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

Dr. Harris said that after many years of doing CWU surgery, he realized that about 40 percent of his patients showed signs of having recurrent cholesteatomas at the time of their second-look procedures. Those lesions, he stressed, “were not recurrent disease based on my leaving some of the cholesteatoma behind; this was what we call ‘recidivistic’ disease, a new cholesteatoma, because the ear, especially in kids, simply could not maintain normal middle ear pressure. Once that negative pressure develops, the eardrum gets sucked in, and when it does, that’s my clue to take the canal wall down and stop the disease process.”

If negative pressure is observed during the healing phase, Dr. Harris added, “it is worth placing a ventilation tube in the ear, because on occasion the tube can prevent recurrence of these epitympanic retractions.”

A Historical Reversal

Dr. Harris said there is nothing unique about his negative experiences with traditional CWU surgery. He pointed to Gordon Smyth, MD, from Belfast, who was initially a staunch advocate of leaving the canal wall intact. Dr. Harris noted that Dr. Smyth was influenced, as were many other surgeons of the day, by the House Clinic’s James L. Sheehy, MD, an ENT surgeon at the House Clinic in Los Angeles, who championed the CWU approach in the 1970s and 1980s. “Dr. Smyth performed canal wall ups in most of his patients for at least five years, maybe longer,” he said. “Then he reviewed his long-term results and wrote a paper in which he stated that this operation resulted in a much higher than acceptable recurrence rate for cholesteatoma; he was seeing up to 50 percent of his patients having to go back for more surgery” (Laryngoscope. 1985;95(1):92-96).

Based on those types of experiences, “most surgeons would agree that the holy grail of maintaining a canal-wall-up approach, no matter what, to all comers, really makes no sense today,” Dr. Harris said. “The pendulum has swung back to what had been the gold standard: canal wall down.”