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Inflammatory external auditory canal (EAC) Stenosis arises from infiltration of inflammatory cells, edema and eventual sclerosing of the medial EAC, leading to complete obstruction and conductive hearing loss. Current treatment includes surgical resection of the affected area with widening and reepithelization of the EAC via postauricular incision, but the condition is reported to recur with high frequency. Our aim was to assess the feasibility of endoscopic transcanal treatment as an alternative to postauricular canalplasty and understand its effect on recurrence rates.Retrospective case review.Tertiary referral center.Four patients were included who had bilateral conductive hearing loss and inflammatory canal stenosis, all with gross thickening of the tympanic membrane.Patients underwent endoscopic removal of obstructive tissue and reepithelization with split-thickness skin grafting.Postoperative air-bone gap (ABG), lack of recurrence, subjective reporting of hearing improvement, and lack of drainage.Eight of 8 ears (n = 4 patients) had significant improvement in hearing. No recurrence has been observed in any of the patients over a mean follow-up time of 90 months (range, 42-189 mo). Average reduction in ABG was 13.40 dB (SD = 9.0 dB) with a statistically significant difference between the pure tone average preoperative and postoperative ABG (p = 0.0008; n = 7).Endoscopic treatment of Inflammatory EAC stenosis obviates the need for postauricular incision and results in clinical improvement with a favorable recurrence rate.

Preoperative imaging assessment influences the decision to perform mastoidectomy for the mastoid extension of middle ear cholesteatoma. This study compared the performance of temporal subtraction CT (TSCT) and non-echoplanar diffusion-weighted imaging (non-EP DWI) in evaluating such mastoid extensions.We retrospectively evaluated 239 consecutive patients with surgically proven middle ear cholesteatoma between April 2016 and April 2021. The diagnostic performance of TSCT, wherein the presence of black color indicated progressive bone erosion, and non-EP DWI, wherein high signal intensity in the mastoid region suggested mastoid extension, was compared using Fisher's exact test.In 34 patients with evaluable TSCT images, black color was significantly more common in patients with mastoid extension than in those without; the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of TSCT were 1.00, 0.95, 0.94, 1.00, and 0.97, respectively. In 90 patients with evaluable non-EP DWI, high signal intensity was significantly more common in patients with mastoid extension than in those without; the sensitivity, specificity, PPV, NPV, and accuracy of non-EP DWI were 0.88, 0.85, 0.91, 0.81, and 0.87, respectively. In 16 patients with both evaluable TSCT and non-EP DWI, the diagnostic performance of the TSCT was slightly superior to that of the non-EP DWI for predicting mastoid extension, although the difference was not significant.TSCT images generated using consecutively acquired preoperative high-resolution CT images are useful for predicting mastoid extension of middle ear cholesteatoma, and the diagnostic performance of TSCT is non-inferior to that of non-EP DWI.

The main objective of this pediatric study of otologic surgery was to analyze factors for success of outpatient management. The secondary objective was to study unscheduled postoperative consultations and readmissions.This retrospective observational study analyzed clinical characteristics and procedures in consecutive children undergoing major ear surgery over a 3-year period in a teaching hospital. The study followed STROBE recommendations.We included 214 day-cases from a total population of 271 children. Median age was 109±44months (9years) [range: 8-196months (16years)]. In 57% of cases, the procedure was performed without mastoidectomy: 84 myringoplasties and 37 tympanoplasties. In 43% of cases, mastoidectomy was associated: 47 cochlear implants and 46 closed tympanoplasties for cholesteatoma. Ninety-five percent of day-surgeries were successful; in 5%, there was crossover to pediatric ENT department admission, for the following symptoms: postoperative nausea and vomiting in 3 cases, pain in 3, and late awakening in 5. Univariate analysis showed a relationship between failure and age under 36months (P=0.002). There were no readmissions. There were unscheduled consultations in 3% of cases: for minor otorrhagia in 5 cases and uncomplicated otorrhea in 2.Major otologic surgery in children is compatible with day-surgery. Younger patients, usually candidates for cochlear implantation, had greater risk of crossover to conventional admission. In this age group, scheduling should be earlier in the morning, with rigorous postoperative nausea and vomiting prophylaxis.

Recurrent otitis media and persistent otitis media with effusion in early childhood may cause an atelectatic eardrum and adhesive otitis media, which sometimes progress to pars tensa cholesteatoma. When and how children with adhesive otitis media should be operated on remain controversial. Therefore, this study aimed to analyze the clinical characteristics of children with adhesive otitis media and pars tensa cholesteatoma, and to determine the risk factors of progression to cholesteatoma.Seventeen ears of 15 children with adhesive otitis media (adhesive group) and 14 ears of 13 children with pars tensa cholesteatoma (tensa cholesteatoma group) who underwent tympanoplasty were included in this study. We analyzed the following clinical characteristics of children in both groups: medical and life history, associated diseases, sites of the adhesion, and development and aeration of mastoid air cells as shown by temporal bone computed tomography.Most of the children in both groups had a history of recurrent otitis media and/or persistent otitis media with effusion. They showed a male predominance and a frequent association of allergic rhinitis. The number of ears showing undeveloped mastoid air cells in the tensa cholesteatoma group was significantly larger than that in the adhesive otitis media group (P=0.0068). A lack of aeration of the middle ear, including the eustachian tube, was more frequently found in ears with pars tensa cholesteatoma than in ears with adhesive otitis media (P=0.0012). Using multivariate logistic regression, the presence of otorrhea (odds ratio [OR], 14.847; 95% confidence interval [CI], 0.834-264.184), total adhesion (OR, 28.550; 95% CI, 0.962-847.508), and undeveloped mastoid air cells (OR, 19.357; 95% CI, 1.022-366.589) were related to pars tensa cholesteatoma.Children with adhesive otitis media should be carefully followed up in the outpatient setting. Ears with poor mastoid development may develop pars tensa cholesteatoma. Additionally, ears with middle ear effusion, total adhesion, and the presence of otorrhea tend to be at risk of pars tensa cholesteatoma. Tympanoplasty or tympanostomy tube insertion should be considered for children with adhesive otitis media who have these risk factors to prevent progression to pars tensa cholesteatoma.

