining the posterior andsuperior canal walls

The basic steps in performing the three standard mastoidectomy dures are described below The approach in all cases is postauricular (seeChapter 2), and intraoperative monitoring of facial nerve function is usedroutinely.1

proce-SIMPLE (CORTICAL, COMPLETE) MASTOIDECTOMY

A simple or complete mastoidectomy, which is more appropriately called acortical mastoidectomy, is indicated for acute mastoid osteitis.2,3An impor-

tant distinction is acute mastoiditis without osteitis (with or without

periosteitis), which generally does not require surgical management Whensurgery is needed, the term acute “coalescent” mastoiditis is commonly

In the first section of this chapter, I describe my indications and surgical technique formastoidectomy In the next section, I describe specific surgical procedures forcholesteatoma (depending upon the site and extent of the disease), which may or may notinclude a mastoidectomy

92 Surgical Atlas of Pediatric Otolaryngology

used, but a more consistent term related to the underlying pathology is

acute mastoid osteitis The term acute “surgical” mastoiditis is also used, but

again does not appropriately describe the pathology

Another indication for cortical mastoidectomy, which is more common

in the antibiotic era than acute mastoid osteitis, is in conjunction withsurgery for middle-ear disease When performed in this manner, the proce-

dure becomes a “canal wall–up” tympanomastoidectomy (see

Tympanomas-toidectomy later in this chapter).

Cholesteatoma later in this chapter)

• Cochlear implant, in which a posterior tympanotomy is part of the cedure (see Chapter 9)

pro-• Other reasons, such as facial nerve decompression, translabyrinthinelabyrinthectomy, neoplasm, and mastoid trauma, which are relativelyuncommon indications in infants and children

94 Surgical Atlas of Pediatric Otolaryngology

• A curette removes the thinned bone over the incus (Figure 5–3); drilling

at this stage could injure the incus and result in conductive, sorineural (due to acoustic trauma), or mixed hearing loss

sen-• Dissection is complete when the anterior epitympanum, zygomatic cells,body of the incus, and head of the malleus are identified (Figure 5–4),and there is free flow of the irrigant from the mastoid into the middle ear

• Specimens for culture and antibiotic susceptibility are taken from themastoid mucosa and bone, and also from the middle ear and mastoidpurulent material

• A tympanostomy tube (with or without the addition of a wide-fieldmyringotomy) is placed when acute mastoid osteitis is an indication forsurgery (Figure 5–5)

• The postauricular wound is closed with an absorbable suture The needfor drainage, if any, relates to the primary indication for surgery:

♦ For acute mastoid osteitis, a plastic drain with holes cut into the

por-tion that lies within the mastoid cavity, is placed in the mastoid ity (Figure 5–6)

cav-♦ For chronic suppurative otitis media, a rubber band or Penrose drain is

used

♦ For cholesteatoma, without acute or chronic infection, placement of a

drain is optional

• When the procedure is performed for acute mastoid osteitis, no packing

is inserted into the external canal

Postoperative Care

• The child is maintained on intravenous antimicrobial therapy, whichcan be adjusted after the results of the culture and susceptibility studiesare available

• The drain is removed when there is no further drainage from the wound

• The child can be discharged on a culture-directed, oral antimicrobialagent when afebrile and when there is no further discharge from themiddle ear or mastoid wound

96 Surgical Atlas of Pediatric Otolaryngology

MODIFIED RADICAL MASTOIDECTOMY

A modified radical mastoidectomy is most commonly performed for genital or acquired cholesteatoma, chronic suppurative otitis media withmastoiditis, or both The mastoid cavity, the epitympanum, and the exter-nal canal are exteriorized into a common cavity, but the tympanic mem-brane is either maintained or grafted In a study of 232 Pittsburgh childrenwith cholesteatoma, there were 244 surgical procedures, of which 24%were modified radical mastoidectomies.4 A Bondy modified radical mas-toidectomy was performed in selected cases (eg, small, constricted mastoid)

con-in which cholesteatoma was localized to the epitympanum and lateral tothe ossicles Today, however, a canal wall–up tympanomastoidectomy, ifpossible, is preferred over a modified radical mastoidectomy for

cholesteatoma (see Cholesteatoma later in this chapter)

