Prevalence of ventilation blockages in patients affected by attic pathology: a case-control study

Using a retrospective video evaluation of exclusive endoscopic middle ear procedures, we analyzed the different anatomical and pathological findings between patients with attic disease or cholesteatoma and patients without attic disease.

A case-control study based on a retrospective chart review in a tertiary university referral center.

Videos from endoscopic middle ear procedures carried out between February 2007 and August 2012 were reviewed. We analyzed and compared two groups of patients who underwent surgery in our university hospital: patients with selective attic disease (e.g., non-self-cleaning attic selective retraction pockets or attic cholesteatoma) were compared with subjects without attic disease (e.g., chronic middle ear disease, congenital cholesteatoma, or secondary cholesteatoma).

In total, 152 patients were included in the study. Of these, 102 were affected by primary acquired cholesteatoma (84/102) or severe pars flaccida retraction pockets (18/102), whereas 50 cases were controls. A blockage of the isthmus was present in almost all cases (98/102) compared with a lower prevalence in controls (3/50) (P < .0001). Similarly, a complete tensor fold was identified in 99/102 patients compared to controls (9/46; data were not available in four controls) (P = .001).

Selective epitympanic dysventilation occurred when a blockage of the isthmus was present and associated with a complete tensor fold, causing ventilatory separation between the epitympanum and mesotympanum. This mechanism could be the basis for a selective decrease in pressure in the attic, with the subsequent development of attic retraction pockets and cholesteatoma even in subjects with a normally functioning eustachian tube.