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Objective: To evaluate the clinical parameters, outcomes, and complications of transcanal endoscopic ear surgeries for middle ear cholesteatoma., Study Design: Retrospective study., Setting: Tertiary university-affiliated medical center., Patients: Adult patients (age >18) who underwent transcanal endoscopic ear surgeries for cholesteatoma, between March 2009 and March 2015., Intervention: Transcanal endoscopic surgery was indicated when the cholesteatoma did not extend posterior to the anterior limb of the lateral semicircular canal. Rigid endoscopes 4 and 2.7 mm in diameter, 0, 30, 45, and 70 degrees were used with angled picks, suction, and forceps.Preoperative assessment included high-resolution computed tomography of the temporal bones and/or non echo-planar diffusion-weighted magnetic resonance imaging and pure-tone audiometry., Main Outcome Measures: Residual or recurrent disease was diagnosed by clinical examination and/or magnetic resonance imaging findings consistent with cholesteatoma. Intra- and postoperative complications, pre- and postoperative audiometric results were recorded., Results: Sixty operations (56 patients, mean age = 43.6) were included.Six operations (10%) were performed under local anesthesia. The most common sites of cholesteatoma involvement were: posterior epitympanum (n = 51, 91%), anterior epitympanum (n = 19, 33.9%), posterior mesotympanum (n = 13, 23.2%), and sinus tympani (n = 11, 19.6%). Intraoperative ossicular chain reconstruction was performed in 18 (30%) cases.Our overall residual and recurrence rates were 10% (n = 6) and 8.3% (n = 5), respectively, with mean duration of follow up of 35 months. The most common sites of residual disease were the mastoid cavity/antrum (n = 3, 50%), tympanic cavity, and posterior mesotympanum. Overall minor and major complication rates were 16.6 and 6%, respectively., Conclusions: Transcanal endoscopic ear surgery was found to be an acceptable and safe technique for the exposure and eradication of middle ear and/or attic cholesteatoma.

To investigate the feasibility of applying the transcanal endoscopic approach (TEA) for surgical treatment of residual/recurrent cholesteatoma and present the preliminary results of 17 revision procedures that were carried out with this minimally invasive approach. The records of 17 patients (aged 5-76 years) who underwent transcanal revision procedure using rigid 3-mm diameter, 0°, 30° and 45° endoscopes between 2009 and 2012 were retrospectively reviewed. A wide posterior tympanomeatal flap was elevated via the external auditory canal and then transposed inferiorly in cases of cholesteatoma situated in the middle ear under a tympanic membrane. In certain cases, cholesteatoma was assessed and removed using the endoscopes directly from the radical cavity or from the mastoid cavity remaining after a canal-wall-down procedure. Six patients had originally undergone the canal-wall-up mastoidectomy, 6 patients had a canal-wall-down mastoidectomy and 5 patients had radical mastoid cavities. The interval between the previous and the index surgery ranged between 1 and 6 years. The attic was the most common site involved with cholesteatoma, followed by the tympanic portion of the facial nerve, sinus tympani, mastoid, supratubal recess, promontory, round and oval windows. The size of residual/recurrent lesion varied between 3 and 15 mm. The patients were followed up 26-67 months (mean 52.1 months). The single recurrence (a 4-mm pearl over the tympanic portion of the facial nerve) was eradicated by a transcanal re-revision 1 year following the index surgery. Minimally invasive TEA can be successfully applied in carefully selected patients with endoscopically accessible cholesteatoma subsequent to various types of mastoidectomy.

Objective: To investigate a correlation between preoperative non-echo planar diffusion-weighted magnetic resonance imaging (non-EPI DW MRI) with surgical findings of localization and extension of cholesteatoma and to develop criteria for surgical planning., Patients: Preoperative non-EPI DWMRI was available and positive for cholesteatoma in 27 patients with primary and 23 with residual/recurrent lesions., Interventions: Patients with cholesteatoma limited to the middle ear and its extensions were managed with a transcanal endoscopic approach. Patients with extension of the cholesteatoma posteriorly to the lateral semicircular canal underwent retroauricular mastoidectomy combined with an endoscopic approach., Main Outcome Measure: Comparison of preoperative radiologic to surgical findings., Results: DWI showed isolated tympanic and attic extension in 33 cases and attico-antral and mastoid extension in 17 cases. MRI findings correlated with surgical findings in all patients with primary cholesteatoma, 19 of whom were managed with a transcanal endoscopic approach and 8 with endoscope-assisted ear surgery. The transcanal endoscopic approach was applied in 14 of the patients with residual/recurrent cholesteatoma, and the other 9 residual/recurrent lesions were eradicated using endoscope-assisted mastoidectomy. DWI overestimated cholesteatoma sites in 1 patient with residual lesion. The smallest cholesteatoma detected on DWI was a 3-mm lesion in the middle ear over the facial nerve., Conclusion: Primary and residual/recurrent cholesteatoma was accurately detected on non-EPI DWI with 98% clinical and radiologic concordance. Lesions less than 8 mm confined to the middle ear and its extensions can be eradicated with a minimally invasive endoscopic transcanal technique, whereas endoscope-assisted retroauricular mastoidectomy is preferred for larger lesions.