The purpose of this Technical Note is to describe the surgical technique to transform canal wall down tympanoplasty into canal wall up tympanoplasty, that is, to rehabilitate a recess cavity by filling the mastoid and epitympanic cavities with synthetic tissue (bioactive glass) and recreating a normal-caliber external auditory canal. Mastoid cavity obliteration leads to a clinically significant improvement in health-related quality of life without increasing risk of recurrent or residual cholesteatoma, conditional upon technically impeccable surgery.

Minimally invasive surgery of benign middle ear tumours is possible by using the endoscope. The optimal lighting and the broadest vision it offers, allow a transcanal approach to these rare tumours. The objective of this work is to summarise its key points through a case series.Retrospective study of benign middle ear tumours that underwent exclusive endoscopic surgery in a third-level adult university hospital between June 2018 and June 2020. Postoperative follow-up was performed by otoendoscopy and audiometry.Six patients underwent surgery during the study period. Five patients were female and one male, with an average age of 57.8 years (±21.9). Four tumours were in the left ear and 2 in the right ear. These included four tympanic paragangliomas (three type I and one type II), a chorda tympani neuroma, and a congenital cholesteatoma. There were no serious postoperative complications. At present, no tumour recurrence has been found in either case, with a minimum follow-up of 7 months.The present study adds evidence on the safety and efficacy of endoscopic transcanal ear surgery, as a minimally invasive technique, for the treatment of benign middle ear tumours confined to the tympanic cavity.

This study aimed to determine the effectiveness of using endoscopes in reducing recidivism secondary to residual cholesteatoma after canal wall-up tympanomastoidectomy.Randomized clinical trial.Tertiary referral center.Patients with cholesteatoma, aged 7 to 70 years.Subjects were randomly allocated into two groups: endoscopic-assisted canal wall-up (EACWU; group 1) and conventional canal wall-up (CWU; group 2) techniques. Pars flaccida and pars tensa subgroups were analyzed according to the anatomic location of cholesteatoma origin.Presence or absence of residual cholesteatoma, based on second look surgery, diffusion-weighted magnetic resonance imaging, or video-otoscopy at 12 and 18 months after surgery.In total, 57 ears were analyzed: 29 in group 1 and 28 in group 2. Group 1 revealed residual disease in 17.2% of ears, whereas group 2 had residual disease in 35.7% (p0.05) of the ears. In the pars tensa cholesteatoma subgroup, the incidence of residual disease was 13.3% for EACWU and 47.1% for the CWU technique (p0.05). A tendency of reduced incidence was observed for cholesteatoma due to residual disease using EACWU. In addition, a statistically significant reduction in the residual disease was observed in the subgroup of pars tensa cholesteatomas. In this subgroup, the relative risk was 0.28, and the number needed to treat was 4.6.The use of the endoscope reduces the incidence of recidivism secondary to residual disease in pars tensa cholesteatomas. Endoscopic-assisted surgery may be useful in cases with an indication for canal wall-up tympanomastoidectomy.1b.

Congenital cholesteatomas account for just up to 5% of all cholesteatomas and most commonly arise in the petrous apex and middle ear. Congenital cholesteatomas arising in the mastoid are rare and typically present late.In this study, we report a case series of 3 cases managed in our department between 2006 and 2021 and present a summary of the current literature.Congenital cholesteatomas arising in the mastoid is a rare finding and even among reported cases, not all are clearly mastoid in origin. Their location allows for considerable growth before symptoms develop. Pain and localized swelling in the temporal area are the most common presenting symptoms which can lead to diagnostic challenges. Our cases show that although surgery is often appropriate, conservative manage- ment may be suitable in certain situations.Congenital cholesteatoma of mastoid origin is rare and can present a diagnostic challenge. Greater awareness is important to facilitate early detection. A high index of suspicion is needed in those presenting with retro-auricular pain and swelling in the context of a normal ontological examination.

Cholesteatoma is occasionally accompanied by excessive calcification and presumably has different osteogenic dynamics compared to noncholesteatomous chronic otitis media. Cholesteatoma-related sclerotic lesions through the temporal bone can pose manipulatory difficulties, possibly leading to worse surgical outcomes or complications. Therefore, we compared surgical outcomes of cholesteatomas with and without sclerotic lesions.Retrospective cohort study.Tertiary academic medical center.Consecutive ears with acquired cholesteatomas requiring primary resection between January 2009 and December 2019. The ears followed up for1 year were excluded.Tympanoplasty with/without mastoidectomy.Prevalence and location of sclerotic lesion, comorbid fistulae, postoperative air-bone gap, recidivism, and complications.Overall, 19 (6.4%) of 299 ears had sclerotic lesions. More than two-thirds (68.4%) of sclerotic lesions were located adjacent to the lateral semicircular canal (LSC). Among ears with sclerotic lesions adjacent to the LSC, 46.2% had a comorbid fistula in the LSC. The prevalence of labyrinth fistula was significantly greater in ears with sclerotic lesions (42.1%) than in ears without sclerotic lesions (5.0%) (p0.0001, Fisher's exact test). Sensorineural hearing deterioration was significantly higher in ears with sclerotic lesions than in ears without (p = 0.0004, Fisher's exact test). Multivariate logistic regression analysis demonstrated that the presence of sclerotic lesions was a significant prognostic factor for residual disease (odds ratio [95% confidence interval]: 6.820 [2.055-22.633], p = 0.0017).Surgeons should be conscious of preoperative identification of sclerotic lesions adjacent to one of the semicircular canals, possibly leading to postoperative sensorineural hearing deterioration or residual cholesteatoma.

