Chirurgie du Cholesteatome LA TECHNIQUE FERMEE

Retraction pocket CHOLESTEATOMA

TYMPANOPLASTY – Wullstein & Zollner Eradication cholesteatome matrix Reparation Eardrum = Myringoplasty Ossicles = Tympanoplasty Ear Canal = Rehabilitation of anatomo-physiology of the ear Eustachian tube

Cholesteatoma First question: Second question: Third question: Can we remove aall size of cholesteatoma from the middle ear? Second question: What is the best way to prevent from recurrence Third question: Are we able to respect or restore the normal anatomo-physiology of bothe external canal and middle ear?

Cholesteatoma Open Techniques Good wound healing – Skin in a wrong place Defective: Wrong skin in a wrong place

1677 Closed Techniques 1977-1999 Unselected patients – Several Surgeons Children>16 353 Cases 21% Adults >15 1317 Cases 79%

Cholesteatoma removal to prevent residues Reconstruction to prevent recurrence Tympanic graft Fascia 804 Perichondrium 697 Allograft Xenograft Canal Wall Intact 32 % Partial 62 % Total 5%

Secon Look CHILDREN ADULTS 60% (214/353) Before 1993 78% After 1993 42% ADULTS 44,5% (586/1317) Before 1993 54% After 1993 25%

Systematic second look versus Criteria in decision making OTOSCOPY CT SCAN FUNCTIONAL RESULT

Endoscopic Second Look

REQUIREMENTS -well ventilated middle ear LIMITATIONS -Bony structures -Fibrous tissue -Bleeding -Visual limitation to differentiate pathology -Ossicular chain 18% endoscopic Second look

Short term results during second look CHILDREN 353 Recurrence 18% Residual 20% ADULTS Recurrence 16,5% Residual 8,5%

Short term results regarding only the second stages CHILDREN 214 Recurrence 29% Residual 32% ADULTS 586 Recurrence 37% Residual 20%

Out of 1670 cases 498 reviewed over 10 years 5 years follow-up 60 cases 12 % 3rd revision 11 cases 2% 2nd revision Including 48 cases 8% children cholesteatoma

conclusions The purpose of the surgery is not to performe a closed or an open technique but to get a safe ear. Residual cholesteatoma means we have to improve the exeresis of the disease. Recurrence means we have to improve the reparation of the ear

OTITE CHRONIQUE OTORRHEE PERFORATION MALADIE Abondante, muqueuse pars tensa, antero-inf. non marginale tubo-tympanique pneumatisée simple SAFE EAR non dangereux Epaisse, fétide, peu abondante Shrapnell, postero-sup marginale antro-atticale éburnée cholesteatome UNSAFE EAR dangereux

TYMPAN PERFORATION : absence des 3 couches. RETRACTION : absence de la fibreuse, épiderme stable. ADHESIF : absence de la fibreuse et de la muqueuse, épiderme stable. CHOLESTEATOME :absence de la fibreuse et de la muqueuse, épiderme instable

POCHES DE RETRACTION S. d ’appel Localisation Epiderme Os ABSENT NON MARG NORMAL MOBILE SAFE PRESENT MARGINALE DYSKERATOSE FIXEE UNSAFE

migration retraction metaplasia

TYMPAN Absence lamina propris – myringomalacia, retraction, collapsus Absence LP et absence muq – atelectasie, otite adhésive Absence LP et absence muq et proliferation epiderme - cholesteatome

POCHES DE RETRACTION TYMPANIQUE Tympan flaccide Attraction mediale du tympan Collapsus tympanique Tympanum atelectasique