Evaluation of Residual Disease Following Transcanal Totally Endoscopic vs Postauricular Surgery Among Children With Middle Ear and Attic Cholesteatoma

Abstract

IMPORTANCE Transcanal totally endoscopic ear surgery (TEES) improves tympanic cavity visibility during cholesteatoma resection but does not readily permit 2-handed surgery, which is possible with a postauricular approach and use of an operating microscope. Improved visibility and 2-handed access may reduce rates of incomplete surgical clearance and residual cholesteatoma.OBJECTIVE To compare rates of residual cholesteatoma after TEES vs those after open surgery with a postauricular approach for initial disease limited to the middle ear and/or attic. DESIGN, SETTING, AND PARTICIPANTSThis propensity score-matched cohort study considered a consecutive sample of 209 pediatric cases of cholesteatomas resected at a tertiary referral center between January 1, 2005, and December 31, 2017, by either TEES or postauricular approach. The 177 cases (84.7%) in 172 patients that were eligible for inclusion in the study had undergone at least 1 of the following assessments: second-look tympanoplasty, diffusion-weighted magnetic resonance imaging, or in-clinic follow-up examination at least 2 years after the operation. Ears were matched on the basis of the propensity score, a function of age, sex, comorbid diagnoses, etiology, disease extent, ossicular chain condition, presence or absence of tympanic membrane perforation, and otorrhea status at the time of surgery.EXPOSURES Transcanal totally endoscopic ear surgery was defined as a transcanal approach with surgeon-reported use of an endoscope for resection of cholesteatoma. Use of an operating microscope was permitted in the TEES group for graft placement during tympanoplasty. The postauricular approach was characterized by a postauricular incision and use of an operative microscope with or without adjunct use of an endoscope. MAIN OUTCOMES AND MEASURES Residual cholesteatoma.RESULTS Of 177 cases included in the study, the unmatched cohort consisted of 65 ears that had undergone TEES (mean [SD] age, 9.9 [3.6] years; 33 [50.8%] female) and 112 ears of patients who had undergone surgery with a postauricular approach (mean [SD] age, 9.9 [3.5] years; 72 [64.3%] male). Propensity score matching was accomplished for a total of 128 cases, with 64 in each group. After matching, standardized differences between TEES and postauricular approaches were less than 0.20 for all measured baseline characteristics, indicating balanced groups. The TEES group had a residual disease incidence of 4 of 64 (6.3%) compared with 7 of 64 (10.9%) in the propensity score-matched postauricular approach group (absolute risk difference, -4.7%; 95% CI, -14.8% to 5.4%).CONCLUSIONS AND RELEVANCE This study's findings suggest that there was no apparent advantage of the 2-handed postauricular microscopic approach with respect to surgical clearance of cholesteatoma limited to the middle ear and/or attic. Transcanal totally endoscopic ear surgery may be an effective alternative to a postauricular approach for removal of limited cholesteatoma in children.

Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review

“…The duration of surgery was compared in 21 of these studies, 13 of which reported a shorter surgical time in the endoscopic technique. 14,16,[18][19][20][21][22][24][25][26][27][28][29][30][31][33][34][35][36] The postoperative recovery time and level of pain presented by patients were evaluated by nine retrospective studies, seven of which had a 39 Retrospective TEES may be an alternative to a postauricular approach for removal of cholesteatoma limited to the middle ear and/or the attic in children. 18 Retrospective Similar results for ET and MT approach without significant statistical differences.…”

A ‘chemical help’ in middle-ear surgery? A systematic review on sodium 2-mercaptoethanesulfonate

“…20,21 However, although the recidivism rate in endoscopy surgery has been shown to be lower, the global rate of residual and recurrent cholesteatoma has not reached 0 per cent. 22–24 Another major cause of residual disease is incomplete cleaning of the matrix. Typical examples are cholesteatomas remaining around the ossicles or on bony defects of the middle cranial fossa, labyrinth and fallopian canal.…”

Factors affecting the incidence of chorda tympani nerve transection in middle ear surgery

“…In recent years, transcanal endoscopic ear surgery (TEES) has been popularly applied to different types of middle ear disease. 12 TEES has many advantages, including a wide field of view, higher magnification of delicate anatomical structures, and clear visualization of anatomical areas located in blind spots when viewed through a microscope. 13 , 14 , 15 Consequently, TEES is thought to be less invasive than microscopic ear surgery (MES).…”