When chronic suppurative otitis media and mastoiditis fail to improvefollowing intensive medical management, a tympanomastoidectomy is usu-

ally the next step in management (see Tympanomastoidectomy later in this

chapter).5 If, during surgery, there appears to be a persistent obstructionbetween the middle ear and the mastoid cavity when the simple mas-toidectomy is completed (ie, irrigation fluid fails to flow freely between thetwo areas), then the canal wall may have to be removed and the operationconverted into a modified radical mastoidectomy An alternative would be

a posterior tympanotomy approach to the facial recess, but this technique

is not as effective in controlling and preventing the infection as removingthe canal wall An alternative to removing the posterior canal wall in a childwould be to remove the incus

Neither removal of the posterior canal wall nor the incus is desirable in

a child, thus the surgeon should make every effort to be conservative byremoving as much disease (eg, granulation tissue) as possible from the facialrecess and attic, to promote adequate drainage from the aditus ad antrumand mastoid into the middle ear

Indications

• Cholesteatoma: When the disease extends to the mastoid air cells and

cannot be effectively managed using the more preferred method of an

intact canal wall–up tympanomastoidectomy (see Cholesteatoma later in

this chapter)

• Chronic suppurative otitis media and mastoiditis: When nonsurgical

methods fail and a simple mastoidectomy will most likely be, or hasbeen, unsuccessful in providing adequate aeration between the middleear and the mastoid cavity

Anesthetic Considerations and Preparation

• The anesthesia and the preparation for this procedure have been

described in Chapter 2 under Postauricular Approach.

• When chronic suppurative disease (with or without cholesteatoma) ispresent, perioperative antimicrobial therapy is usually administered; an

agent effective against Pseudomonas aeruginosa is usually recommended,

because it is the most commonly isolated organism

Mastoidectomy and Cholesteatoma 97

Procedure

• A simple mastoidectomy is usually performed first (Figure 5–7)

• The posterior canal wall is taken down to the facial ridge (Figure 5–8)

• The tympanic membrane is replaced (Figure 5–9); the epitympanumand the mastoid cavity are exteriorized

Figure 5–7 A complete “simple” mastoidectomy is usually

98 Surgical Atlas of Pediatric Otolaryngology

• In children, the mastoid cavity is usually not grafted or obliteratedbecause residual disease may be obscured, and the cavity frequentlybecomes smaller with advancing age

• A layer of Gelfoam is placed on the tympanic membrane/graft, and twostrips of Adaptic gauze (Johnson & Johnson Medical, Inc, Arlington,TX) are lightly packed into the external canal; the mastoid cavity may ormay not require packing depending upon the degree of bleedingencountered when performing the mastoidectomy

• A drain in the postauricular wound is usually unnecessary, since the toid (and the wound) is in continuity with the external canal

mas-Postoperative Care

• The postoperative care is similar to that described for the Postauricular

Approach discussed in Chapter 2.

• When the indication is chronic suppurative otitis media and tis, perioperative and postoperative intravenous antimicrobial therapy isusually administered

mastoidi-• Cavity care is more difficult in the infant and young child, and the cedure may have to be performed in the operating room with the patientunder general anesthesia, especially when residual cholesteatoma is pre-sent Thus, one of the goals of cholesteatoma surgery at this age should

pro-be to make every effort to avoid a cavity by preserving the canal wall (see

Cholesteatoma later in this chapter).

