Surgery for Cholesteatomatous Labyrinthine Fistula

Abstract

The level of evidence on which to base surgical decision making related to cholesteatomatous labyrinthine fistula is poor, and the data do not demonstrate significant differences in hearing outcomes based on surgical technique.

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

“…The surgeon faced the unenviable choice of having either to dissect the cholesteatoma matrix off the fistula endothelium or create a mastoid cavity with its attendant long-term consequences. If the fistula involved the cochlea, the surgical consequences were notably worse 4 …”

“…The otological literature contains many articles concerned with the treatment of fistulas of the labyrinth due to cholesteatoma. A recent systematic review has summarised the available information 4 . In essence, there are two principal techniques for dealing with cholesteatoma over a labyrinthine fistula: (1) complete removal of cholesteatoma matrix, including over the fistula, and repair of any ensuing labyrinthine defect; and (2) exteriorisation, in which the cholesteatoma over the fistula is left in place, whilst the cholesteatoma bed is saucerised by forming a cavity with removal of the posterior ear canal wall 4 …”

“…The latter technique requires removal of the posterior wall of the external ear canal as part of the saucerisation, so that the epithelium over the fistula becomes part of the skin lining of a mastoid cavity. In this circumstance, the patient may be subject to the adverse effects of living with a mastoid cavity 4 …”

“…Fistulas of the cochlea are associated both with an enhanced risk of hearing loss if an excision technique is used and long-term intrusive post-operative symptoms if an exteriorisation procedure is undertaken 4 . The problems with cochlear fistulas led the senior author to consider a different approach to the treatment of labyrinthine fistulas in general.…”

One-Stage Complete Resection of Cholesteatoma With Labyrinthine Fistula: Hearing Changes and Clinical Outcomes

“…Some surgeons have argued for conservative management, leaving the overlying cholesteatoma matrix undisturbed for cases with large-sized fistulas, while others prefer complete removal of the matrix regardless of size. 5,6,[8][9][10][11][12] Supporters of conservative management warn against postoperative sensorineural hearing loss caused by potential intraoperative opening of the labyrinth, whereas advocates of complete matrix removal point out that the remaining matrix could predispose to further progression, leading to suppurative labyrinthitis. 6,8,[13][14][15] Because these debates have not yet been resolved, the optimal approach to management still needs to be examined.…”