Functional and Anatomical Outcome of Inside Out Technique For Cholesteatoma Surgery
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:
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Any age
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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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