Canal wall down tympanomastoidectomy: the ‘on-disease’ approach for retraction pockets and cholesteatoma

Abstract

It is well known that cholesteatoma is three-dimensional; hence, we feel that its surgical management requires a three-dimensional approach in order to achieve the best curative and functional results. Retraction pockets are undeniably caused by chronic and recurrent eustachian tube obstruction. However, we found that the presence of a large mastoid antrum was an important, additional aetiological factor in the formation of a retraction pocket and its progression to cholesteatoma formation, with bone destruction and subsequent complications. Canal wall down tympanomastoidectomy--the 'on-disease' approach--is an innovative, three-dimensional technique based on universally accepted surgical principles. We modified the technique to ensure complete exposure and thereby eradication of the disease, with a resultant small cavity. Working in a three-dimensional field, we began drilling at the posterior meatal wall, lowering it while simultaneously widening the cavity as the mastoid was drilled to reach the antrum and the aditus. The bridge was lowered and the incus removed to completely expose the entire disease. The facial ridge was debulked and the temporalis fascia graft placed so as to simplify the middle-ear cleft. We present a comprehensive report of this technique, based upon 600 patients studied retrospectively over a five-year period. After one-year follow up, 546 patients had a dry, healed cavity. Canal wall down tympanomastoidectomy performed by the on-disease approach ensures complete eradication of the disease, with excellent curative as well as functional results.

Aural Cholesteatoma in Twenty Dogs

“…5,6 Curative treatment involves surgical removal of the cholesteatoma. 4,[7][8][9] The surgical goal is to remove all keratin debris and stratified squamous epithelium, and to control infection. In humans, surgery is performed using magnification, microsurgical tools, and endoscopy to ensure complete removal of epithelium and to preserve middle ear structures, if possible.…”

Results of Primary Ossiculoplasty and Prognostic Factors in Canal Wall-Down Tympanoplasty

“…Prognostic factors affecting results of hearing include the presence or absence of otorrhea preoperatively, status of drum perforation, presence or absence of stapes superstructure, status of middle ear mucosa, functional status of the eustachian tube, ability and experience of the surgeon, type of graft material, and functional malleus handle (reported as important in sound transmission). 9,11,14,15 Among them, the status of the middle ear mucosa and the presence or absence of stapes superstructure are reported to be the most important factors for the successful restoration of postoperative hearing. 11 We evaluated the results of surgery according to cholesteatoma, malleus, stapes superstructure, and type of material used.…”

Surgical management of cholesteatoma: The two main options and the third way – atticotomy/limited mastoidectomy

“…It is supposed to be easier, of shorter duration, necessitates less surgical experience than the CWU procedures, and has low recurrence and residual rate. The anatomic and functional outcome is satisfactory, and the rate of complications is acceptably low [10]. A tympanoplasty can be performed simultaneously [11].…”

“…The procedure is progressive, anterior-toposterior dissection, exposing the cholesteatoma, thus creating atticotomy, atticoantrostomy and mastoidectomy (Figs. [8][9][10]. Following the cholesteatoma and removing as much bone as needed [32] allows to create the smaller mastoid cavity possible (Fig.…”