Attic cholesteatoma with tiny retraction of pars flaccida

This clinical study was performed to analyze the characteristics of attic cholesteatoma occurring behind a tiny retraction of the pars flaccida, which was classified as Tos type I or II and had an intact pars tensa of the tympanic membrane.

The clinical records of patients who underwent tympanomastoidectomy for attic cholesteatoma at a tertiary care referral center (Kangdong Sacred Heart Hospital of Seoul, Korea) between March 2004 and December 2012 were retrospectively reviewed. Eleven patients (five men and six women) who underwent tympanomastoidectomy between March 2004 and December 2012 for attic cholesteatoma occurring behind a tiny attic retraction were included. The mean age of patients was 41.1 years (range 20-58 years) and the mean duration of follow-up was 29.5 months (range 13-52 months).

Every patient had a unilateral cholesteatoma, and the opposite side was normal except in one patient. Hearing loss was the most common symptom, followed by earfullness and otalgia. Five patients had type I attic retraction, and six patients had type II attic retraction. No patient had definite scutum erosion. Interestingly, during regular postoperative checkup, one patient was found incidentally for the opposite ear. Six patients had a cholesteatoma sac that was separated from the pars flaccida, whereas in five patients it was in contact with the pars flaccida but was easily separated. Six patients had a limited cholesteatoma within the epitympanum, and five patients had extension beyond the epitympanum. The average air-bone gap was 24.3±10.1dB before the operation and 14.2±6.6dB after the operation. Every patient had an intact tympanic membrane without retraction pocket postoperatively. There was no recurrence of cholesteatoma during follow-up.

The rate of attic cholesteatomas occurring behind a tiny retraction of the pars flaccida was 7.7% (11 of 142 patients with attic cholesteatoma). Attic retractions must be followed closely using endoscopy, microscopy, and temporal bone Computed tomography, even though the patient has a tiny retraction of the pars flaccida or a normal hearing level.