To evaluate the diagnostic accuracy of 2D BLADE turbo gradient- and spin-echo diffusion weighted imaging (TGSE BLADE DWI) for primary middle ear cholesteatoma diagnosis, using qualitative and quantitative methods.Retrospective case series.University hospital.Participants included those with suspected primary middle ear cholesteatoma after assessment by clinical otorhinolaryngologists combined with magnetic resonance imaging (MRI) examination. Finally, of the 85 ears from 65 patients enrolled in the study, 73 had cholesteatoma, and 12 had otitis media.Two radiologists independently assessed images and measured apparent diffusion coefficient (ADC) values. Sensitivity, specificity and accuracy were evaluated. Kappa (k) statistics, the intraclass correlation coefficient (ICC), the Kolmogorov-Smirnov normality test, the independent t test, and receiver operating characteristic (ROC) analysis were used for statistical analysis. Pair-wise comparison of the area under the ROC curve (AUC) was also performed using the Delong test.Imaging and histopathologic findings.The mean ADC value of cholesteatoma group (mean, 0.923 ± 0.246 × 10 -3 mm 2 /s) was significantly lower than that of noncholesteatoma group (mean, 1.744 ± 0.205 × 10 -3 mm 2 /s; p0.001). In ≤3 mm cholesteatoma group, the AUC of qualitative DWI was 0.846; the sensitivity, specificity, and accuracy for diagnosing cholesteatoma were 69.23%, 100%, and 84%, respectively; while the AUC of quantitative diagnosis was significantly increased to 1.0 ( p = 0.0209); and based on the optimal threshold of ADC, ≤1.352 × 10 -3 mm 2 /s, the sensitivity, specificity and accuracy improved to 100%. For3 mm cholesteatoma group, there were no significant differences in diagnostic performance. Excellent interobserver agreement and ICC for the qualitative and quantitative evaluations (k = 0.90 and ICC = 0.80, respectively) was noted between reviewers.TGSE BLADE DWI is useful for the detection of primary middle ear cholesteatomas, especially ≤3 mm lesions.

Intracranial extension of acquired cholesteatoma is a rare occurrence that can develop secondary to trauma, chronic otitis media or acquired aural cholesteatoma. The most commonly observed symptoms are headache and hearing loss. The authors report on a rare case of intracranial cholesteatoma presenting with atypic symptoms: swelling and temporomandibular joint disorders.

BACKGROUND AND PURPOSE: Cholesteatoma is an aggressive disease that may lead to hearing impairment. This study aimed to compare the utility of high-resolution CT and TSE-DWI fusion images with that of T2WI and TSE-DWI fusion images in the localization of middle ear cholesteatoma. MATERIALS AND METHODS: Seventy-one patients with middle ear cholesteatoma were retrospectively recruited. High-resolution CT, T2WI with fat suppression, and TSE-DWI scans were obtained, and image fusion was performed using a 3D reconstruction postprocessing workstation to form CT-DWI and T2WI-DWI fusion images. The quality of the 2 fused images was subjectively evaluated using a 5-point Likert scale with the horizontal semicircular canal transverse position as the reference. Receiver operating characteristic analysis was performed, and the diagnostic efficacies of CT-DWI and T2WI-DWI fusion images in localizing middle ear cholesteatoma were calculated. RESULTS: The overall quality of T2WI-DWI fusion images was slightly higher than that of CT-DWI fusion images (P

To assess the hearing outcomes of surgery for patients with chronic otitis media (COM) with or without cholesteatoma in case of the only hearing ear (OHE).This meta-analysis included COM patients with hearing in only one ear. The PubMed, Scopus, and Cochrane databases were reviewed.Thirteen studies were included, 252 excluded. The total number of operated ears was 229. The patients' ages ranged from 6 to 78 years. A change greater than 10 dB in hearing thresholds in the OHE was considered as a significant result. When both the COM with (cCOM) and without cholesteatoma (ncCOM) cases were considered, the air bone gap (ABG), air conduction (AC) and bone conduction (BC) thresholds were stable or improved in 91.06% (95% CI:81.94-97.19%), 87.91% (82.14-92.34%), and 94.99% (95% CI:90.20-97.97%) of patients, respectively. Stable or improved ABG, AC and BC thresholds were observed in 92.36% (95% CI:81.67-97.86%), 87.36% (95% CI:71.46-96.23%), and 94.85% (95% CI:81.36-99.49%) of those with ncCOM, respectively. For patients with cCOM, the results were 85.96% (95% CI:81.36-99.49%), 85.20% (95% CI:76.04-91.87%), and 97.01% (95% CI:89.62-99.63%), respectively. There were no significant differences in these thresholds between either category.Hearing deterioration in AC and BC thresholds can be expected in about 13-15% and 5-3%, respectively, of patients, with ncCOM or cCOM. Our results should not be construed as a guide for determining surgery eligibility in patients with COM in the OHE.

Mastoid obliteration technique combines the advantages of canal wall-up (CWU) and canal wall-down (CWD) approaches in the surgery of chronic suppurative otitis media with cholesteatoma. We aim to demonstrate our experience with mastoid obliteration technique using bone dust and BonAlive® (S53P4) bioactive glass granule in a comparative prospective clinical study.Between 1st of March 2012 and 31st of November 2021, mastoid obliteration surgery was performed in 14 patients using bone dust (7 cases) and BonAlive® granule (7 cases). Prior to these interventions, the patients had undergone more than three ear surgeries (CWU and CWD) generally in both groups. Changes of complaints, audiological results, and changes in quality of life were analysed in both groups, postoperatively.Having performed the mastoid obliteration technique, cochlear damage did not occur in either patient group. Long-term ear discharge and vertigo were occasionally observed after performing obliteration with bone dust. However, these complaints disappeared after a while. Complications were not reported in the case of obliteration with BonAlive®. Outstanding improvement was experienced in both groups.In our practice, mastoid obliteration surgery, using either bone dust or BonAlive® granule, has proved to be a safe and effective method in the management of chronic suppurative otitis media with cholesteatoma, resulting in continuous putrid ear discharge after CWU or CWD tympanoplasty. Obliteration with BonAlive® granule provides several advantages for patients, such as antibacterial effect, osteoconductive effect ensuring frame for bone growth and osteoproductive effect stimulating the ossification. Orv Hetil. 2022; 163(21): 838-845.Bevezetés és célkitűzés: Az otitis media suppurativa chronica cholesteatomatosa sebészetében a mastoidobliterációval végzett megoldás egyesíti a nyitott és a zárt technikával végzett műtétek előnyeit. Összehasonlító prospektív klinikai tanulmányunkban a csontporral és a BonAlive® (S53P4) bioaktív üveggranulátummal végzett mastoidobliterációs műtéteinkkel szerzett tapasztalatainkat összegeztük. Beteganyag és módszerek: 2012. március 1. és 2021. november 31. között 14 felnőtt betegünknél végeztünk mastoidobliterációs műtétet csontporral (7 beteg), illetve BonAlive® granulátummal (7 beteg). A mastoidobliterációt megelőzően a betegek mindkét csoportban átlagosan több mint 3 fülműtéten (nyitott vagy zárt technikájú tympanoplastica) estek át. A műtéteket követően mindkét csoportban elemeztük a panaszok változását, az audiológiai eredmények alakulását és a betegek életminőségében bekövetkezett változásokat. Eredmények: A mastoidobliterációs műtéti megoldás egyik betegcsoportban sem okozott cochlearis károsodást. A csontporral történt obliterációt követően gyakrabban tapasztaltunk elhúzódó fülváladékozást és esetenként szédülést, mely panaszok idővel megszűntek. A BonAlive® granulátummal obliterált esetekben komplikációt nem észleltünk. Mindkét betegcsoportban igen jelentős életminőség-javulást figyeltünk meg. Következtetés: A mastoidobliterációs műtétek – akár csontporral, akár BonAlive® granulátummal végezve – gyakorlatunkban biztonságos és hatásos megoldásnak bizonyultak korábban otitis media suppurativa chronica cholesteatomatosa miatt akár nyitott, akár zárt technikával végzett, állandó bűzös fülváladékozással járó esetekben. A BonAlive® granulátummal végzett obliterációk számos előnnyel járnak a betegek számára: az üveggranulátum antibakteriális hatású, oszteokonduktív hatású (keretet biztosít a csont növekedéséhez), és oszteoproduktív hatást is kivált (stimulálja a csontosodást). Orv Hetil. 2022; 163(21): 838–845.

