The presence of a labyrinthine fistula has remained one of the major problems in cholesteatoma surgery. Confronted with this problem, the surgeon may ultimately base his choice of procedure on four basic conditions: the size of the fistula, its location in the ear, the condition of the other ear, and the cochlear function. Our attitude has been changing, and currently we prefer to perform a staged closed tympanoplasty. When a closed technique is performed, we either remove the cholesteatoma matrix and then cover the fistula immediately or we leave the matrix in situ and re-explore the mastoid process 5 or 6 months later. The series consists of 88 cases out of a total of 701 patients with cholesteatoma operated on between January 1971 and June 1982. In 20 patients the matrix was left over the fistula at the first stage. The results suggest that a staged operation, i.e. closed tympanoplasty, is to be preferred even in cases with an extensive labyrinthine fistula.

The results of treatment of 124 cases of childhood cholesteatoma are reported in the present study and compared with an adult group of patients. Intact canal wall tympanoplasty was performed in over 90 per cent of cases in children and the procedure was staged in nearly 80 per cent of cases. The children had a 43.8 per cent incidence of residual cholesteatoma and an 8.8 per cent incidence of recurrent cholesteatoma in intact canal wall tympanoplasty cases. Intact canal wall tympanoplasty remains the technique of choice in our hands for the treatment of childhood cholesteatoma; pre-planned staging of the operation is mandatory for the detection and elimination of residual cholesteatoma which occurs more frequently in children.

Hearing results and causes of failure with three types of ossicular reconstruction techniques over an infact stapes, during second-stage intact canal wall tympanoplasty, are reporte herein.The three types of reconstruction are: fitted autologous incuc (38 cases): PlastiporeTM PORP with cartilage (41 cases): PlastiporeTM PORP without cartilage (32 cases).A residual air-bone gap within 15 dB. was found in 63.2 per cent of fitted incudes, in 41.5 per cent of PORPs with cartilage, and in only 37 per cent of PORPs without cartilage.Eighty-four per cent fitted incudes, 63 per cent PORPs with cartilage and 44 per cent PORPs without cartilage yielded a residual air-bone gap within 25 dB.Extrusion has been the main cause of failure among PlastiporeTM prostheses.

Twenty-three Plasti-Pore ossicular prostheses removed from the human middle ear following partial or total extrusion were investigated by light microscopy. No specific tissue reaction other than the ingrowth of histiocytic cells elicited from the porous Plasti-Pore was found. The only histologic feature typical of extruded prostheses was the presence of granulocytes in all parts extruded. In our opinion this finding was the inflammatory reaction following the ischemic necrosis of tissue grown inside the pores and the superimposed bacterial colonization. We concluded that no histologic feature supports a biologic cause of extrusion, and that extrusion instead is related to biofunctional characteristics.

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Recurrent cholesteatoma in a series of 534 staged intact canal wall tympanoplasties performed over a 10-year period has been reviewed for the present study. Overall detected incidence of recurrent cholesteatoma is 5.2% (28 of 534 operated ears). A steady decrease of recurrent cholesteatoma was found, however, in the second period of our surgical experience (1978 to 1982) when prevention techniques were adopted in all operations, resulting in a 1.07% incidence (four of 373 operated ears). Our present policy for prevention of recurrent cholesteatoma in intact canal wall tympanoplasties with mastoidectomy includes the use of plastic sheeting with thick Silastic, the repair of bony sulcus defects with cartilage shavings, staging of the operation with preplanned reexploration of the middle ear and mastoid, and transtympanic ventilation tube insertion in cases of refractory tubal insufficiency.

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