Presentation is loading. Please wait.

Presentation is loading. Please wait.

Management of Cholesteatoma in the 21st Century John Rutka MD FRCSC Department of Otolaryngology University of Toronto.

Similar presentations


Presentation on theme: "Management of Cholesteatoma in the 21st Century John Rutka MD FRCSC Department of Otolaryngology University of Toronto."— Presentation transcript:

1 Management of Cholesteatoma in the 21st Century John Rutka MD FRCSC Department of Otolaryngology University of Toronto

2 Mastoid Misery Index (Why mastoidectomy surgery fails) Mucosal disease (incomplete epithelialization)Mucosal disease (incomplete epithelialization) High facial ridgeHigh facial ridge Inadequate meatoplastyInadequate meatoplasty Recurrent cholesteatomaRecurrent cholesteatoma

3 Question Does surgery for cholesteatoma prevent complications from occurring?” “Does surgery for cholesteatoma prevent complications from occurring?” Historical controlsHistorical controls Glasgow study (Nunez & Browning, JLO 1990)Glasgow study (Nunez & Browning, JLO 1990)

4 Complications: TTH Experience From cholesteatoma –LSCC “fistula” - 13 pts (5.8%) –Brain abscess / meningitis - 4 pts (1.8%) –Facial paralysis - 4 pts (1.8%) –SNHL - 6 pts (3%) –Mastoiditis - 3 pts (1.5%)

5 Complications: TTH Experience Iatrogenic –Facial paralysis - 10 pts (5%)* –Brain herniation - 2 pts (1%) –CSF leak - 1 pt (0.5%) –Symptomatic fistula - 1pt (0.5%) –Significant pain - 2pts (1%) Facts * all patients had 7th palsy on referral * surgery was 2x’s more likely to cause facial paralysis than cholesteatoma

6 Controversies When does a retraction pocket become a cholesteatoma? (The Friedberg Doctrine)When does a retraction pocket become a cholesteatoma? (The Friedberg Doctrine) Does all cholesteatoma require surgery?Does all cholesteatoma require surgery?

7 Thai Rural Ear Nose and Throat Foundation Founded in 1972 by Dr Salyaveth LekagulFounded in 1972 by Dr Salyaveth Lekagul > patients assessed >4000 mastoidectomy procedures >7000 tympanoplasty procedures

8 Prevalence of ear disease from * * data collected from mobile ENT unit

9 Ear Disease in Thailand* * data collected from mobile ENT unit

10 Why has ear disease decreased in Thailand? 1972 –Thailand had 26 ENT surgeons (25 were in Bangkok) –In the 70 provinces, there were no ENT surgeons or operating microscopes –Patients required to travel average 400 km for treatment

11 Why has ear disease decreased in Thailand? 1998 –There are now 500 ENT surgeons in Thailand –All provincial capitals have hospital with ENT surgeon and operating microscopes –Patients now travel less than 50 km

12 Why has ear disease decreased in Thailand? Complete immunization programs nationwide / national health careComplete immunization programs nationwide / national health care Better nutrition and little malnutritionBetter nutrition and little malnutrition TransportationTransportation District and community hospitals (600 hospitals, beds)District and community hospitals (600 hospitals, beds) Better education / teaching about dangers of ear diseaseBetter education / teaching about dangers of ear disease - personal communication, Salyaveth Lekagul 1998

13 Risks of Developing an Otogenic Intracranial Abscess Annual risk with active CSOM is 1/10,000Annual risk with active CSOM is 1/10,000 3x’s more common in males3x’s more common in males Lifetime risk of individual age 30 years with CSOM is 1/200Lifetime risk of individual age 30 years with CSOM is 1/200 5% abscesses occur in the immediate postoperative period5% abscesses occur in the immediate postoperative period *Nunez & Browning 1990

14 Cholesteatoma Surgery 225 Mastoidectomy procedures at TTH from pts - primary cholesteatoma188 pts - primary cholesteatoma modified radical 134modified radical 134 radical 45radical 45 CAT 9CAT 9 37 pts- revision surgery (referred)37 pts- revision surgery (referred) modified radical 25modified radical 25 radical 12radical 12

15 Revision Surgery (JAR) 9 patients9 patients mucosal disease - 5 patientsmucosal disease - 5 patients recurrent cholesteatoma - 2 patients*recurrent cholesteatoma - 2 patients* web formation - 1 patientweb formation - 1 patient cholesterol granuloma - 1 patientcholesterol granuloma - 1 patient revision raterevision rate 9 / 225 pts (4.0%)9 / 225 pts (4.0%) recurrence (recidivistic)recurrence (recidivistic) 2 / 225 pts (1%)2 / 225 pts (1%) *hypotympanic cholesteatoma, petrous apex cholesteatoma *hypotympanic cholesteatoma, petrous apex cholesteatoma

16 Over the past fifty years, there has been an apparent decline in: prevalence of cholesteatomaprevalence of cholesteatoma surgery for cholesteatomasurgery for cholesteatoma intracranial complications (brain abscess, meningitis)intracranial complications (brain abscess, meningitis) acute mastoiditisacute mastoiditis

17 Future challenges in cholesteatoma surgery in the 21st century: intralabyrinthine / petrous apex diseaseintralabyrinthine / petrous apex disease footplate / sinus tympanifootplate / sinus tympani childhood cholesteatomachildhood cholesteatoma

18 Childhood Cholesteatoma Probability of recurrence*Probability of recurrence* 40% at 10 years40% at 10 years ReasonsReasons 40-50% of children have extensive pneumatization40-50% of children have extensive pneumatization infiltrating nature of cholesteatomainfiltrating nature of cholesteatoma less aggressive surgery performedless aggressive surgery performed * Gristwood 1979, Clinical Otolaryngology

19 Growth Rates of Cholesteatoma Variations in growth potential of residual cellular elementsVariations in growth potential of residual cellular elements –i.e. cholesteatoma doubling time attic (10 months), mastoid (25 months) Blood supply to matrixBlood supply to matrix Vascular factors / infection / growth factors / proteolytic enzymesVascular factors / infection / growth factors / proteolytic enzymes Anatomic factors (i.e. pneumatization)Anatomic factors (i.e. pneumatization)

20 Surgical Techniques Open ProceduresOpen Procedures atticotomyatticotomy modified radical mastoidectomymodified radical mastoidectomy –attico-antrostomy –Bondy variant radical mastoidectomyradical mastoidectomy Closed ProceduresClosed Procedures combined approach tympanoplasty (canal wall up)combined approach tympanoplasty (canal wall up) Mastoid obliterationMastoid obliteration

21 Surgical Management High resolution CT preopHigh resolution CT preop CO 2 laser - footplate diseaseCO 2 laser - footplate disease Facial nerve monitoringFacial nerve monitoring

22 Cause for concern? Declining incidence of cholesteatoma may mean: 1. Decreased recognition of disease Will more complications arise as a result? 2. Decreased surgical exposure Can surgical skills be maintained? 3. Decreased educational teaching (residency training) Should mastoidectomy surgery be considered fellowship material?

23 Causes for Facial Paralysis


Download ppt "Management of Cholesteatoma in the 21st Century John Rutka MD FRCSC Department of Otolaryngology University of Toronto."

Similar presentations


Ads by Google