1. Chirurgie du Cholesteatome LA TECHNIQUE FERMEE

3. Retraction pocket
CHOLESTEATOMA

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

7. 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?

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

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

17. 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%

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

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

20. Endoscopic Second Look

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

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

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

26. 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

27. 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

28. 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

29. 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

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

31. migration
retraction
metaplasia

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

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