gms | German Medical Science

Introduction: The canal wall down-technique in cholesteatoma surgery with an open mastoid cavity offers many disadvantages i.e. prolonged healing time, necessity for periodic cleaning and subsequent infections. Therefore reconstruction of the posterior canal wall is the more and more preferred technique to restore the physiologic anatomy of the external auditory canal without lacking a good surgical exposure to the tympanal and retrotympanal spaces. Cartilage is the mainly used material for this technique, as cartilage is easy to prepare and to fit into the defect with good viability. However, cartilage resorption and retraction is observed increasing the risk for recurrent cholesteatoma. In contrast, by the use of bone chips from the temporal squama a stable and close restoration of the posterior canal wall can be achieved.

Methods: In 21 patients (16 attic and 5 sinus cholesteatomas including three recurrences in each group) we have performed an anterior atticoantrotomy with cholesteatoma removal and have reconstructed the postero-superior wall of the auditory canal using bone chips, which were harvested from the temporal squama by chisels. The bone chips and remaining gaps in the reconstructed wall were covered by bone paté and temporal fascia. In 3 cases the ossicular chain could be conserved (type-1 tympanoplasty [TP]), type-3 TP with PORP was performed in 12 and TORP-TP in 6 cases. The mean follow-up was 12,1 months (range 6-34 months). 7 patients had undergone a second-look procedure.

Results: On follow-up all patients showed a good healing of the external ear canal with no graft insufficiency. In one case we observed a slight ear canal narrowing due to bone excess, two patients developed epitympanic retraction pockets. Residual cholesteatoma was not seen yet. Second-look tympanotomy revealed complete ingrowth of the transplanted bone chips into the surrounding bony structures in all 7 cases. One residual cholesteatoma had to be removed. The postoperative air-bone gap was 9,3 ± 8,3 dB for type-1 TP, 8,6 ± 3,8 dB for PORP-TP and 19,3 ± 9,2 dB for TORP-TP.

Conclusions: Osteoplastic atticoantrotomy allows adequate anatomic and physiologic restoration of the auditory canal after even extensive cholesteatoma removal. Bony stability should reduce recurrent cholesteatoma. Due to the underlieing impaired tubal function long-time results must be further evaluated.