Treatment using diffuse laser energy of cochlear and vestibular fistulas caused by cholesteatoma

Abstract

ObjectiveTo measure the outcomes of laser treatment of cholesteatoma covering cochlear and vestibular fistulas.MethodsCholesteatoma matrix over the fistula was denatured; the power density was sufficient only to gradually heat, but not vaporise, the keratin-forming matrix. The denaturing speed was controlled so that the integrity of the fistula cover was maintained. The change in bone conduction threshold and the residual rate of cholesteatoma at the fistula were measured.ResultsThirty-six fistulas were assessed. There were seven cochlear fistulas. All were 5 mm or less in maximum length. For the entire group, the average change in bone conduction threshold was −0.3 dB. For cochlear fistulas, the average change in bone conduction was + 0.2 dB. The distribution of hearing results for the entire group was Gaussian; the apparent changes in hearing could be attributed to errors associated with testing. All patients underwent second-stage surgery. In all cases, the cholesteatoma was completely cleared from the fistula site. There were no facial palsies.ConclusionLaser denaturing of cholesteatoma matrix over fistulas measuring 5 mm or less of vestibular apparatus and the cochlea is effective at eliminating cholesteatoma, and is not associated with cochlear hearing loss or facial palsy.

Lasers in Cholesteatoma Surgery: A Systematic Review

“…While laser surgery is thought to facilitate atraumatic dissection of cholesteatoma from mobile ossicles and therefore reducing the risk of trauma to the cochlea from mechanical traction, there has only been one study 18 that compared the outcomes from 2 groups that were treated with laser (patients with ossicular chain intact vs disrupted). The hearing results did not show that using laser surgery improved hearing in Two fistulas were inadvertently perforated, each was closed by a fat graft and then covered by fascia 15 The average change in bone conduction threshold was À0.3 dB deterioration in hearing. Pure tone audiogram (PTA) results…”

“…These studies were published between 1997 and 2020 and conducted in America, Asia, and Europe. Four of them were case reports, [8][9][10][11] 5 were retrospective cohort studies, [12][13][14][15][16] and 3 were prospective cohort studies. [17][18][19] Recruited participant numbers ranged from 2 8,11 to 200.…”

“…As part of their outcome measure, 9 papers 10,11,[13][14][15][16][17][18][19] looked at the presence or absence of residual disease at either a second stage operation, with diffusion-weighted magnetic resonance imaging or computed tomography scan at least 12 months after the first operation or clinical observation. There were 2 papers that had a control group and compared the outcomes of laser versus no laser, while Hamilton in 2005 17 showed that using a laser significantly reduced the chance of residual disease after 12 months, Sharma et al in 2020 19 did not report any significant difference between using the laser or not.…”

“…The other papers report their recurrence rate between 0% and 33%. 10,11,[13][14][15][16]18 Table 5 summarized the disease eradication outcomes.…”

“Sandwich technique” enables preservation of hearing and antivertiginous effect in cholesteatomatous labyrinthine fistula

“…Among methods facilitating removal of the matrix from the fistula laser [21], special techniques, e.g., underwater ear surgery [22] and mesna [23] are described. We do not have experience with the first mentioned method, but we appreciate significant role of mesna in atraumatic LF clearance.…”