Treatment of cholesteatoma

Clinicians view cholesteatoma as a middle ear condition in which stratified squamous epithelium produces non-self-cleansing amounts of keratin. This clinical definition includes retraction pockets as well as big, deep-seated epidermoids. The two may have different origins, and they often require different therapeutic approaches. Clearance and control of shallow retraction pockets may be achieved with suction cleaning. Larger or longstanding retraction pockets, if not too deep, may be excised, and the tympanic membrane grafted. Deep-seated cholesteatomas require more elaborate surgery, whether they involve advanced retraction pockets or big and deep-seated middle ear epidermoids. The intact wall technique, though elegant, has about a 50% failure rate, regardless of the surgeon's skill. The failures are due to either retraction pocket formation, with or without posterior wall atrophy or the reappearance of epidermoids (so-called residual disease). Reconstruction of the bony defect in the scutum does not prevent retraction pocket formation. It is obvious that an approach that envisages successful removal of the matrix as curing the disease is too simplified. The intact wall operation should be reserved for ears with extensive mastoid pneumatization and small cholesteatomas. Most ears with cholesteatoma (85%) are, however, poorly pneumatized and they fare best with a small radical conservative (modified) mastoidectomy. The procedure should aim at creating the smallest mastoid cavity possible. Small mastoid cavities, possessing a tympanic membrane, an adequate mastoplasty, and no recess behind the facial ridge, will be found to be dry in about 90% of cases. A technique for achieving a minimal mastoid cavity is described.