RADICAL MASTOIDECTOMY

Radical mastoidectomy creates a common cavity that consists of the dle ear, epitympanum, mastoid cavity, and external canal The operation isnot performed as frequently today as it was in the preantibiotic era; how-ever, it is performed when extensive cholesteatoma, which cannot be con-trolled with a less radical procedure, is present In children, an extensiverapidly growing cholesteatoma is not uncommon, and radical mastoidec-tomy is still performed in selected cases In our series of 244 surgical pro-cedures for cholesteatoma, 26% were radical mastoidectomies.4

mid-In the past, radical mastoidectomy was advocated when a suppurativeintracranial complication developed in a patient who had acute or chronicotitis media and mastoiditis, but today, a lesser procedure is usually safe andeffective in individualized patients, especially when cholesteatoma isabsent Even when cholesteatoma is present, the availability of the telescopefrequently allows a canal wall–up tympanomastoidectomy, which is a moredesirable procedure in children than a radical mastoidectomy (see

Cholesteatoma later in this chapter).

Closure of the eustachian tube at the bony (protympanic) portion canprevent troublesome postoperative recurrent or chronic otorrhea caused byreflux of nasopharyngeal secretions (see Chapter 6) This author does notroutinely perform this part of the procedure, because all patients do nothave postoperative drainage Moreover, future reconstruction of an aeratedmiddle-ear space may not be possible unless a tympanostomy tube is insert-

ed or a perforation is present in the reconstructed tympanic membrane

Mastoidectomy and Cholesteatoma 99

indi-Anesthetic Considerations and Preparation

• When suppurative disease is present within the middle-ear cleft, venous antimicrobial therapy is frequently administered perioperatively(and postoperatively) and should be given when there is a suppurativecomplication of middle-ear mastoid disease

intra-• The anesthesia and preparation for this procedure are the same asdescribed earlier in this chapter

• If an intracranial procedure is to be performed in conjunction with themastoidectomy, the patient should also be prepared for that procedure

Procedure

• The posterior external auditory canal is taken down and a facial ridge iscreated as in a modified radical mastoidectomy (Figure 5–10)

• The tympanic is removed Removal of the malleus and incus is

includ-ed in the classic operation, but depends upon the extent of the disease(Figure 5–11)

• A meatoplasty, in which soft tissue and a portion of conchal cartilage areremoved through the postauricular wound, is usually performed

Postoperative Care

• The postoperative care is similar to that described above following amodified radical mastoidectomy

Figure 5–10 The posterior ear canal is taken down, and a

facial ridge is created.

Figure 5–11 The tympanic membrane, malleus, and incus are removed.

100 Surgical Atlas of Pediatric Otolaryngology

TYMPANOMASTOIDECTOMY

A tympanomastoidectomy combines a simple mastoidectomy with a dle-ear surgical procedure, which frequently includes a tympanoplasty, ie,tympanomastoidectomy with tympanoplasty The goals of this procedure, inaddition to eradication of the disease, are to maintain an intact canal wall,and to maintain, or reconstruct, the tympanic membrane and ossicularchain For children, this procedure should be the goal of the operation, since

mid-it is much more desirable than a radical modified radical mastoidectomy Tympanomastoidectomy is used when chronic suppurative otitis media

(and mastoiditis), or cholesteatoma, or both, are present (see Cholesteatoma

later in this chapter) When chronic suppurative otitis media (withoutcholesteatoma) is unresponsive to medical management, including intra-venous antimicrobial therapy, a tympanomastoidectomy is indicated, which

includes a simple mastoidectomy (see Simple Mastoidectomy above).5 The

middle ear is entered as described in Chapter 2 under Postauricular Approach.

