The Great Debate: Canal-wall-up vs. canal-wall-down surgery for pediatric cholesteatomas

“Almost all of our ears are dry, without recurrent retraction pockets, so patients can swim and bathe with no problem,” Dr. Gantz said. “With CWD, in contrast, you have a wet ear, and patients are going to need repeat visits back to the surgeon for debridement and drainage, sometimes requiring sedation.” As for hearing results, “they’re mixed,” he noted, due to compromised Eustachian tube function.

Of 130 cases studied by Dr. Gantz and colleagues in 2005, the failure rate of the canal wall reconstruction technique was 1.2 percent (Laryngoscope. 2005;115(10):1734-1740). “By failure, we mean patients who had recurrent cholesteatomas and required a repeat surgery, in which case we do a traditional CWD procedure but try to use periosteal flaps and muscle flaps,” he said.

Given that low failure rate, is canal wall reconstruction and mastoid obliteration a technique that more surgeons should be offering patients with cholesteatomas? “I guess it depends on how you’ve been trained,” Dr. Gantz said. “The surgeons who have been trained at [the University of Iowa] understand this, and many of my fellows and residents still do it in their own practices. It does take some time to learn and requires some finesse to do well, and it’s certainly more complicated than a traditional canal-wall-up.”

He added that some physicians are hesitant to adopt the canal wall reconstruction technique because the facial nerve is thought to be at risk during the procedure. “But I haven’t had any instances where we injured the nerve,” Dr. Gantz said.

He urged surgeons to consider another benefit of his approach: “You don’t have to wait until you’re actually operating on the patient to decide whether to take the canal wall down or leave it up,” he said. “I always found that type of intraoperative planning [with traditional CWD or CWU] very unsatisfactory; you’re not always a good judge of the disease process at that point.”

After seeing way too many patients who needed repeated surgeries after leaving the canal wall up, I knew there had to be a better way.
—John L. Dornhoffer, MD

Canal-Wall-Up Defended

According to John P. Leonetti, MD, director of the Center for Cranial Base Surgery at Loyola University Chicago Stritch School of Medicine, both CWU and CWD procedures have roles in the management of cholesteatomas. Unlike Dr. Gantz, he prefers to decide intraoperatively which of the two procedures is needed.

“If I determine that the cholesteatoma involves the mastoid air cells to the degree that I am not confident I can remove every skin cell in the mastoid cavity, then I’ll do a [CWD] mastoidectomy,” he said. “In children, I try to make that surgical cavity and the meatus as small as possible, so it’s less conspicuous.” As a result, Dr. Leonetti noted, about 90 percent of the patients he treats with CWD surgery can get the ear wet after three months.