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

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

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

4. 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%)

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

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

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

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

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

10. 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

11. 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

12. 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, beds)
Better education / teaching about dangers of ear disease
- personal communication, Salyaveth Lekagul 1998

13. 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

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

15. 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

16. 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

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

18. 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

19. 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)

20. 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

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

22. 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?

23. Causes for Facial Paralysis