CHOLESTEATOMA Classification and Etiology

Aural cholesteatoma can be congenital or acquired Congenital

cholesteatoma is caused by a congenital rest of epithelial tissue within the

middle ear (including intratympanic), or in other portions of the temporalbone, which may appear as a white cyst-like structure or as sheets of tissue.The tympanic membrane is usually intact, and the cholesteatoma is appar-ently not a sequela of otitis media or eustachian tube dysfunction; howev-

er, Tos6 recently proposed that a congenital cholesteatoma may be acquiredand may be a sequela of otitis media

The most common site of congenital cholesteatoma, in the early phase,

is within the middle ear in the anterosuperior quadrant of the num Disease frequently extends into the anterior attic, or into the pos-terosuperior portion of the mesotympanum, and can also invade the facialrecess, sinus tympani, and the attic Also, the site can be in the posterosu-perior portion of the mesotympanum More advanced congenital middle-ear cholesteatoma can extend into the aditus ad antrum, mastoid, petrousapex, labyrinth, and can even spread outside the temporal bone, such asinto the intracranial cavity The tympanic membrane may not be intact ifthe disease is extensive

mesotympa-Acquired cholesteatoma can be a sequela of middle-ear disease or may arise

from implantation of epithelium, caused by trauma or surgery (ie, genic) of the middle ear (including the tympanic membrane), ear canal, ormastoid Acquired cholesteatoma can be present anywhere in the middle-ear cleft, can extend to any portion of the temporal bone, and can spreadoutside the temporal bone Often the cause of the cholesteatoma, eithercongenital or acquired, is uncertain, especially when the disease is faradvanced and the tympanic membrane is not intact

iatro-Of 232 children operated on at the Children’s Hospital of Pittsburghbetween 1973 and 1990, 43 (18%) had a congenital cholesteatoma(excluding intratympanic), 83 (36%) had an acquired cholesteatoma, and

in 106 (46%) children, the cholesteatoma could not be distinguished as

Mastoidectomy and Cholesteatoma 101

either congenital or acquired.4 Of 59 children who had a cholesteatomatreated in Switzerland between 1981 and 1996, 18 (29%) were congenitaland 41 (71%) were acquired.7

Cholesteatoma Surgery in Children vs Adults

The ideal goals of surgery for cholesteatoma in children are similar to those

in adults:

1 Eradicate disease

2 Preserve or reconstruct the anatomic structures

3 Preserve or restore hearing

4 Prevent residual and recurrent disease

Many surgical procedures have been advocated to achieve these goals, but,unfortunately, none have been subject to randomized clinical trials Thelack of rigorously designed trials relates to many factors, but primarily tothe variation in site, extent, and severity of the disease, and the rather lim-ited number of pediatric cases at any one individual center As well, mostotologic surgeons have their own preferences based on their skills, training,and experience Therefore, controversy remains over the optimal proce-dures to treat and prevent residual cholesteatoma (disease remaining aftersurgical attempts to eradicate it) and recurrent cholesteatoma (development

of new disease)

Canal Wall–Up vs Canal Wall–Down Mastoidectomy

Controversy exists over whether to perform a canal wall–up or canalwall–down procedure when the extent of cholesteatoma requires mas-toidectomy In infants and children, every effort should be made to avoid

a canal wall–down mastoidectomy because it is especially desirable to tain or reconstruct the anatomy in this age group Among the many disad-vantages of having a potentially life-long open mastoid cavity, is the factthat children usually require a general anesthetic for the periodic cleaningand debridement that ensues The cavity is more difficult to clean postop-eratively for children than in adults because children are frequently appre-hensive during the procedure Furthermore, since swimming is a commonactivity in youngsters, they are more susceptible to infection when an openmastoid cavity is exposed to water

main-Therefore, whenever possible, perform a canal wall–up tomy and additional tympanoplasty, if needed Since the middle ear and mas-toid are not directly visible following these procedures, a “second look” oper-ation is performed approximately 6 months later to detect any residualcholesteatoma Exploration is recommended at 6 months becausecholesteatoma is more aggressive in children than adults Waiting 12 months,

tympanomastoidec-as advocated for adults, can result in more extensive residual disetympanomastoidec-ase than isdesirable If a residual cholesteatoma is encountered at the “second look,” it

is removed and the child is re-explored in another 6 months These repeatprocedures are performed until there is no further residual cholesteatoma

