Chronic otitis media: new alternatives in the treatment of cholesteatoma and functional reconstruction

Prof. Manuel Manrique Alexandria, 2010

Pamplona

Open technique

Closed technique

Treatment of the cholesteatoma

Open techniques:
L Low risk i k of f cholesteatoma relapse But Otorrhea ENT follow-up Limitations to water

Closed techniques:
No otorrhea No limitations to water But Increase the risk of residual o recurrent cholesteatoma ENT follow-up

Rule for the treatment of the cholesteatoma h l t t

V i bl Variables:
Anatomy, cholesteatoma type, associated diseases, socio-cultural environment, age, etc.

Individualize operative management

Surgical g technique q indication

Open p techniques: q Small sclerotic mastoid. EAC bone erosion Labyrinthine fistula Facial nerve or intracranial complications Poor eustachian tube function Closed techniques: q Pneumatized mastoid. Integrity of the EAC EAC. Encapsulation Good eustachian tube function

Are there alternatives for the cholesteatoma treatment? treatment?

Attic-Exposition Attic Exposition Antrum-Exclusion

Open Cavities Reconstruction Techniques

Active Middle Ear Implants

Vibrant Sound Bridge RW

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Attic-Exposition p Antrum-Exclusion

Anatomical concepts p

Attic Antrum

Surgical concept
Attic-Exposition (Marsupialization)

Attic Antrum

Antrum-Exclusion

AtticAttic -Exposition concept

Attic Antrum
Squamous epithelium, without cillia, cells, or glands. E. Hentzer, , Ultrastructure of the middle ear mucosa, Acta Otolaryngol (Stockh) Suppl 414, 414 1984

AEAE -AE
Attic exposition-Exclusion of antrum Indication: Attical cholesteatoma not crossing the additus, with erosion of the attic wall, regardless of it is medial or lateral to the malleus-incus axis.

Indication samples

Addit Additus

Additus

Indication samples
Endoscopic vision
Additus

Indications samples

Surgical technique
1

Superior canal wall

Ramrez Camacho

Cholesteatoma

Surgical g technique q
2 Attic c control co o

Tegmen

Ramrez Camacho

Surgical g technique q
3

Ramrez Camacho

Cartilage or Cortical of bone

Surgical technique
4

Fascia graft

Extended AEAE-AE

Extended AEAE-AE
ATTIC Tegmen tympani i Head malleus Handle H dl malleus Pars t P tensa TM

BONE BRIDGE Additus Tegmen antri ANTRUM

Post wall EAC

Martillo Colesteatoma Promontorio

Tegmen

Cierre additus con cartlago

TORP

3A

3C

3E

Atico

3D
Puente seo pared post. CAE

3F

3B
Antromastoidectomia Explorador en Additus Injerto fascia Platina R Reposicin i i d de injerto fascia

Extended AEAE-AE
Extended Indication for Attic exposition-Antrum exclusion: Attical cholesteatoma crossing the additus, with p invasion of the mastoid antrum, well encapsulated, and not eroding the ottic capsule.

Attic Cartilage to close the additus

Pars tensa TM

Attic

Cartilage to close l the h additus ddi

POP Pars tensa MT

Cartilage to close the additus Attic

Pars t P tensa TM

Cartilage to close the additus

Attic

Pars tensa TM

Cartilage to close the additus Attic

Pars tensa TM 590913

Cartilage to close the additus

Attic

Pars tensa TM 447599

Cartilage to close the additus

2 months postop

Atico

611073

Pars tensa

Cortical mastoidectomy

Closed additus

Closed additus

Excluded Antrum

Excluded Antrum

A. AE-AE technique

B. Extended AE-AE technique

Closed additus

Excluded Antrum

501313

Attic exposition exposition-Antrum exclusion

If indications are correctly followed, the control cholesteatoma is excellent: 0 cases of residual cholesteatoma

Additus

Atico exposicion exposicion-Antro exclusion

The closure of the additus does not provoke any mastoid disease: 0 cases of relapsing p g cholesteatoma due to cartilage resorption and/or formation of a e c o pocket poc e retraction

Ramrez Camacho

Atico exposicionexposicion-Antro exclusion

Attic-exposition converts the tegmen into the superior i wall ll of f the h EAC, EAC and d the h antrumexclusion convert the cartilage and remaining structures t t into i t the th posterior t i wall ll of f the th EAC: EAC Auto-cleanable spaces, compatible with water entering

Atico exposicionexposicion-Antro exclusion

Attic-exposition and the antrum-exclusion does not impair chances of ossicular chain reconstruction: F Functional ti l results lt depend d d on the th status t t of f the ossicular chain and possible medial attic tti invasion i i by b the th cholesteatoma h l t t .

Open Cavities Reconstruction Techniques

Objetives
To avoid retractions and relapsing p g cholesteatoma, by an attic exteriorization To reduce the mastoid cavity volume, by an obliteration using bone bone pat pat To reproduce p the anatomy, y, by y an EAC reconstruction To improve hearing, by the creation of a minibox and simultaneous ossiculoplasty box

Concepts Co cep s

SURGICAL STEPS
Revision of mastoidectomy y Bone dust recollection Extraction of the osseous cortical and bone fragments Preparation of a Palvas flap and/or periosteal flap Filling of the cavity with bone pate posterior EAC wall Reconstruction of the p Ossicular reconstruction Graft allocation allocation, and flap reposition EAC package

Revision ev s o o of mastoidectomy s o dec o y

Filling g of the cavity y with bone pate p

Reconstruction of the posterior EAC wall

Reconstruction of the posterior EAC wall

Reconstruction of the posterior EAC wall

Reconstruction of the p posterior EAC wall Cartilage grafting

Ossicular reconstruction

Allocation of Grafts

CONTRAINDICATIONS
Small mastoid cavities Cholesteatomatosis Poor infection control Otoneurological Ot l i l complications li ti Labyrinthine fistula

ADVANTAGES
Good acces to the attic attic, and reduction of rate of tympanic membrane retractions Lower dependence of ENT, although patients need d periodic i di controls t l Watering, Hearing Hearing-aids aids

DISADVANTAGES

Two surgical procedures Posible infections Risk of residual cholesteatoma

RESULTS n: 7, 3 yr of followfollow-up
No N cholesteatoma h l t t No infections (Gantz 11%) No retraction pockets 1 case of partial resorption of posterior EAC wall

FOLLOW-UP: FOLLOW UP ENT examination Diffusion MRI

VIDEO