To compare the performance of the EAONO/JOS, STAMCO, and ChOLE Cholesteatoma Staging Systems in prognostic evaluation of children acquired middle ear cholesteatoma after primary surgery and identify the other factors that could predict cholesteatoma recidivism. And the correlation between the staging and the recidivism of cholesteatoma after grouping according to operation was evaluated.A total of 123 ears of 118 patients that underwent surgery for primary cholesteatoma from November 2008 to May 2020 were included in this retrospective study, and then classified and staged according to the EAONO/JOS, STAMCO, and ChOLE cholesteatoma staging system, respectively. Each indicator involved in the system above was analyzed separately to evaluate its prognostic value for cholesteatoma recidivism.The type of surgical procedure performed (P = 0.020) was shown to be associated with cholesteatoma recidivism. Cholesteatoma location the supratubal recess (S1) (P = 0.026, HR = 3.614, 95% CI 1.137, 7.945), and the sinus tympani (S2) (P = 0.004, HR = 4.208, 95% CI 1.574, 11.250) were shown to be significantly associated with disease recidivism. When focusing on the CWU operation group, ossicular chain status in STAMCO stage (P = 0.043) and in the ChOLE stage (P = 0.018) were significantly associated with cholesteatoma recidivism. The results had shown no association between the three stages and cholesteatoma recidivism in the CWD and endoscopic surgery groups.Based on our study, the EAONO/JOS, STAMCO, and ChOLE Classifications have limited value in predicting cholesteatoma recidivism, in acquired middle ear cholesteatoma in children. Adding the pathological status of the ossicular chain may be useful for predicting the recidivism of cholesteatoma. Additional validation studies are entailed to definitively assess the clinical utility of these classifications.

BackgroundThe aggressiveness of paediatric cholesteatoma has long been a matter of debate. While much of the evidence is substantiated by data from the Western world, it is further limited by the retrospective nature of most studies. Therefore, this paper presents a comparative analysis of various characteristics of cholesteatoma between paediatric and adult populations seen at our centre.MethodsA total of 50 patients (25 adults and 25 paediatric) with clinical diagnosis of chronic suppurative otitis media with cholesteatoma underwent canal wall down mastoidectomy over a period of two years. The intra-operative findings were noted and patients were followed up for six months.ResultsThere was more extensive spread and ossicular erosion in paediatric cases. However, complications such as facial canal dehiscence and lateral semicircular canal dehiscence were more common in adults.ConclusionPaediatric cholesteatoma is more aggressive and invasive than adult cholesteatoma, and the clinical behaviour is consistent with findings from other parts of the world.

Purpose To map healthcare utilized by subjects with chronic otitis media, with or without cholesteatoma and perform a cost analysis to determine key drivers of healthcare expenditure. Methods A registry study of 656 adult subjects with chronic otitis media that underwent a middle ear surgery between 2014 and 2018. Healthcare contacts related to all publicly funded specialist ENT care, audiological care and primary care for a disease of the ear and mastoid process were extracted. The data are extracted from the Swedish National Patient Registry on subjects that reside in western Sweden. Results Subjects made 13,782 healthcare contacts at a total cost 61.1 million SEK (6.0 million EUR) between 2014 and 2018. The mean cost per subject was 93,075 SEK (9071 EUR) and ranged between 3971 SEK (387 EUR) and 468,711 SEK (45,683 EUR) per individual. In the most expensive quartile of subjects, mean cost was 192,353 SEK (18,747 EUR) over the 5-year period. These subjects made 3227 ENT contacts (roughly four each year) and 60% of total costs were associated with in-patient ENT care. Conclusion Patients with chronic otitis media are associated with high ENT resource utilization that does not diminish after surgical intervention and the disease places a long-term burden on healthcare systems. Significant costs are attributed to revision surgeries, indicating that these patients could be managed more effectively. In many such cases, reoperation cannot be avoided, especially due to recurrence of cholesteatoma. However, in some patients, when the indication for subsequent surgery is only hearing improvement, alternative options, such as hearing aids or implants, should also be considered. This is especially true in difficult cases, where revision ossiculoplasty is likely.

BackgroundCholesteatoma is a benign but destructive epithelial lesion in the middle ear and/or mastoid. It is hard to translate data from previous research to daily clinical practice. In this study, factors influencing recurrence rates in daily clinical practice were identified.MethodThe study included 67 patients who were treated for a cholesteatoma with combined approach tympanoplasty. The average follow-up time was 35 months.ResultsThe recurrence rate was 23.3 per cent in adults and 45.5 per cent in children. Predictors of recurrence were younger age and a low tegmen. A cholesteatoma in a child and the simultaneous presence of a low tegmen led to recurrence in 82.8 per cent of the patients.ConclusionPatients – especially children – with a low tegmen have an increased risk of recurrence. It is recommended that ENT surgeons be aware of recurrence in children, particularly in the case of a low tegmen.