In our study of 232 children who had 244 surgical procedures, residual

or recurrent cholesteatoma developed in 38% of cases and 23% of thosecholesteatomas were detected at the time of the “second look” procedure.4

102 Surgical Atlas of Pediatric Otolaryngology

Residual or recurrent disease was significantly associated with ossicular sion at the time of the original surgery, in direct proportion to the number

ero-of ossicles involved In a Japanese review ero-of children operated on forcholesteatoma, residual cholesteatoma was uncovered at the “second look”tympanotomy in 64% of cases.8During the “second look” exploratory tym-panotomy this author uses the 70˚ Hopkins rod-lens telescope to inspectthe middle ear for residual and recurrent disease

Currently, a canal wall–down mastoidectomy is performed for:

1 Suppurative complications (intratemporal or intracranial) ofcholesteatoma, with cholesteatoma in the mastoid The decision for oragainst removing the canal wall, however, should be individualized,based on the site, extent, and severity of the complication, as well asother factors below

2 Cholesteatoma in inaccessible areas (by transmastoid approach) of thetemporal bone, such as the retrolabyrinthine region or the petrous apex

3 Children with another medical condition (eg, severe congenital heartdisease) which would make a re-operation (eg, “second look” tympan-otomy) a potential health hazard

4 Children who are unable (eg, living in remote areas) or unlikely (eg,poor compliance) to return for a “second look” tympanotomy Thisapplies not only to developing countries, but also to certain populations

in the United States

5 “Second look” procedures revealing aggressive extensive residualcholesteatoma that is unlikely to be controlled in the future without acanal wall–down procedure

Otologic Telescope

The most significant factor in the preservation of the posterior and

superi-or canal walls in most children is the relatively recent availability of an cal telescope, which enhances visualization of the middle-ear cleft I use the2.7-mm 70˚ Hopkins rod-lens telescope (Hopkins-Karl Storz, Endoscopy-America Inc, Culver City, CA) With this instrument, the surgeon candirectly visualize the facial recess and the attic; whereas in the past, the supe-rior canal wall (medial portion) would have to be removed to ensure thatcholesteatoma was not attached to the lateral attic wall The telescope can beplaced in the attic following the tympanomastoidectomy, and focused infe-riorly to determine whether or not there is persistent disease

opti-Although not related to performing a canal wall–up versus a canalwall–down procedure, the telescope also greatly enhances examination ofthe middle ear in areas not visible with the otomicroscope (especially whenthe canal walls remain intact), such as the osseous portion of the eustachi-

an tube, the sinus tympani, and the hypotympanum

Timing of Ossiculoplasty

If an ossiculoplasty is required to restore the hearing, it is delayed untilthere is no residual or recurrent cholesteatoma, and otitis media andeustachian tube dysfunction (including atelectasis) are absent and unlikely

to recur Persistent or recurrent middle-ear problems can result in an

unfa-Mastoidectomy and Cholesteatoma 103

vorable outcome of ossiculoplasty, such as postoperative extrusion of theprosthesis (see Chapter 4) Residual cholesteatoma found during “secondlook” at the site of ossiculoplasty not only inhibits attempts at removal ofthe cholesteatoma, but the ossiculoplasty may have to be disassembled.Since children are more likely than adults to have recurrent or persistentotitis media and eustachian tube dysfunction, prevention of these middle-ear problems is a required part of cholesteatoma surgery Placement of atympanostomy tube, cartilage batten, or both, may be necessary not only

at the time of the surgery, but for as long as middle-ear or eustachian tubeproblems persist Postoperative formation of a retraction pocket is oftenassociated with cholesteatoma recurrence (see Chapter 3)

Follow-up Visits

Following surgery for cholesteatoma that involves the middle ear, with orwithout extension into the mastoid gas cell system, children are re-exam-ined periodically for at least 5 years There are two major concerns:

