The supratubal recess in cholesteatoma surgery

Acquired attic retraction cholesteatoma involving the anterior epitympanum is infrequently encountered and even less frequently discussed in the literature. The lack of cholesteatoma in this region is mostly due to a ridge of bone extending inferiorly from the tegmen tympani, just anterior to the cochleariform process. The term "cog" was coined and popularized to refer to this bony ridge. Erosion of the cog by cholesteatoma matrix allows extension of cholesteatoma into the supratubal recess. A number of vital structures including the facial nerve, cochlea, middle fossa dura, and internal carotid artery are intimately related to the supratubal recess. A clear three-dimensional understanding of these structures is necessary to remove disease safely from this area regardless of whether the posterior canal wall is left up or taken down. We present a series of dissection illustrations of the supratubal recess and discuss the possible routes of cholesteatoma extension. A series of patients with varying degrees of involvement of the supratubal recess and related structures is presented, and the pitfalls and management of cholesteatoma in this area are discussed.