Can Radiologic Imaging Replace Second-Look Procedures for Cholesteatoma?

Background

Cholesteatoma surgery is performed to eradicate disease, create a dry and safe ear, and restore hearing. The primary concern of the surgeon is to minimize the odds of recurrent and residual cholesteatoma. Recurrent cholesteatoma is a new cholesteatoma that forms from retraction of the tympanic membrane or ear canal skin. Recurrent cholesteatoma occurs at rates of 10 to 15 percent and are usually easy to diagnose in the office setting. Residual cholesteatoma forms from microscopic or gross disease left behind by the surgeon during the primary surgery. Reported rates of residual cholesteatoma vary from 5 to 63 percent in the literature. Residual cholesteatoma is not easily diagnosed in the office setting by otomicroscopic examination as the disease is often hidden within the mastoid or middle ear cleft.

Canal-wall-down procedures can reduce the odds of both recurrent and residual cholesteatoma but commit the patient to a lifetime of follow-up appointments and lifestyle restrictions. To circumvent this issue, many surgeons treat the chronic ear by means of a canal-wall-up procedure, done via a planned process of two surgeries, staged 6 to 18 months apart.

In severely diseased ears, when the mucosa is inflamed to such a degree as to threaten maintenance of a middle ear space and to obscure the certainty of complete cholesteatoma removal, the decision to stage the procedure is easy. It is presumed that a planned second-stage surgery will permit total resection of residual cholesteatoma pearls as well as achievement of a well-aerated middle ear cleft lined with healthy mucosa within which ossicular chain reconstruction (OCR) can be expected to provide a better acoustic result. In mildly diseased ears, the mucosa may appear generally healthy and the surgeon may have confidence in complete eradication of the cholesteatoma during the primary surgery. In these cases, it is an appealing option to save the patient from additional surgery by performing primary OCR with no definitive plan for a second look.

Best Practice

New MRI techniques that have improved sensitivity for residual cholesteatoma afford the surgeon more confidence when considering a single-stage surgical approach to the management of cholesteatoma. These studies, however, should not be considered conclusive because the sensitivity of MRI for a large number of patients over a long time period is not available. Given these shortcomings of the MRI experience, single-stage surgery with follow-up monitoring by imaging should presently be reserved for those patients found on initial surgery to have only mildly diseased ears from which cholesteatoma has likely been completely eradicated. Unfortunately, the evidence to date does not support more broadly applicable recommendations. Whether or not imaging is necessary or sufficient after a presumably successful procedure represents a knowledge gap that has significant clinical importance and requires a high-quality prospective randomized study to answer definitively. Read the full article in The Laryngoscope.