1 Residual cholesteatoma that remains following the initial surgical

proce-dure

2 Recurrent cholesteatoma (new disease) because of persistent eustachian

tube dysfunction, and a new retraction pocket in an anatomic site lar to the original one, or in another area of the tympanic membrane4,9–12

simi-Recurrent cholesteatoma is most effectively prevented in children with atympanostomy tube, cartilage graft tympanoplasty, or both, as described in

Chapter 3 under Cartilage Graft Tympanoplasty In addition, implantation

(iatrogenic) cholesteatoma can develop following this type of middle-earand mastoid surgery This author usually follows children every 3 monthsduring the first postoperative year, every 6 months during the second andthird postoperative years, and then yearly for another 5-7 years

CONGENITAL CHOLESTEATOMA

In general, the surgical procedures for removing a congenital cholesteatomaare similar to those employed when an acquired cholesteatoma is diag-nosed There are two additional procedures for congenital cholesteatoma,

however, that are not described in the section on Acquired Cholesteatoma:

(1) removal of intratympanic membrane cholesteatoma, and (2) removal ofcholesteatoma in the anterosuperior quadrant of the middle ear.Cholesteatoma is encountered relatively frequently in both of theseanatomic sites in infants and children Another commonly encountered site

is the posterosuperior portion of the mesotympanum, which is approached

in a similar manner as that described for acquired cholesteatoma

In our study of 45 surgical procedures for congenital cholesteatoma formed in the 1970s and 1980s (excluding intratympanic disease), 56%were limited to the middle ear (with or without atticotomy), 13% werecanal wall–up tympanomastoidectomies, 9% were modified radical mas-toidectomies, and 20% were radical mastoidectomies.4The present trend,however, is to maintain the posterior canal wall, and avoid a postoperativeopen cavity (radical or modified radical mastoidectomy) whenever possible

per-104 Surgical Atlas of Pediatric Otolaryngology

Indications

• Intratympanic membrane congenital cholesteatoma

• Congenital cholesteatoma medial to the intact tympanic membrane inthe anterosuperior quadrant of the middle ear

Anesthetic Considerations and Preparation

• The anesthesia and the preparation depend on the site and the approach

• For an intratympanic membrane cholesteatoma, the anesthesia and

preparation are similar to those described in Chapter 2 under Transcanal

Approach.

• For a congenital cholesteatoma that is within the anterosuperior portion

of the middle ear and epitympanum, the anesthesia and preparations are

the same as described in Chapter 2 under Endaural Approach.

• A facial nerve monitor is used when the disease is in the middle ear

Procedures

No 1 Intratympanic membrane congenital cholesteatoma

• Congenital cholesteatoma is seen within the intact tympanic brane (Figure 5–12)

mem-• The cholesteatoma is removed with a pick; a cup forceps is also used(Figure 5–13)

• A Steri-Strip patch is placed over the defect if a small perforation ispresent (Figure 5–14)

• If the perforation is large, a tissue graft myringoplasty is performed,

as shown in Chapter 3

Figure 5–12 Congenital

cholesteatoma within the intact

tympanic membrane.

106 Surgical Atlas of Pediatric Otolaryngology

No 2 Anterosuperior middle-ear congenital cholesteatoma

• A congenital cholesteatoma is visualized in the middle ear, medial tothe anterosuperior quadrant of the intact tympanic membrane (Fig-ure 5–15)

• The choice of approach (see Chapter 2) depends on the extent ofcholesteatoma and the size of the child’s ear canal:

♦ An endaural approach (Figure 5–16A) is used for disease localized to

the anterosuperior mesotympanum, but with inadequate directaccess or visualization because of a narrow ear canal Only a shortincision is needed in the incisura, because the mastoid will not beentered

♦ A transcanal approach (Figure 5–16B) is used for disease localized

to the anterosuperior mesotympanum, with a large enough earcanal to permit adequate visualization and access to the anterosu-perior canal wall

♦ A postauricular approach is used for disease extending into the terior attic, aditus ad antrum, and mastoid (see Acquired

pos-Cholesteatoma below).