This study investigated the utility of temporal subtraction computed tomography (TSCT) obtained with temporal bone high-resolution computed tomography (HRCT) for the preoperative prediction of mastoid extension of middle ear cholesteatomas.Twenty-eight consecutive patients with surgically proven middle ear cholesteatomas were retrospectively evaluated. The presence of black color in the mastoid region on TSCT suggested progressive changes caused by bone erosion. Enlarged width of the anterior part of mastoid on HRCT was interpreted as suggestive of mastoid extension. Fisher's exact test was used to compare the widths and black color on TSCT for cases with and without mastoid extension. The diagnostic accuracy of TSCT and HRCT for detecting mastoid extension and interobserver agreement during the evaluation of black color on TSCT were calculated.There were 15 cases of surgically proven mastoid extension and 13 cases without mastoid extension. Patients with black color on TSCT were significantly more likely to have a mastoid extension (p0.001). The sensitivity and specificity of TSCT were 0.93 and 1.00, respectively. Patients in whom the width of the anterior part of the mastoid was enlarged were significantly more likely to have a mastoid extension (p = 0.007). The sensitivity and specificity of HRCT to detect the width of the anterior part of the mastoid were 0.80 and 0.77, respectively. Interobserver agreement during the evaluation of TSCT findings was good (k = 0.71).This novel TSCT technique and preoperative evaluations are useful for assessing mastoid extension of middle ear cholesteatomas and making treatment decisions.•TSCT shows a clear black color in the mastoid region when the middle ear cholesteatoma is accompanied by mastoid extension. •TSCT obtained with preoperative serial HRCT of the temporal bone is useful for assessing mastoid extension of middle ear cholesteatomas.

ObjectiveTo examine the effects of mastoid and middle-ear volume on the anatomical and functional success of type 1 tympanoplasty in paediatric patients.MethodsThis study included 45 paediatric patients who underwent type 1 cartilage tympanoplasty. Patients’ demographic data, pre- and post-operative audiological evaluation results, and post-operative graft status were evaluated. Middle-ear and mastoid cavity volumes were calculated (in cubic centimetres) using temporal bone high-resolution computed tomography. Middle-ear and mastoid cavity volume values were compared between patients with and without post-operative anatomical and functional success.ResultsAnatomical success was achieved in 82.2 per cent of patients (n = 37), and functional success in 68.9 per cent (n = 31). When anatomical success and failure groups were compared, a statistically significant difference was found in mean mastoid volume (p = 0.037), while there was no significant difference in relation to mean middle-ear volume (p = 0.827). The comparison of functional success and failure groups revealed no significant difference in mean mastoid volume (p = 0.492) or middle-ear volume (p = 0.941).ConclusionThe study showed that mastoid pneumatisation volume affects surgical success in paediatric tympanoplasty.

Objectives The main goal of the present study was to assess hearing outcome for malleus removal in cholesteatoma surgery compared to a group with malleus conservation. The secondary aim was to compare the auditory involvement of the stapes between the two groups. Material and methods A single-center observational study included adult patients operated on by ossiculoplasty for acquired cholesteatoma between 2015 and 2019. Endpoints comprised improvement in pure-tone average air-bone gap (PTA-ABG) and air-bone gap (ABG) at conversational frequencies and, independently, per frequency. 136 patients were included: 95 with conserved malleus (M+) and 41 with malleus removal (M(). Mean time to audiometric follow-up was 9 months in both groups. Results The PTA-ABG improvement was 4.4 ± 12.6 dB for the M+ group and 3.8 ± 13.4 dB for the M− group, with no significant significance (P = 0.8). Better results (not exceeding 7.5 dB) were found for the M+ group at 2 and 8 kHz (P = 0.3 and P = 0.052 respectively). Presence or absence of the stapes did not affect the results in either group. Conclusion Those results suggest a negligible role of the malleus in early hearing outcome of tympanoplasty for cholesteatoma. A slight improvement was observed in the M+ group at 2 and 8 kHz, but its interpretation remains uncertain.

Compare surgical and audiological outcomes of patients with congenital aural stenosis (CAS) with cholesteatoma to patients with CAS without cholesteatoma and patients with complete congenital aural atresia (CCAA).Retrospective case series.Tertiary care hospital.Patients with CAS (with and without cholesteatoma) and CCAA.Surgery for CAS/CAA.Patients with CAS and CAA undergoing surgical repair from June 2004 to July 2020 were identified from an institutional database. Included patients were divided by presence of a canal cholesteatoma. Clinical history, pre- and postoperative audiometric data, and clinical outcomes were compared.Of the 283 patients (300 ears), 18 (19 ears) had a canal cholesteatoma. When compared to ears without cholesteatoma (CCAA ears plus CAS ears without cholesteatoma), ears with cholesteatoma were more likely to be younger (9.2 ± 6.6 vs. 11.5 ± 9.2; p = 0.015), female (66.7% vs. 38.1%; p = 0.02; OR 3.2, 95% CI 1.18-8.9), and have normal/Grade I microtia (47.4% vs. 9.6%; p 0.0001; OR 0.12, 95% CI 0.044-0.32), but not a history of draining ear (5.3% vs. 0%; p = 0.05; OR 0.06, 95% CI 0.004-0.999). Preoperative audiometric data demonstrated a lower mean air-bone gap (45.8 dB vs. 52.3 dB; p = 0.009) and better speech reception threshold (48.7 dB vs. 57.4 dB; p = 0.0004) in cholesteatoma ears. Postoperatively, ears with cholesteatoma were more likely to close the ABG within 20 dB (p = 0.001; OR 0.19, 95% CI 0.072-0.52). No patient in the cholesteatoma group developed post-operative bony/soft-tissue stenosis (0% vs. 9.7%; p = 0.65; OR 1.61; 0.21-12.6) or required revision surgery (0% vs. 11%; p = 0.38; OR 2.46, 0.32-19).Patients with CAS and cholesteatoma have better audiometric outcomes and likely a more durable repair with a decreased need for revision possibly secondary to greater embryologic development of the meatus, ear canal, and middle ear space despite the cholesteatoma.

BackgroundWith a growing ageing population, there is a higher prevalence of dementia in patients with conditions that can be managed surgically. Patients with dementia undergoing surgery under general anaesthesia often have poorer outcomes than those without. Therefore, local anaesthesia can be an option.MethodsTwo patients with severe dementia and advanced cholesteatoma were identified for operative management. They were deemed too high risk to proceed with general anaesthesia. This article describes our experience of performing mastoid surgery under local anaesthesia in the presence of a primary carer in the operating theatre.ResultsThe complete extirpation of cholesteatoma was achieved in both cases. The carers reported that local anaesthesia helped to facilitate communication and aid patient co-operation.ConclusionOur experience, albeit limited to two cases, illustrates an alternative individualised peri-operative strategy in the surgical management of patients with dementia and concurrent advanced cholesteatoma.

