Hearing outcome after sequential cholesteatoma surgery

Abstract

The objective of this study was to assess hearing outcome after sequential cholesteatoma surgery stratified for exclusively transcanal technique (ETC), combined transcanal and transmastoidal technique (TCM) and canal wall down surgery (CWD) and to analyze the impact of ossicular reconstruction technique (partial ossicular replacement prostheses/PORP and total ossicular replacement prostheses/TORP) on hearing outcome. This study is a retrospective case review and clinical case study conducted in a tertiary referral center. Patients who underwent 376 cholesteatoma surgeries (2007-2009) and 92 ears in clinical re-examination at least 12 months postoperatively were included. Sequential cholesteatoma surgery with ETC, TCM, or CWD; ossiculoplasty with PORP or TORP were the interventions administered. Pre- and postoperative air-bone gap (ABG) and air conduction threshold (AC) for 0.5-3 kHz were the main outcome measures. Overall, the mean preoperative ABG decreased from 25.3 ± 1.3 to 19.8 ± 0.9 dB with a mean ABG closure of 5.4 ± 1.3 dB (p ≤ 0.001). According to surgical technique, the postoperative ABG after CWD 23.5 ± 2.1 was significantly worse compared to ETC (17.3 ± 1.0 dB, p < 0.05) and TCM (19.4 ± 1.3 dB). A significant ABG closure was observed after ETC (6.8 ± 2.0 dB, p < 0.01) and TCM (6.5 ± 2.0 dB, p < 0.01) contrary to CWD (2.1 ± 2.9 dB, p > 0.05). Patients receiving PORP showed a significantly less ABG postoperatively (19.0 ± 0.9 dB, p ≤ 0.05) compared to the TORP group (24.1 ± 2.5 dB). However, a significant hearing gain was assessed after PORP- (4.7 ± 1.6 dB, p ≤ 0.01) and TORP- implantation (10.4 ± 3.7 dB, p ≤ 0.01). Sequential cholesteatoma surgery allowed for an excellent hearing outcome postoperatively. An intact posterior canal wall and a present stapes suprastructure were identified to predict a significantly superior hearing result. In addition to the technical and prosthetic considerations, the audiological outcome was confounded by the attending middle ear pathology.

Comparison of total and partial ossicular replacement prostheses in patients with an intact stapes suprastructure

“…[10][11][12] There are several factors under discussion that influence the audiological outcome of middle ear surgery. The underlying middle ear disease, 7,13 status of the malleus handle, 7,14-17 ventilation and mucosa of the middle ear, 7,17 presence of the stapes suprastructure, 7,13,14,17 surgical technique (e.g., canal wall up [CWU] vs. canal wall down [CWD]), 14,15,18 reconstruction material, 14,19,20 surgeon's experience, 15 and number of previous ear surgeries 16 seem to play a role in the outcome of surgery. Hence, it remains challenging to make comparisons among published data because hearing outcome depends on multiple factors and, to date, there is no standardized manner of documenting the extent of middle ear disease, details of surgery, and reporting of outcomes.…”

Data and Reporting Quality in Tympanoplasty and Ossiculoplasty Studies

“…It is widely discussed that the postoperative hearing result is determined not only by the chosen technique of middle ear reconstruction (including technique and grafting material of tympanic membrane reconstruction, kind, material and coupling of middle ear prosthesis, surgical technique of pathology eradication) but also by various environmental conditions (ie, the presence of the stapes suprastructure and the malleus handle, mucosa pathology, and middle ear aeration). 4-17…”

Surgical results of modified canal wall down tympanoplasty

“…The obvious advantages include: (1) good exposure as in open-cavity mastoidectomy [9,10] and hearing reconstruction as in closed-cavity procedure [2,11]; (2) close to normal anatomy and function in the attic; (3) a larger middle ear space essential for intraoperative successful ossiculoplasty; (4) reduction of the burden of the eustachian tube; (5) an enlarged ear canal, not much of a mastoid.…”

“…CWD mastoidectomy provides excellent intraoperative exposure of the middle ear, and this aids in total disease elimination with low rates of recidivism. A major disadvantage of CWD is the removal of the lateral attic wall, which increases the difficulty of structural function reconstruction and hearing preservation or restoration [2]. In contrast, the CWU mastoidectomy maintains the natural anatomy and provides better hearing results but a higher recidivism rate than CWD [3].…”