The Medially-Invasive Cholesteatoma: An Aggressive Subtype of a Common Pathology

Abstract

Objective: Describe the outcomes of treatment for patients with cholesteatomas that are medially invasive to the otic capsule, petrous apex, and/or skull base. Study Design: Retrospective case series Setting: Two tertiary care academic centers. Patients: Patients surgically managed for medially-invasive cholesteatoma at two tertiary care institutions from 2001 to 2017. Interventions: Surgical management of medially-invasive cholesteatomas. Main Outcome Measures: The presenting symptoms, imaging, pre- and post-operative clinical course, and complications were reviewed. Results: Seven patients were identified. All patients had pre-operative radiographic evidence of invasive cholesteatoma with erosion into the otic capsule beyond just a lateral semicircular canal fistula. Five patients had a complex otologic history with multiple surgeries for recurrent cholesteatoma including three with prior canal wall down mastoidectomy surgeries. Average age at the time of surgery was 41.3 years (range 20-83). Two patients underwent a hearing preservation approach to the skull base while all others underwent a surgical approach based on the extent of the lesion. Facial nerve function was maintained at the pre-operative level in all but one patient. No patient developed cholesteatoma recurrence. Conclusions: The medially-invasive cholesteatoma demonstrates an aggressive, endophytic growth pattern, invading into the otic capsule or through the perilabyrinthine air cells to the petrous apex. Surgical resection remains the best treatment option for medially-invasive cholesteatoma. When CSF leak is a concern, a subtotal petrosectomy with closure of the ear is often necessary.

Abordaje y decisiones en el colesteatoma: revisión de la literatura

“…Se presenta generalmente en población pediátrica (4)(5)(6) . Histológicamente se encuentra conformada por el epitelio escamoso queratinizante (4,(7)(8)(9) . La mayoría de casos se asocia con falta de aireación de la hendidura del odio medio (1) .…”

“…El tratamiento que se brinda a los pacientes siempre es quirúrgico; en casos de compromiso extenso es indispensable pensar en realizar mastoidectomia (1,3,4) . Entre las alternativas quirúrgicas, individualizando cada paciente, se encuentran: mastoidectomia de la pared del canal con timpanoplastia, mastoidectomia (radical) debajo de la pared del canal con meatoplastia o mastoidectomia (radical) debajo de la pared del canal con reconstrucción del conducto audito externo, timpanoplastia y obliteración mastoidea (1) , lo cual estaría en estrecha relación con el compromiso anatómico y la extensión patología (7,8) . En otros casos, cuando se encuentra presencia de fuga del líquido cefalorraquídeo, una opción terapéutica es la petrosectomía subtotal con cierre del oído (7) .…”

Surgical management of petrous apex cholesteatomas in the pediatric population: A systematic review

“…Surgery is often required for definitive treatment, however, with the goal of gross total resection and to minimize recurrence. [ 3 ] There are several possible operative approaches including transsphenoidal, transpalatinal-transclival, and middle cranial fossa. [ 30 ] Dedicated postoperative surveillance is vital to monitor surgical morbidity and lesion recurrence.…”

Comparison of High-Resolution Computed Tomography and Surgical Findings in Patients with Temporal Bone Cholesteatoma

“…High-Resolution Computed Tomography (HRCT) allows for determining the extent of the disease that cannot be evaluated by examination, evaluating the surgical landmarks, evaluating the risk of intraoperative complications, evaluating the condition of the temporal bone structures, and determining the complications related to the disease (5). Imaging methods can detect the suspicion of cholesteatoma, however, the definite diagnosis of cholesteatoma is made by pathological evaluation (5,6). Chronic otitis media treatment includes medical and surgical methods.…”