Purpose The purpose of this study was to investigate the usefulness of temporal subtraction CT (TSCT) of temporal bone CT for the detection of postoperative recurrent/residual cholesteatoma of the middle ear. Methods Thirty-two consecutive patients with surgically proven postoperative recurrent/residual cholesteatoma and 14 consecutive patients without recurrent/residual lesion matched the selection criteria and were retrospectively evaluated. TSCT imaging was generated with the use of serial postoperative CT. Two experienced radiologists and two residents evaluated the presence of bone erosive change by comparison serial CT studies, and CT and TSCT. The detection rate of bone erosive change, sensitivity and specificity of the recurrence/residual lesions, and reading time for each reader were evaluated. Results TSCT + CT significantly improved the detection of bone erosive changes compared to CT-only evaluation (17.4–41.3% vs. 37.0–58.7%, p = 0.008–0.046). The mean sensitivity and specificity of TSCT + CT for experienced radiologists were 0.77 and 1.00, and 0.52 and 0.97 without TSCT. The mean sensitivity and specificity of TSCT + CT for residents were 0.64 and 1.00, and 0.41 and 1.00 without TSCT. Sensitivity showed an increase in all readers. The use of TSCT significantly reduced the reading time per case in all readers (p Conclusion TSCT improves the depiction of newly occurring progressive bone erosive changes, and detection sensitivity and reading time in postoperative recurrence/residual cholesteatoma of middle ear.

OBJECTIVE: In cholesteatoma surgery, obliteration of the mastoid and epitympanic space (bony obliteration tympanoplasty, BOT) is an increasingly used technique with low recurrent and residual cholesteatoma rates. While factors as the postoperative hearing level and infection rate are important for the patient as well, these outcome parameters are not frequently reported on in current literature. The objective of this study is to evaluate the recurrent and residual cholesteatoma rates of the BOT technique and nonobliterative canal wall up (CWU) and canal wall down (CWD) mastoidectomy in a large patient cohort. Secondary objectives were to evaluate the infection rate and hearing outcome for all three techniques. DESIGN: Retrospective cohort study. SETTING: Single-center study. PATIENTS: All 337 adult patients (≥18 yrs) who underwent primary or revision cholesteatoma surgery between January 2013 and March 2019 were included. MAIN OUTCOME AND MEASURES: Recurrent cholesteatoma rates, residual cholesteatoma rates, postoperative infections and other complications, hearing outcome. RESULTS: The estimated combined rate of recurrent and residual cholesteatoma at 5 years follow-up was 7.6% in the BOT group, 34.9% in the CWU group, and 17.9% in the CWD group. The postoperative infection rate in the different groups ranged from 4.3% to 4.9%. The median gain in AC threshold level varied from 0.0 dB in the BOT and CWD group to 3.8 dB in the CWU group. CONCLUSIONS: We show that cholesteatoma recurrence rates after the BOT technique in our clinic are significantly lower compared to CWU surgery. There were no differences in infection rate and no clinically relevant differences in postoperative hearing between the BOT, CWU, and CWD technique.

Objective: To present the long-term outcomes of mastoid obliteration in cholesteatoma surgery using S53P4 bioactive glass (BAG) in an adult population. Study Design: Retrospective cohort study. Setting: Single-center study. Patients All 173 adult patients who underwent primary or revision surgery for cholesteatoma with mastoid obliteration using S53P4 BAG with at least 1 year of follow-up including nonecho planar diffusion-weighted magnetic resonance imaging (MRI) (non-EP DWI MRI) and/or second-look surgery to evaluate recidivism. Both canal wall up (CWU) and canal wall down (CWD) procedures were included. Intervention(s) Patients underwent CWU or CWD mastoidectomy using S53P4 BAG. Main Outcome and Measures Cholesteatoma recidivism, postoperative complications, Merchant grade, hearing outcome. Results: Cholesteatoma recidivism was assessed by MRI in 97% of all cases and second-look surgery look surgery in 3% of cases. After a mean follow-up period of 53 months, cholesteatoma recidivism was seen in 10% of the cases (n = 18). Using the Kaplan-Meier curve to extrapolate, a 5-year recidivism rate of 12% was estimated. Only minor complications occurred, all resolving spontaneously or after minor treatment. Merchant grade of 0 to 1 was achieved 95% of the patients, no persistently wet ears were observed. Closure of the air-bone gap within 20 dB was possible in 32%. Conclusion: In this long-term (up to 10 yr) follow-up study, we demonstrated the safety of S53P4 BAG. Minimal and only minor postoperative complications were observed. The effectiveness of BAG was indicated by the low rate of recidivism, even when using non-EP DWI MRI, a sensitive and specific noninvasive technique to detect cholesteatoma recidivism.

Heterotopic pancreas is the congenital presence of pancreatic tissue outside its normal location in the absence of vascular and anatomical connection with the main pancreas. To our knowledge, no case of heterotopic pancreas cyst in the middle ear has been reported to date. In this study, we report the first case of a 6-year-old boy with ectopic pancreas in the area of middle ear. The patient underwent canal wall down mastoidectomy with tympanoplasty. It was finally diagnosed as ectopic pancreas (left middle ear). During the 6-year follow-up, no evidence of recurrence or residual disease in the middle ear cleft or mastoid was found. Heterotopic pancreas in the middle ear is an uncommon condition and may present with otorrhea or aural fullness. Diagnosis is usually straightforward on the histologic evaluation of resection specimen, complemented with immun ohist ochem istry . Total excision with such lesion is preferred to avoid some complications. Regular follow-up is necessary due to the potential risk of recurrence and malignant transformation.

