Elsevier

American Journal of Otolaryngology

Volume 39, Issue 4, July–August 2018, Pages 423-430
American Journal of Otolaryngology

Functional and Anatomical Outcome of Inside Out Technique For Cholesteatoma Surgery

https://doi.org/10.1016/j.amjoto.2018.04.008Get rights and content

Abstract

Background

To study the efficacy of inside-out technique in completely eradicating the cholesteatoma from middle ear and mastoid, preservation of hearing & and quality of life post mastoidectomy with regards to recurrent discharge, wax, granulations.

Material and methods

Non-randomized, prospective, observational study performed at the Department of ENT in our hospital. In the study we included 100 patients presenting with chronic suppurative otitis media with cholesteatoma, they underwent inside out mastoidectomy and were followed up till the end of the study to evaluate the efficacy of inside out mastoidectomy in eradicating the disease from the middle ear cleft. To assess preservation of hearing and to assess cavity problems.

Results

Of the 100 patients, 98 patients had a total clearance of disease by the inside out approach, and 2 patients, had doubtful clearance. All patients came for regular follow up and none of them had residual disease at the end of the study period. Thus, the overall success rate was 100% in our study. A significant improvement in the mean air conduction (p < 0.01) and the mean air bone gap (p < 0.01) was seen in all postoperatively at 3rd month PTA. Only one patient had conductive hearing loss one and a half years postoperatively after initial improvement. A dry self-cleansing cavity was achieved in 95% of the patients and only 5% required regular cleaning of wax the cavities.

Conclusion

Inside out mastoidectomy is a better alternative in canal wall down procedures as it not only clears the disease from the middle ear cleft, but also leaves behind a small postoperative cavity, which will preserve the hearing, decrease the cavity problems and increase the quality of life of such patients.

Introduction

Over the last 50 year, the treatment of chronic middle ear disease has undergone a series of technical advances causing a shift in emphasis from extirpation of disease to preservation and reconstruction of middle ear structures [1].

The subject debated endlessly in the choice of surgical technique, open versus closed mastoidectomy. Generally, open techniques provide good control of excision of the cholesteatoma, but facilitate the development of infections, require regular control and entail limitations for bathing. Closed techniques showed a lower rate of infection and do not restrict bathing, but result in a higher percentage of residual and recurrent cholesteatomas, whilst also requiring periodic controls [2,3].

Also the proponents of the closed cavity procedures state the fact that the hearing results are low due to change in the anatomy and physiology after creation of a open mastoid cavity. Pathogenesis, surgery is aimed at interfering with the pathological process to stop the continuum of the disease and to establish the functions.

The purpose of these surgeries was to create a safe ear by exteriorizing the disease. Treatment of chronic middle ear disease has causing a shift in emphasis from extirpation of disease to preservation and reconstruction of middle ear structures [1].

Also the proponents of the closed cavity procedures state the fact that the hearing results are disappointing with the change in the anatomy and physiology after creation of a open mastoid cavity.

Jansen adopted a combined anterior and posterior tympanotomy approach to surgically treat cholesteatoma and chronic infection. Since the introduction of combined approach tympanoplasty (CAT), various modifications have been suggested by different otologists [1].

Newer techniques adopted to make the ear disease free along with restoration of hearing mechanism and also minimizing the post operative problems.

An ‘inside out' approach differs from the classical “outside in” for cholesteatoma surgery by following the disease in the direction of its spread. This helps in limiting the extent of the cavity, ability to stop the operation as required. Otherwise this approach has the same incision and same exposure as the “outside in”.

Here we study the ‘inside out' approach of modified radical mastoidectomy, its functional and anatomical advantages.

Section snippets

Material & methods

The study has been conducted in the Department of Otorhinolaryngology at our Hospital from 2014 to 2017 after an approval of the same by the Institutional Ethics Committee. An informed and written consent was obtained from all patients involved in the study. A total number of 100 patients undergoing inside out technique surgery for cholesteatoma under local or general anaesthesia were included in the study. Non randomized, prospective observational study.

Inclusion criteria:

  • Any age

  • Presence of

Preoperative evaluation and preparation

The detailed history taking and complete examination of the ear, nose, paranasal sinuses, oral cavity and pharynx were done of all study patients to rule out any foci of infection. Systemic diseases unrelated to the ear disease were ruled out. Otoscopic, otomicroscopy and tuning fork tests were performed. (Fig. 1, Fig. 2).

The selected cases underwent appropriate investigations. Routine blood investigations like hemoglobin percentage, total and differential leucocytes count along with blood

Results

The results of these hearing assessments indicate a significant improvement in hearing gain following surgery.

In our study of total 100 patients, 63 were male patients (63%) predominant as compared to female patients 37 (37%) (Table 1). Patients' ages ranged between 7 to 67 years. More patients were surgically treated for cholesteatoma in the age range of 11 to 20 years (30%) and 31 to 50 years (40%) than the other age groups (Table 2). 50% of the patients presented with Sinus cholesteatoma

Discussion

100 patients presenting with chronic suppurative otitis media with cholesteatoma were selected to study the efficacy of inside-out approach in completely eradicating the cholesteatoma from middle ear and mastoid, preservation of hearing and functionality of the ear and quality of life post mastoidectomy with regards to recurrent discharge, wax, granulations.

Conclusion

In ‘inside out’ technique tailouring of mastoid bone was done in the direction of spread of cholesteatoma, a smaller postoperative cavity is achieved which in the long run will help in minimizing problems of a large cavity. The postoperative hearing results and quality of life also significantly improved. The efficacy of inside-out approach in completely eradicating the cholesteatoma from middle ear and mastoid, preservation of hearing & and quality of life post mastoidectomy with regards to

Financial disclosure

The authors have no funding, financial relationships.

Conflict of interest

Conflicts of interest to disclose.

Ethical approval

The study was approved by the Institutional Ethics Committee.

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