The Case for Second Look Procedures

by John Kveton, MD •

Are there any intraoperative findings that could determine whether a second look procedure should be performed in pediatric cholesteatoma surgery?

Background: There is no clear consensus regarding the surgical management of pediatric cholesteatoma. Canal wall up surgery is a popular approach, but the indications and timing of a second look procedure remain vague.

Study design: Retrospective chart review.

Setting: Vanderbilt University Medical Center, Nashville.

Synopsis: Researchers reviewed the cases of 493 patients—517 ears—operated on over a 37-year period by six surgeons. All were primary cholesteatoma cases, including tympanoplasty (11 percent), canal wall up tympanomastoidectomy (79 percent) and canal wall down tympanomastoidectomy (10 percent). Primary cholesteatoma was found in the attic (76 percent), mastoid (49 percent), mesotympanum (45 percent), sinus tympani (44 percent) and hypotympanum (19 percent). Ossicular erosion occurred in 82 percent of patients (incus 70 percent, malleus 64 percent, stapes 34 percent). Forty-seven percent of patients required a second look procedure, with recurrent cholesteatoma identified in 48 percent of cases. Cholesteatoma recurrence was found in the attic (42 percent), mastoid (32 percent) and sinus tympani (25 percent). Overall recurrence rate in all 517 cases was 23 percent with a mean follow-up of three years.

Associations of the various preoperative and intraoperative variables with the outcome variables of cholesteatoma recurrence, canal wall down tympanomastoidectomy, postoperative hearing and second look procedures were assessed using odds ratios in logistic regression analyses. Decreased risk of cholesteatoma recurrence was associated with lack of ossicular erosion at the primary surgery. The need for ossicle removal was a statistically significant risk factor for ultimate canal wall down surgery. Cholesteatoma in the sinus tympani and incus erosion were associated with a statistically increased risk of cholesteatoma recurrence.

Bottom line: The presence of cholesteatoma in the sinus tympani and/or erosion of the incus are indications that a second look procedure should be performed in a child with cholesteatoma.

Citation: McRackan TR, Abdellatif WM, Wanna GB, et al. Evaluation of second look procedures for pediatric cholesteatoma. Otolaryngol Head Neck Surg. 2011;145(1):154-160.

—Reviewed by John Kveton, MD