5Complications: TTH Experience 1987-97 IatrogenicFacial 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
6ControversiesWhen does a retraction pocket become a cholesteatoma? (The Friedberg Doctrine)Does all cholesteatoma require surgery?
7Thai Rural Ear Nose and Throat Foundation Founded in 1972 by Dr Salyaveth Lekagul> patients assessed>4000 mastoidectomy procedures>7000 tympanoplasty procedures
8Prevalence of ear disease from 1980-91* * data collected from mobile ENT unit
9Ear Disease in Thailand* * data collected from mobile ENT unit
10Why has ear disease decreased in Thailand? 1972Thailand had 26 ENT surgeons (25 were in Bangkok)In the 70 provinces, there were no ENT surgeons or operating microscopesPatients required to travel average 400 km for treatment
11Why has ear disease decreased in Thailand? 1998There are now 500 ENT surgeons in ThailandAll provincial capitals have hospital with ENT surgeon and operating microscopesPatients now travel less than 50 km
12Why has ear disease decreased in Thailand? Complete immunization programs nationwide / national health careBetter nutrition and little malnutritionTransportationDistrict and community hospitals (600 hospitals, beds)Better education / teaching about dangers of ear disease- personal communication, Salyaveth Lekagul 1998
13Risks of Developing an Otogenic Intracranial Abscess Annual risk with active CSOM is 1/10,0003x’s more common in malesLifetime risk of individual age 30 years with CSOM is 1/2005% abscesses occur in the immediate postoperative period*Nunez & Browning 1990
14Cholesteatoma Surgery 225 Mastoidectomy procedures at TTH from188 pts - primary cholesteatomamodified radical 134radical 45CAT 937 pts- revision surgery (referred)modified radical 25radical 12
16Over the past fifty years, there has been an apparent decline in: prevalence of cholesteatomasurgery for cholesteatomaintracranial complications (brain abscess, meningitis)acute mastoiditis
17Future challenges in cholesteatoma surgery in the 21st century: intralabyrinthine / petrous apex diseasefootplate / sinus tympanichildhood cholesteatoma
18Childhood Cholesteatoma Probability of recurrence*40% at 10 yearsReasons40-50% of children have extensive pneumatizationinfiltrating nature of cholesteatomaless aggressive surgery performed* Gristwood 1979, Clinical Otolaryngology
19Growth Rates of Cholesteatoma Variations in growth potential of residual cellular elementsi.e. cholesteatoma doubling time attic (10 months), mastoid (25 months)Blood supply to matrixVascular factors / infection / growth factors / proteolytic enzymesAnatomic factors (i.e. pneumatization)
21Surgical Management High resolution CT preop CO2 laser - footplate diseaseFacial nerve monitoring
22Cause for concern? Declining incidence of cholesteatoma may mean: 1. Decreased recognition of diseaseWill more complications arise as a result?2. Decreased surgical exposureCan surgical skills be maintained?3. Decreased educational teaching (residency training)Should mastoidectomy surgery be considered fellowship material?