The role of imaging in cholesteatoma continues to evolve with excellent bony details provided by high-resolution computed tomography and high soft tissue identification for cholesteatoma by diffusion-weighted magnetic resonance imaging. The fusion of highresolution computed tomography and diffusion-weighted magnetic resonance imaging combines the advantages of both imaging techniques.A random sample of 40 consecutive patients with chronic suppurative otitis media with cholesteatoma was included in this study. Both high-resolution computed tomography of the petrous bone and non-echoplanar diffusion-weighted magnetic resonance imaging were performed. This was followed by their fusion. Patients were classified according to The European Academy of Otology and Neurotology, in cooperation with the Japanese Otological Society Joint Consensus Statement on the Definitions, Classification, and Staging of Middle Ear Cholesteatoma. All patients were operated, and the technique was tailored according to the data obtained from the preoperative fusion of computed tomography and diffusion-weighted magnetic resonance imaging and the intraoperative findings.Patients were equally divided between males and females with a mean age of 26.8 years of which 52.5% were left-sided ears. The fusion of high-resolution computed tomography and diffusion-weighted magnetic resonance imaging had a 100% sensitivity and 88.9% specificity regarding The European Academy of Otology and Neurotology, in cooperation with the Japanese Otological Society classification. On the other hand, it showed 100% specificity and 100% sensitivity for all middle ear subsites except sinus tympani which obtained 55.56% sensitivity and 100% specificity. In all patients with preoperative fusion showing cholesteatoma not reaching the mastoid antrum (30%), exclusive endoscopic approach was employed, and no postauricular incision was needed.The fusion of high-resolution computed tomography and diffusion-weighted magnetic resonance imaging images is an accurate tool for localizing cholesteatoma in various middle ear cleft subsites. This makes it a valuable tool for cholesteatoma classification and staging and surgical planning preoperatively.

The aim of this study was to investigate the inhibitory effect of different doses of sodium-2-mercaptoethanesulphonate (MESNA) and 5-fluorouracil on cholesteatoma formation.Fifty-six Wistar albino male rats were divided into seven groups with eight rats in each. On the first, eighth and fifteenth days, 0.2 ml of saline was administered to the group 1 (control group), and propylene glycol to induce cholesteatoma the other groups. On the 22Significant differences were found between Group 1 and all other groups except Group 3. Significant differences were also found between Group 3 and Groups 2, 5 and 6 (P0.05).According to the results of this study, experimental cholesteatoma induced with propylene glycol may be inhibited by MESNA at 100% concentration.Gli effetti inibitori del mesna e 5-fluorouracile nel colesteatoma indotto dal glicol-propilene nei topi.Lo scopo di questo studio era di indagare l’effetto inibitorio dell’applicazione di diverse dosi di sodio-2-mercaptoetansolfonato (MESNA) e 5-fluorouracile sulla formazione di colesteatoma.Cinquantasei ratti maschi albini Wistar sono stati divisi in sette gruppi da otto ratti ciascuno. Il primo, l’ottavo e il quindicesimo giorno, sono stati somministrati 0,2 ml di soluzione salina al gruppo 1 (gruppo di controllo) e glicole propilenico per indurre il colesteatoma negli altri gruppi. Il 22° giorno dello studio, sono stati somministrati 0,2 ml di soluzione salina al Gruppo 1 e al Gruppo 2. I gruppi da 3 a 7 sono stati trattati con 0,2 ml di MESNA al 100%, 0,2 ml di MESNA al 50%, 0,2 ml di MESNA al 20%, 0,2 ml di 5-fluorouracile e 0,1 ml di MESNA al 100% più 0,1 ml di 5-fluorouracile, rispettivamente, con tutte le applicazioni eseguite mediante iniezione intratimpanica.Sono state trovate differenze significative tra il Gruppo 1 e tutti gli altri gruppi eccetto il Gruppo 3. Differenze significative sono state trovate anche tra il Gruppo 3 e i Gruppi 2, 5 e 6 (P0,05).Secondo i risultati di questo studio, il colesteatoma sperimentale indotto con glicole propilenico può essere inibito da MESNA a una concentrazione del 100%.

Background: Non-echoplanar diffusion-weighted MRI (DWMRI) has a role in the surgical planning for cholesteatoma. Aims/Objectives: The aim of the study was to assess the use of DWMRI in the management of cholesteatoma across the UK, and measure clinicians’ confidence in the use of DWMRI. Materials and Methods: Telephone survey in 139 Otolaryngology Departments in the United Kingdom between March 2017 and July 2017, and asking radiology delegates at the British Society of Head and Neck Imaging 2017 meeting. Results: The response rate was 101 out of 139 Trusts (73%). Of those respondents who did have DWMRI available, 68/88 respondents (77%) use it for cholesteatoma. The mean confidence (±standard deviation) of the respondents with DWMRI in identifying cholesteatoma presence was 7.3 ± 2.1, in identifying volume of cholesteatoma was 6.8 ± 1.8, and in identifying subsites of cholesteatoma was 4.6 ± 2.1. Conclusions and Significance: DWMRI has a well-defined role in the follow-up of patients after cholesteatoma surgery, and those primary cases of cholesteatoma where the diagnosis is in question. The use of DWMRI for cholesteatoma is variable across the UK, but there are certain clinical scenarios where there is not enough awareness regarding the benefits of imaging (such as petrous apex cases of cholesteatoma).

Horizontal canal fistulas are not uncommon in patients with cholesteatoma. Patients with canal wall down cavities and exposed horizontal canal fistulas develop significant dizziness with wind or suction exposure. Obliteration of mastoid cavities in patients with exposed fistulas can be challenging. We describe a patient with horizontal canal fistula and chronic dizziness from wind exposure who underwent successful mastoid cavity obliteration with preservation of hearing. Patients with horizontal canal fistulas in a canal wall down cavity can be managed with mastoid obliteration for relief of dizziness.

Objective Non-echo planar diffusion weighted magnetic resonance imaging is a reliable surveillance tool of residual cholesteatoma nowadays. It is not known whether the material of the ossicular chain prosthesis modifies the sensitivity and specificity of MRI in these cases. The aim of the study was to compare the sensitivity, specificity and a localization-specific accuracy of non-EPI DW MRI sequences for residual cholesteatoma in the following 3 subgroups: patients with titanium ossicular prosthesis (group T), with autologous cortical bone columella (group A) or without any reconstruction (group WR) of hearing bones. Methods This prospective study covered 28 cases with cholesteatoma of the middle ear undergone second-look surgery, who had preoperative PROPELLER DW-MRI. Surgical findings were compared to the results of the DWI-MRI. Results The overall sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were: 0.76-0.8-0.76-0.8. Group T, group A and group WR sensitivity was 0.83-0.6-1, specificity: 0.75-0.75-0.85, PPV: 0.83-0.75-0.66, NPV: 0.75-0.6-1. Overall accuracy was 0.78. Size of missed cholesteatoma was 2-4 mm (mean: 2.66±1.15). Conclusions Various materials are suitable for ossicular chain reconstruction. The poor detectability of residual or recurrent cholesteatoma in the middle ears reconstructed with autologous bony prosthesis may still claim second-look surgery instead of the usage of non- EPI DWI sequences independently in these patients.

