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78th Annual Meeting of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery

German Society of Oto-Rhino-Laryngology, Head and Neck Surgery

16.05. - 20.05.2007, Munich

The bony „attic clip“ for reconstruction and reinforcement of the lateral attic wall in cholesteatoma surgery

Meeting Abstract

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  • corresponding author Eckard Gehrking - Department of ENT, Head & Neck Surgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany

German Society of Oto-Rhino-Laryngology, Head and Neck Surgery. 78th Annual Meeting of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery. Munich, 16.-20.05.2007. Düsseldorf, Köln: German Medical Science; 2007. Doc07hno054

The electronic version of this article is the complete one and can be found online at:

Published: August 8, 2007

© 2007 Gehrking.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.



Introduction: A main disadvantage of canal wall-up techniques in cholesteatoma surgery compared to canal wall-down mastoidectomy is the higher incidence of recurrent cholesteatomas, which often develop from epitympanic retraction pockets of the pars flaccida. Thus, adequate care should be paid in gapless reconstruction and reinforce-ment of the lateral attic wall and the pars flaccida up to the posterior mallear ligament when rebuilding the canal wall.

Methods: In 16 patients with cholesteatomas or epitympanic retraction pockets (3 primary and 13 secondary interventions) a retrograde atticoantrotomy was performed and the bony tympanic membrane frame was reconstructed and reinforced by a customized bone chip (“attic clip”) from the temporal squama. The attic clip was notched at the caudal end for resting on the mallear neck and subtle adjustment into the epitympanic defect. If necessary, the remaining postero-superior canal wall was rebuild with bone chips, bone pate and temporal fascia. Evaluation was carried out by otomicroscopy and otoendoscopy using with photo and video documentation. The mean follow-up was 7,6 months (range 5-11 months).

Results: In all but one patient the attic clip healed without graft insufficiency, leading to only one recurrent epitympanic retraction pocket up to now. The postoperative air-bone gap was 5,5 ± 0,5 dB for type I-tympanoplasty (TP), 18,0 ±11,3 dB for type III(PORP)-TP and 20,0 ± 16,2 dB for type III(TORP)-TP. In six cases a second TP was considered as not necessary and the postoperative hearing results remained unchanged. As suspected from these audiologic results a second-look-TP in one case revealed a pseudarthrosis between the attic clip and the malleus with no obvious fixation.

Conclusions: Stable restoration of the the posterior-superior canal wall following atticoantrotomy can be achieved by using bone chips from the temporal squama. The crucial attic area can be reconstructed and reinforced by modeling and fitting of an additional notched bone chip with support on the mallear neck. Postoperative hearing impairment due to bony fixation of the malleus and the attic clip is not be expected.