• The tympanomeatal flap is elevated off the malleus to completelyexpose the cholesteatoma Although the tympanic membrane canoften be maintained intact, any portion that appears penetrated bythe cholesteatoma should be excised to prevent recurrence and thetympanic membrane grafted

• Cholesteatoma extension into the anterior epitympanum is commonand can be visualized on the preoperative computed tomography(CT) scan An anterior atticotomy is done with a microdrill (Figure5–17), and the cholesteatoma is removed (for more extensive disease,

see Acquired Cholesteatoma below).

Figure 5–15 A congenital

cholesteatoma is visualized in

the middle ear, medial to

antero-superior quadrant of the intact

tympanic membrane.

108 Surgical Atlas of Pediatric Otolaryngology

• The tympanomeatal flap is replaced (Figure 5–18) A defect, if sent, is repaired using a medial fascia graft as described in Chapter 2

pre-• If the endaural approach was used, the incision is closed with 2-3absorbable sutures

Postoperative Care

• The postoperative care is dependent on the approach used (see Chapter 2)

• A “second look” exploratory tympanotomy is usually performed 6months after the procedure to remove any residual middle-ear or epi-tympanic cholesteatoma The site and extent of the cholesteatoma, thestatus of the hearing, and the degree of translucency of the tympanicmembrane are key factors in recommending a “second look” operation

(see Acquired Cholesteatoma below).

Figure 5–18 A tympanomeatal

flap is replaced.

Mastoidectomy and Cholesteatoma 109

ACQUIRED CHOLESTEATOMA

The most common type of cholesteatoma is acquired, which is a sequela ofmiddle-ear disease (eg, eustachian tube dysfunction, otitis media).Acquired cholesteatoma can also occur as an unwanted sequela of otologicsurgery, such as tympanostomy tube placement.13 The most frequentanatomic site in which an acquired cholesteatoma is encountered in chil-dren is the posterosuperior quadrant of the pars tensa; the second mostcommon site is the pars flaccida area

In a study of 1024 patients (adults and children), a cholesteatoma of theattic was seen in 42% of cases and a cholesteatoma of the posterosuperiorquadrant in 31% of cases A cholesteatoma was present in 18% of patientswhen there was a total perforation, in 6% when there was a central perfo-ration, and in 3% when there was no perforation (possibly congenital).14

However, it is possible that the patients in whom the cholesteatoma was

associated with a total perforation originally had involvement of the

pos-terosuperior portion of the pars tensa

In children, the most common defect in the tympanic membrane (ie,retraction pocket) develops first in the posterosuperior quadrant of the pars

tensa, or less commonly, in the pars flaccida The term marginal perforation

has been used to describe the defect in the posterosuperior quadrant, and the

defect in the pars flaccida has been called an attic perforation These are

fre-quently not true perforations, however, but rather retraction pockets orcholesteatomas that otoscopically appear as perforations; no continuitybetween the defect and the middle ear occurs until later in the disease process

Selection of Procedure Related to Site and Extent of Disease

Each child’s final procedure should be individualized based on several tors One surgical procedure is not advocated for all cholesteatomas Thefollowing factors are important in the preoperative planning and the intra-operative decision-making process:

fac-• Anatomic site

• Extent of disease

• Condition of ossicular chain and tympanic membrane

• Presence or absence of chronic suppurative otitis media and mastoiditis

• Presence or absence of suppurative or nonsuppurative complications

• Anatomy of the temporal bone and the middle-ear cleft

• Status of eustachian tube function

• Age and general health of the child

• Findings of CT scans

• Availability of postoperative follow-up care

As stated above, the long-standing goals of cholesteatoma surgery are toeradicate disease, reconstruct the tympanic membrane, maintain the anato-

my of the middle-ear cleft, and preserve (restore) hearing In addition, try

to preserve the external auditory canal to prevent the potential morbidity

of an exposed mastoid cavity Unfortunately, this is not always possible,

110 Surgical Atlas of Pediatric Otolaryngology

because cholesteatoma in children is frequently more invasive, grows morerapidly, and is associated with a higher residual and recurrence rate thancholesteatoma in adults Other factors that may be related to this differenceare the higher rate of recurrent and chronic middle-ear disease and pooreustachian tube function in the pediatric population