The damaging effect of cholesteatomas presents mainly as bone resorption by osteoclasts located in the space between the bone and perimatrix. This process is initiated by the molecular cascade of osteoclast differentiation factors. The aim of the study is to analyse cholesteatoma microstructures via scanning electron microscope (SEM), and associate them with risk and grade of bone erosion.Pathological middle ear tissue fragments with cholesteatoma visible under a microscope were collected from 58 patients operated on for chronic otitis media with features of bone defects in the middle ear walls. These fragments were examined under a scanning electron microscope.Analysis of the cholesteatomas' surface under a SEM revealed both regular and irregular structure of the matrix, most being the latter. Irregular matrix structures were observed in cases with a short disease history and in patients for whom this was the first surgical procedure. In our analysis, a cholesteatoma matrix with regular structures was associated with less bone destruction of the middle ear space.The microstructure of cholesteatomas that showed regular layers under SEM coincides with reduced destruction of the middle ear bone walls. An irregular structure (pathognomonic for a process with a short medical history, and in patients operated on for the first time) is characterised by a tendency towards deeper destruction of bone tissue.Modello di colesteatomi al microscopio elettronico a scansione - un fattore di rischio per il riassorbimento osseo.L’effetto dannoso dei colesteatomi si presenta principalmente come riassorbimento osseo da parte degli osteoclasti situati nello spazio tra l’osso e la peri-matrice. Questo processo è avviato dalla cascata molecolare dei fattori di differenziazione degli osteoclasti. Lo scopo dello studio è analizzare le microstrutture del colesteatoma tramite microscopio elettronico a scansione (SEM) e associarle al rischio e al grado di erosione ossea.Sono stati raccolti frammenti patologici di tessuto dell’orecchio medio con colesteatoma visibile al microscopio da 58 pazienti operati per otite media cronica con difetti ossei delle pareti dell’orecchio medio. Questi frammenti sono stati esaminati al microscopio elettronico a scansione.L’analisi della superficie dei colesteatomi al microscopio elettronico a scansione ha rivelato una struttura irregolare della matrice nella maggioranza dei casi. Essa in particolare è stata osservata nei pazienti con una breve storia di malattia e nei pazienti sottoposti ad una prima procedura chirurgica. Nella nostra analisi, una matrice di colesteatoma con strutture regolari è stata associata a una minore distruzione ossea dello spazio dell’orecchio medio.1. La microstruttura dei colesteatomi che mostravano strati regolari al SEM coincide con una ridotta distruzione delle pareti ossee dell’orecchio medio. 2. Una struttura irregolare (patognomonica per un processo con una storia medica breve, e nei pazienti operati per la prima volta) è caratterizzata da una tendenza alla distruzione più profonda del tessuto osseo.

Objective This study was aimed to determine the characteristics of middle ear cholesteatoma and to investigate short-term outcomes regarding the rates of residual and recurrent cholesteatoma and the postoperative hearing results in Japan, via a nationwide survey using staging and classification criteria for middle ear cholesteatoma, as proposed by the Japan Otological Society (JOS). Methods The first-round survey was conducted in 2016. The target was patients with middle ear cholesteatoma who were surgically treated in Japan between January and December 2015. Medical information on the patients was anonymized. The questionnaire entries were age, sex, cholesteatoma classification and stage, preoperative hearing level, mastoid development, status of the stapes, and surgical method. There were a total of 1,787 registered patients from 74 facilities from all over Japan. The second survey was conducted in January 2018 and received 1,456 responses from 49 facilities in Japan. Of the 1,456 cases, 1,060 were conducted in the postoperative hearing survey and 1,084 in the residual recurrence survey. Results The most common cholesteatoma type was pars flaccida cholesteatoma (63.3%), followed by pars tensa cholesteatoma (13.0%), congenital cholesteatoma (12.9%), and cholesteatoma secondary to chronic tensa perforation (5.6%). Cholesteatoma of uncertain origin accounted for 5.0% (90 cases). Stage II was predominant in pars flaccida and pars tensa cholesteatoma, which frequently involves the mastoid, whereas about half of cases of cholesteatoma secondary to chronic tensa perforation and congenital cholesteatoma were classified as stage I. One hundred fifty-two of 1,084 cases (14.0%) had recurrent cholesteatoma, residual cholesteatoma, or both following first surgeries. The postoperative rates of hearing success rate was 63.3%. Conclusion We were able to clarify not only the current epidemiological status of middle ear cholesteatoma but also the current trends of cholesteatoma surgery in Japan. The development of a staging system by the JOS Committee serving an epidemiological database for international or time-dependent comparison. It is possible to use this staging system with reasonable reliability.

Objectives We aimed to clarify the usefulness of high-resolution computed tomography (HRCT) and establish HRCT criteria for presurgical assessment of the mastoid extension in pars flaccida cholesteatomas of the middle ear. Methods Retrospective observational study. Patients who underwent primary surgery for pars flaccida cholesteatoma and those who underwent temporal bone HRCT for pretreatment evaluation were reviewed. The distance in the anterior-most portion of the mastoid sinus on HRCT was measured, and the presence of surgically verified mastoid extension of cholesteatoma was evaluated. All cases were subclassified as M+ (surgically mastoid extension-positive) or M- (surgically mastoid extension-negative). Results A total of 107 patients with pars flaccida cholesteatoma were included. The distance in the M+ cases was significantly longer than that in the M- cases, and the cutoff value was 3.6 mm. The difference between the ipsilateral/diseased-side distance and the contralateral/evaluable side (difference value) in M+ cases was larger than that in M- cases, with a cutoff value of 0.6 mm. The inter-rater reliability of this distance measurement was excellent, regardless of imaging experience. Conclusions The cutoff values of the distance and the difference value can be used for pretreatment HRCT evaluation of mastoid extension in middle ear cholesteatoma with relatively high accuracy, regardless of the experience and skill levels of the evaluator.