[Recurrent cholesteatoma after combined approach tympanoplasty: pathogenesis and prevention]

Over the last few years, we have increasingly reduced the use of open techniques in favour of combined approach tympanoplasty by adopting a strategy enabling the prevention of genuine recurrences of cholesteatoma. Recurrences due to the development of a residual cholesteatoma moving outwards towards the meatus can be considerably reduced by a careful eradication at the time of exeresis, and by early screening and exeresis of the residual cholesteatoma by a practically systematic second-look operation (two-stage tympanoplasty). To prevent further penetration of the skin into the new middle ear, an effective barrier has to be created between the skin and the mucosa (repair of the wall of the attic, reconstruction of the tympanum by a xenograft (Parmatymp), and proper drainage and airing the new cavity must be assured. To help with the proper regeneration of the mucosa and the maintenance of the drainage and airing pathways within the cavity, the use of silastic proved to be fundamental. This new strategy has enabled us to treat, with the combined approach, 84% of the 1,465 cases of cholesteatoma operated upon between 1975 and 1989.