Conclusions: Our preliminary results indicate that mastoidectomy by reconstruction of the posterior wall and obliteration (MAPRO) avoided the disadvantages of a canal-wall-down mastoidectomy. MAPRO effectively prevented cholesteatoma recurrence, provided an excellent basis for hearing restoration, and was generally water-safe., Objective: To evaluate the authors' experience with the MAPRO technique for eradication of cholesteatomas requiring canal-wall-down mastoidectomy., Methods: The medical files of all the patients who underwent MAPRO for cholesteatoma between 2008 and 2011 at the Sheba Medical Center were retrospectively reviewed., Results: This series included 49 patients (31 children and 18 adults). The index operation was the first procedure for 30 patients and repeat surgery for 19 patients. Eight patients underwent ossiculoplasty. The mean postoperative follow-up was 28 months. Water tolerance and absence of inflammation were achieved in 93.3% of the first-time group and in 73.7% of the repeat group. (Recurrent cholesteatoma was found on the postoperative non-echo planar base diffusion-weighted magnetic resonance imaging in six (12.2%) patients: three (10%) in the first-time group and three (15.8%) in the repeat group).

Objective: To present preliminary results in transmeatal exclusive endoscopic ear surgery., Study Design: Retrospective., Intervention: Rigid endoscopes were used for all procedures. A wide posterior tympanomeatal flap was elevated transmeatally, and the scutum was removed with a bone curette or was drilled until visualization of cholesteatoma extension and the mastoid antrum. The malleus and incus were removed when they were involved in the cholesteatoma or restricted access to it. When present, the stapes was left intact. Endoscopic accessibility was defined by no extension of the cholesteatoma beyond the level of the lateral semicircular canal. Scutumplasty was by with tragal cartilage, and tympanic membrane defects were reconstructed with the palisade technique and perichondrium., Results: Thirty patients, aged 9 to 75 years, underwent the exclusive endoscopic transmeatal cholesteatoma eradication between July 2008 and May 2010. There were no incidents of iatrogenic injuries to the facial nerve or ossicles. Closure of the tympanic membrane and good hygienic status (water tolerance and absence of inflammation) were achieved in all operated ears. Two patients had significant postoperative worsening of their sensorineural hearing loss: the cholesteatoma of one of them involved all 3 ossicles and oval window and the other patient experienced postoperative labyrinthitis. There was no residual disease in 18 patients who were followed for more than 1 year, and the non-echo-planar base diffusion-weighted sequence magnetic resonance imaging was negative in 3 patients., Conclusion: Our preliminary results indicate that the minimally invasive endoscopic ear surgery allowed complete eradication of cholesteatoma from the middle ear and its extensions, with minimal morbidity and good functional results., (© 2011, Otology & Neurotology, Inc.)

Objective: To present conditions requiring mastoid surgery in elderly patients., Study Design: Retrospective., Results: Twenty-seven patients (aged 65-90 years) who underwent mastoidectomy were enrolled. The etiologies included chronic otitis media (COM) with (n = 16) or without (n = 5) cholesteatoma, otogenic meningitis and malignant otitis externa (MOE; n = 3 each). Urgent mastoidectomy was indicated for 4 intracranial complications (3 meningitis and 1 brain abscess) and 14 extracranial complications of acute/COM or MOE (7 patients with labyrinthitis and 7 patients with facial nerve, FN, paralysis). There was only partial improvement in FN function in only 1 of 7 patients with FN paralysis. Two patients lost their hearing as a result of a surgical intervention for cholesteatoma. One patient was reoperated for recurrent cholesteatoma 15 months after the initial mastoid surgery. Chronic otorrhea complicated the postoperative course in 2 patients., Conclusion: Mastoidectomy for geriatric patients is mostly urgent surgery for complications of acute/COM or MOE., (Copyright 2010 S. Karger AG, Basel.)

Cholesteatoma invasion into the internal auditory canal (IAC) is rare and usually results in irreversible, complete hearing loss and facial paralysis on the affected side. This retrospective study examines the clinical characteristics of seven patients with cholesteatoma invading the IAC, analyzes possible routes of the cholesteatoma's extension and describes the surgical approaches used and patient outcome. Extension to the IAC was via the supralabyrinthine route in most patients. A subtotal petrosectomy, a translabyrinthine approach or a middle cranial fossa approach combined with radical mastoidectomy were required for the complete removal of the cholesteatoma. All seven patients presented with some preoperative facial nerve palsy. The facial nerve was decompressed in four patients and facial nerve repair was performed in three others, two by hypoglossal-facial anastomosis and one by a greater auricular nerve interposition grafting. All patients ended up with total deafness in the operate ear. At 1 year following surgery, the facial nerve function was House-Brackmann grade III in six cases and grade II in one. In conclusion, cholesteatoma invading the IAC is a separate entity with characteristic clinical presentations, require a unique surgical approach, and result in significant morbidity, such as total deafness in the operated ear and impaired facial movement.

We conducted a retrospective study of 53 mastoidectomies in 51 patients with acute otomastoiditis. In 26 cases (49.1%), surgery had been performed within 48 hours of the development of symptoms. The most common complication of acute otomastoiditis was subperiosteal abscess, which occurred in 37 cases (69.8%). Intracranial complications were seen in 6 cases (11.3%). The most common pathogens isolated from subperiosteal abscesses, the mastoid cavity, and intracranial collections were Streptococcus spp and Staphylococcus aureus. In 14 cases (26.4%), conservative treatment failed to cure acute otomastoiditis; such cases should raise a suspicion of a subperiosteal abscess, an underlying cholesteatoma, or an infection caused by gram-negative bacteria. Upon hospital admission, patients should receive antibiotics that are effective against both gram-positive and gram-negative organisms. Patients with intracranial complications or facial nerve paralysis may require a combination of two or more antibiotics. Long-term follow-up is highly recommended.