Of the 199 procedures performed for acquired cholesteatoma (orcholesteatoma of uncertain etiology) at Children’s Hospital of Pittsburghfrom 1973 to 1990, 28% involved only a middle-ear procedure, 20% werecanal wall–up tympanomastoidectomies, 25% were modified mastoidec-tomies, and 28% were radical mastoidectomies.4 The current trend, how-ever, is to maintain the posterior canal wall and avoid a postoperative opencavity (radical or modified radical mastoidectomy) whenever possible

Staging of Acquired Cholesteatoma

It is appropriate to stage cholesteatomas for management, reporting, andresearch When staging cholesteatoma, the presence or absence of infectionshould be noted, and if present, the duration of the otitis media Thisauthor has proposed the following classification:15

• Cholesteatoma without infection is a cholesteatoma that is not associated

with infection, either within the cholesteatoma itself, or in any otherportion of the middle-ear cleft

• Cholesteatoma with infection is a cholesteatoma that is associated with

infection, which can be either acute (with or without otorrhea) orchronic The most common infection associated with cholesteatoma ischronic suppurative otitis media

Cholesteatoma is further classified based on its site and extent:

• Stage 1 Cholesteatoma confined to the middle ear (hypo- and

mesoepi-tympanum), without erosion of the ossicular chain

• Stage 2 Same as Stage 1, but with erosion of one or more ossicles

• Stage 3 Middle ear and mastoid gas cell system involved, without

ero-sion of ossicles

• Stage 4 Same as Stage 3, but with erosion of one or more ossicles

• Stage 5 Extensive cholesteatoma of the middle ear, mastoid, and other

portions of the temporal bone, the extent of which is not totally sible to surgical removal (eg, medial to labyrinth), with one or more ossi-cles involved; fistula of the labyrinth may or may not be present

acces-• Stage 6 Same as Stage 5, but cholesteatoma extends beyond the

tempo-ral bone

Surgical Planning

The following examples (posterosuperior quadrant and pars flaccida/atticcholesteatomas) describe the two most common types of acquiredcholesteatoma encountered in children Each example includes the com-mon sites of extension of the cholesteatoma and the final procedure select-

ed, depending on the extent of the disease There is a logical progression ofthe operation, and the reader can follow the decision-making process Pre-operative evaluation of the CT scans can be helpful in planning the proce-

Mastoidectomy and Cholesteatoma 111

dure and discussing the risks versus the benefits (ie, informed consent) withthe parents The CT scans do not have a high enough sensitivity to accu-rately identify the extent of the cholesteatoma in all patients, but they are

a valuable diagnostic aid.16

The following procedures are not only reserved for presumed acquiredcholesteatoma, but can also be used for cholesteatoma of congenital oruncertain etiology

POSTEROSUPERIOR QUADRANT ACQUIRED CHOLESTEATOMA

Cholesteatoma that occurs in the posterosuperior quadrant of the parstensa of the tympanic membrane has been called a “marginal perforation,”but this is in almost all cases a misnomer or misconception, because there

is no perforation, at least when encountered in children It is most likelythe result of recurrent or persistent middle-ear negative pressure, due toeustachian tube functional obstruction, and immediately preceded by aretraction pocket.17

The following surgical procedures describe an acquired cholesteatomaaccording to four possible extensions:

1 Confined to the posterior mesotympanum, facial recess, and sinus pani

tym-2 Extending into the superior portion of the facial recess and epitympanum

3 Extending into the aditus ad antrum and mastoid gas cells

4 Extending into the remaining portion of the middle ear, in addition toother areas

uncertain extension into one or

more of four possible areas,

numbered one through four as

referenced above.