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

In 2004, Dr. Dornhoffer published a review of his eight-year experience with the technique (Otol Neurotol. 2004;25:653-660). The review included 46 patients, representing 50 ears (20 pediatric, 30 adult), who had undergone cholesteatoma surgery using the retrograde technique. The recurrence rate was 16 percent for all patients, including smokers, “which really is superior to most reviews of traditional CWU surgery, where long-term recurrence rates can be well over 50 percent,” Dr. Dornhoffer said.

Since that study was done, he added, “I have done about a thousand ears using the retrograde technique, and I would say our rate of recurrence is down to about 10 percent using a single-stage surgery in more than 90 percent of patients.”

Dr. Dornhoffer acknowledged that his technique, which he learned from a prominent ENT surgeon in Germany, is not well accepted by otorhinolaryngologists in the U.S. “The retrograde approach is very different,” he said. “It takes some getting used to because it is really a hybrid between the traditional techniques of canal wall down and canal wall up.”

But he stressed that such reluctance should not detract from the larger point of his evolving experience with removing cholesteatomas in children. “The current thinking on canal-wall-up surgery, where surgeons knowingly commit patients to at least an initial surgery followed by a planned second-look surgery, is really not acceptable in this era of cost containment,” he said.

Dr. Gantz echoed Dr. Dornhoffer’s concerns over the economics of cholesteatoma surgery. “How many times are insurance companies going to pay for failure?” he said. “I would not be surprised if, someday, third-party payers tell you that they do not want you to continue with techniques that require several operations, especially where you have [such a significant] failure rate.”

With his mastoid reconstruction technique, for example, “you basically get rid of everything that predisposes patients to recurrent cholesteatomas, such as the mastoid mucosa. Yes, you have to be a very meticulous surgeon to do all of that, and to be sure you’re not trapping cholesteatoma-prone skin in the area of reconstruction. But it’s a learnable technique and one that truly benefits a large range of children and adult patients.”

When to Convert?

Jeffrey P. Harris, MD, PhD, FACS, professor and chief of otolaryngology-head and neck surgery at the University of California, San Diego, said that he also has seen a high rate of recurrences with CWU. But he has not abandoned the procedure completely. He still does CWU surgery in most patients with new cholesteatomas, but now he is much more willing to take the canal wall down if, at a planned second-look surgery, disease recurs. That willingness “is mostly due to the nature of this disease in children,” Dr. Harris explained. “Most of them have very poor Eustachian tube function. As a result, negative pressure builds up in the middle ear, and when the canal wall is left intact, that pressure pulls tissue into the epitympanum space where cholesteatomas often reform.”