Osteoplastic atticoantrotomy with autologous bone chips and a bony attic strut in cholesteatoma surgery

Abstract

The objectives of this study were to determine whether autologous bone chips are suitable materials for canal wall reconstruction after cholesteatoma removal and to evaluate the effectiveness of a separate attic bone graft for the prevention or recurrent cholesteatomas using prospective study of two consecutive patient series (29/31 unselected patients with an average follow-up of 36.3 +/- 11.1/21.5 +/- 6.3 months) and retrograde resection of the posterior-superior canal wall followed by reconstruction of the canal defect using one or more temporal squama bone chips. In the second series, lateral attic wall reconstruction and pars flaccida reinforcement was established by a notched bony attic strut attached onto the neck and short process of the malleus for structural support. In the first series, the rate of recurrent cholesteatomas (17.3%), in particular of attic retraction pockets (31%), was significantly high. The average postoperative air-bone gap was 6.4 +/- 6.3 dB in type-I tympanoplasty (TP), 8.7 +/- 3.4 dB in type-III TP with intact stapes suprastructure, and 16.4 +/- 9.3 dB in type-III TP with TORP, respectively. In the second series, recurrent cholesteatoma and retraction pocket rate could be decreased to 9.7 and 6.5%, respectively. The postoperative air-bone gap was 7.5 +/- 5.1 dB HL in type-I tympanoplasty (TP), 11.6 +/- 4.9 dB HL in type-III (PORP) TP, and 17.9 +/- 12.2 dB HL in type-III (TORP) TP. Connecting the attic strut to the malleus neck did not affect the malleus mobility and hearing outcome. Osteoplastic atticoantrotomy with autologous bone chip reconstruction enables a tailor-made anatomical and physiological reconstitution of the auditory ear canal, thus enhancing the acoustic properties. Precise reconstruction of the lateral attic wall and reinforcement of the superior part of the tympanic membrane seems to be important for the prevention of retraction pockets and subsequent recurrent cholesteatoma development.

Hearing results of tympanoplasty with attic reconstruction vs. obliteration in attic cholesteatoma

“…The collumela was placed directly on the stapes footplate. This is similar to the conclusion of the studies that observed the results of atticotomy to hearing and recurrence rate by Kim et al (1) and Gerhrking (2).…”

“…If the cholesteatoma is limited to the tympanic cavity this procedure prevents for opening the mastoid air cells. Many authors favor canal wall up tympanoplasty (CWUp) with attic reconstruction over canal wall down tympanoplasty (CWD) (2,5). Although the intraoperative visualization of the posterior tympanic space and mastoid in CWUp tympanoplasty is limited and cholesteatoma recurrence rate is higher, it provides close to anatomic shape of the postoperative tympanic cavity, proper basis for ossicular reconstruction and consequently better hearing then CWD tympanoplasty (9,10).…”

“…The common surgical approach to the attic is through lateral atticotomy by re-moving part of the superior and lateral bony wall of the external auditory meatus. This way malleus head, incus body and lateral attic space could be exposed (2,3). Canal wall down tympanoplasty with subsequent posterior canal wall reconstruction or mastoid obliteration provides wide exposure of the tympanic and mastoid cavity and safe removal of the cholesteatoma extended in the mastoid anthrum and cells.…”

Reconstruction of the Mastoid Using a Titanium Cage

“…Reconstruction has been performed using a variety of materials, with various results (3Y9). It has been shown that use of a patient's own bone, such as reimplantation of the previously removed posterior canal wall or the use of cortical bone, often results in necrosis (10,11). Foreign materials, even those known to be biocompatible, always bear a risk of nonacceptance in the special environment of the middle ear and mastoid.…”

A Study on the Clinical Outcomes of Scutumplasty in Cases of Attic Cholesteatoma

“…Going back to studies following different techniques, Gehrking E [10] stated that osteoplastic atticoantrotomy with autologous bone chip reconstruction enables a tailor made anatomical and physiological reconstitution of auditory ear canal thus enhancing the acoustic properties. Precise reconstruction of lateral attic wall and reinforcement of superior part of tympanic membrane seemed important for prevention of recurrent cholesteatoma.…”