Management of Cholesteatoma in the 21st Century John Rutka MD FRCSC Department of Otolaryngology University of Toronto

Mastoid Misery Index (Why mastoidectomy surgery fails) Mucosal disease (incomplete epithelialization) High facial ridge Inadequate meatoplasty Recurrent cholesteatoma

Question “Does surgery for cholesteatoma prevent complications from occurring?” Historical controls Glasgow study (Nunez & Browning, JLO 1990)

Complications: TTH Experience 1987-97 From cholesteatoma LSCC “fistula” - 13 pts (5.8%) Brain abscess / meningitis - 4 pts (1.8%) Facial paralysis - 4 pts (1.8%) SNHL - 6 pts (3%) Mastoiditis - 3 pts (1.5%)

Complications: TTH Experience 1987-97 Iatrogenic Facial paralysis - 10 pts (5%)* Brain herniation - 2 pts (1%) CSF leak - 1 pt (0.5%) Symptomatic fistula - 1pt (0.5%) Significant pain - 2pts (1%) Facts * all patients had 7th palsy on referral * surgery was 2x’s more likely to cause facial paralysis than cholesteatoma

Controversies When does a retraction pocket become a cholesteatoma? (The Friedberg Doctrine) Does all cholesteatoma require surgery?

Thai Rural Ear Nose and Throat Foundation Founded in 1972 by Dr Salyaveth Lekagul >100 000 patients assessed >4000 mastoidectomy procedures >7000 tympanoplasty procedures

Prevalence of ear disease from 1980-91* * data collected from mobile ENT unit

Ear Disease in Thailand* * data collected from mobile ENT unit

Why has ear disease decreased in Thailand? 1972 Thailand had 26 ENT surgeons (25 were in Bangkok) In the 70 provinces, there were no ENT surgeons or operating microscopes Patients required to travel average 400 km for treatment

Why has ear disease decreased in Thailand? 1998 There are now 500 ENT surgeons in Thailand All provincial capitals have hospital with ENT surgeon and operating microscopes Patients now travel less than 50 km

Why has ear disease decreased in Thailand? Complete immunization programs nationwide / national health care Better nutrition and little malnutrition Transportation District and community hospitals (600 hospitals, 10-60 beds) Better education / teaching about dangers of ear disease - personal communication, Salyaveth Lekagul 1998

Risks of Developing an Otogenic Intracranial Abscess Annual risk with active CSOM is 1/10,000 3x’s more common in males Lifetime risk of individual age 30 years with CSOM is 1/200 5% abscesses occur in the immediate postoperative period *Nunez & Browning 1990

Cholesteatoma Surgery 225 Mastoidectomy procedures at TTH from 1987 - 97 188 pts - primary cholesteatoma modified radical 134 radical 45 CAT 9 37 pts- revision surgery (referred) modified radical 25 radical 12

Revision Surgery (JAR) 9 patients mucosal disease - 5 patients recurrent cholesteatoma - 2 patients* web formation - 1 patient cholesterol granuloma - 1 patient revision rate 9 / 225 pts (4.0%) recurrence (recidivistic) 2 / 225 pts (1%) *hypotympanic cholesteatoma, petrous apex cholesteatoma

Over the past fifty years, there has been an apparent decline in: prevalence of cholesteatoma surgery for cholesteatoma intracranial complications (brain abscess, meningitis) acute mastoiditis

Future challenges in cholesteatoma surgery in the 21st century: intralabyrinthine / petrous apex disease footplate / sinus tympani childhood cholesteatoma

Childhood Cholesteatoma Probability of recurrence* 40% at 10 years Reasons 40-50% of children have extensive pneumatization infiltrating nature of cholesteatoma less aggressive surgery performed * Gristwood 1979, Clinical Otolaryngology

Growth Rates of Cholesteatoma Variations in growth potential of residual cellular elements i.e. cholesteatoma doubling time attic (10 months), mastoid (25 months) Blood supply to matrix Vascular factors / infection / growth factors / proteolytic enzymes Anatomic factors (i.e. pneumatization)

Surgical Techniques Open Procedures Closed Procedures atticotomy modified radical mastoidectomy attico-antrostomy Bondy variant radical mastoidectomy Closed Procedures combined approach tympanoplasty (canal wall up) Mastoid obliteration

Surgical Management High resolution CT preop CO2 laser - footplate disease Facial nerve monitoring

Cause for concern? Declining incidence of cholesteatoma may mean: 1. Decreased recognition of disease Will more complications arise as a result? 2. Decreased surgical exposure Can surgical skills be maintained? 3. Decreased educational teaching (residency training) Should mastoidectomy surgery be considered fellowship material?

Causes for Facial Paralysis