Surgery of sinus tympani cholesteatoma: Endoscopic necessity

Int. Adv. Otol. 2009; 5:(2)

Surgery of sinus tympani cholesteatoma: Endoscopic necessity
Mohamed M.K. Badr-El-Dine
Department of Otorhinolaryngology, Alexandria School of Medicine, University of Alexandria, Alexandria, EGYPT.

Objective: Residual cholesteatoma occurs as a consequence of growth of a fragmental remnant of the matrix inadvertently left behind at the time of primary surgery. Poor access is the major reason for residual disease, particularly in the sinus tympani (ST). The ST is a critical anatomic region considered the most hidden recess of the middle ear. The aim of our study was to highlight the importance of extension of cholesteatoma into the ST and to demonstrate the efficacy of oto-endoscopy allowing direct access to eradicate disease from this potentially dangerous site.
Materials and Methods: A total of 294 ears with acquired cholesteatoma (primary or secondary) were operated on. In this study, 212 cases were operated upon using canal wall up (CWU) technique, and 82 cases were operated upon using canal wall down (CWD) procedure. Oto-endoscopy was incorporated complementary to the microscope as a principal part of the procedure in all cases. Second-look endoscopic exploration was performed on some selected cases, depending on the operative details during the primary surgery and the postoperative findings of clinical and radiologic studies.
Results: In the primary surgery after completion of microscopic cleaning, the overall incidence of intraoperative residuals detected with the endoscope was (49 cases) 16.7%. Sinus tympani was the most common site of intraoperative residuals in both CWU and CWD groups (36.7%), followed by the facial recess (28.6%), and the undersurface of the scutum in the CWU cases (20.4%); and the anterior epitympanic recess (14.3%). Reconstruction of the hearing mechanism was performed during the primary surgery in 246 cases (83.7%) and postponed to the second stage in only 48 cases (16.3%). Out of the 212 CWU cases, 93 second-look endoscopic explorations (43.9%) were performed. Eight recurrences (8.6%) were identified: 5 cases showed one or more recurrent cholesteatoma pearls, and 3 cases showed a larger open cholesteatoma recurrence extending to the aditus and mastoid. In this series, no morbidity or complication was encountered secondary to the use of endoscopes in the mastoid or middle ear.
Conclusion: From our experience in endoscopic ear surgery we have come to the conclusion that the ability of endoscopes to peer into the recesses of middle ear and mastoid cavity proved without doubt its usefulness. The use of endoscope achieved significant higher degree of control over the disease and dramatically reduced the incidence of cholesteatoma recurrence particularly in those hidden recesses such as the sinus tympani.