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Pooled analysis of the evidence for open cavity, combined approach and reconstruction of the mastoid cavity in primary cholesteatoma surgery

Published online by Cambridge University Press:  15 February 2016

A T Harris ,
B Mettias  and
T H J Lesser
A T Harris
Affiliation:
ENT department, Aintree University Hospital, Liverpool, UK
B Mettias
Affiliation:
ENT department, Aintree University Hospital, Liverpool, UK
T H J Lesser*
Affiliation:
ENT department, Aintree University Hospital, Liverpool, UK
*
Address for correspondence: Mr T H J Lesser, ENT Department, Aintree University Hospital, Lower Lane, Liverpool L9 7AL, UK E-mail: tristram.lesser@aintree.nhs.uk
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Abstract

Background:

Cholesteatoma is keratinising epithelium within the middle-ear cleft or mastoid. This disease destroys the peripheral organs of balance and hearing, with possible intracranial sequelae. The management of cholesteatoma is surgical and the primary aim is to remove the disease and prevent recurrence. Secondary aims are to obtain a non-discharging, hearing ear. Cholesteatoma surgery falls into two broad categories: open cavity surgery and combined approach surgery. A third surgical category is reconstruction of an open mastoid cavity after open surgery. This study performed a pooled analysis of the worldwide literature to compare the rates of cholesteatoma not being cured (i.e. recidivism), ear discharge and hearing change among open cavity, combined approach and reconstruction mastoid surgery for primary cholesteatoma.

Methods:

A literature search for all types of cholesteatoma surgery in the PubMed, Google Scholar and Medline databases and in published conference proceedings was undertaken.

Results:

There was no level 1 evidence for the best method of primary cholesteatoma surgery. The highest evidence level found (level 2; 5366 patients) shows no difference in hearing change or discharge rate between open and combined approach surgery; however, these methods fail to cure the cholesteatomas in 16.0 per cent and 29.4 per cent of cases, respectively. In a total of 640 patients, reconstruction and/or repair mastoid surgery using a variety of non-comparable techniques had a failure rate of between 5.3 per cent and 20 per cent.

Conclusion:

The available evidence suggests that reconstruction of the posterior canal wall and/or obliteration of the mastoid may be the best surgical treatment alternative. This technique appears to provide the lowest recidivism rate combined with a low post-operative ear discharge rate.

Keywords

CholesteatomaMastoid SurgeryHearing

Information

Type
Main Articles
Information
The Journal of Laryngology & Otology , Volume 130 , Issue 3 , March 2016 , pp. 235 - 241
Copyright
Copyright © JLO (1984) Limited 2016 

Introduction

Cholesteatoma is defined as keratinising squamous epithelium within the middle-ear cleft and mastoid.Reference Ojala and Palva1 The classic clinical presentation of cholesteatoma is a foul-smelling aural discharge with a pearly lesion seen on otoscopic examination. Cholesteatoma may progress to destroy the organs of hearing and balance, damage the facial nerve, and cause intracranial complications such as a brain abscess. Cholesteatoma management is usually surgical and aims to create a safe ear with no residual or recurrent cholesteatoma. Secondary aims of cholesteatoma surgery are optimising the hearing level and creating a non-discharging, self-cleaning ear.Reference Ojala and Palva1 Cholesteatoma surgery falls into two broad categories: closed, referring to canal wall up procedures (i.e. combined approach tympanoplasty) and open, referring to procedures that result in an open mastoid cavity (e.g. after radical or modified radical mastoidectomy). A third type of surgery involves reconstruction or repair of the posterior ear canal wall or obliteration of the mastoid cavity. The various reconstruction and repair methods use cartilage, bone, fascial and muscle grafts or synthetic material.Reference Ojala and Palva1

The debate surrounding the best surgical technique for primary cholesteatoma surgery generally sets evidence against surgical experience. This study therefore assessed the available evidence base to support future surgical decision-making in primary cholesteatoma.

Firstly, a pooled analysis of the literature on open cavity, canal wall up, and reconstruction or repair mastoid surgery for primary cholesteatoma was undertaken to compare the recidivism and post-operative ear discharge rates along with the hearing levels achieved for all three surgical techniques. The term ‘recidivism’ as used here includes recurrence and residual cholesteatoma because it is difficult to determine causality, especially over a follow-up period of years.

Materials and methods

A search for articles on primary surgery for cholesteatoma in the PubMed, Google Scholar and Medline databases and in published conference proceedings was undertaken using the search terms ‘cholesteatoma’, ‘mastoid surgery’, ‘mastoidectomy’, ‘complications’, ‘results’, ‘reconstruction’, ‘recurrence’, ‘intact canal wall’ and ‘canal wall down’. The outcome measures were post-operative recidivism and ear discharge rates and pre- and post-operative hearing levels.

Cochrane methodology was used to classify the published evidence levels for mastoid surgery for cholesteatoma as: level 1a, systematic review or meta-analysis of randomised controlled trials; level 1b, at least one randomised controlled trial; level 2a, at least one well-designed controlled study without randomisation; level 2b, at least one well-designed quasi-experimental study, e.g. a cohort study; level 3, well-designed, non-experimental descriptive studies, such as comparative studies, correlation studies, case–control studies and case series; and level 4, expert committee reports, opinions and/or clinical experience of respected authorities.2 Inclusion criteria for evidence level 2 or 3 were (1) the procedure or technique was performed by more than one surgeon and (2) residual disease and/or recurrence was recorded more than one year after surgery.

Results

No prospective randomised controlled trial (i.e. evidence level 1) comparing primary cholesteatoma surgical techniques was found in the literature search. However, four retrospective studies reporting evidence level 2 were found reporting the use of open, closed and repair or reconstruction mastoid surgical techniques.Reference Lau and Tos3–Reference Godinho, Kamil, Lubianca, Keogh and Eavey6 Cholesteatoma recidivism, pre- and post-operative objective hearing assessment, and post-operative ear discharge could be compared among the different techniques in this group of studies (Table I).

Table I

Outcomes of all three surgical techniques in four retrospective studies

n = number of patients; D = post-operative ear discharge rate (in %); R = recidivism rate (in %); pre-HL = pre-operative hearing level (in dB); Post-HL = post-operative hearing level (in dB)

A total of 131 patients underwent the closed surgical technique: in this group, the recidivism rate was 25.7 per cent, the average pre- and post-operative hearing loss was 32 dB and 20 dB, respectively, and the post-operative ear discharge was 3.3 per cent. A total of 130 patients underwent the open technique: in this group, the recidivism rate was 16.9 per cent, the average pre- and post-operative hearing loss was 35.6 dB and 30 dB, respectively, and the post-operative ear discharge rate was 26.6 per cent. A total of 184 patients underwent repair mastoid surgery: in this group, the recidivism rate was 20.1 per cent, the average pre- and post-operative hearing loss was 30.6 dB and 22 dB, respectively, and the post-operative ear discharge rate was 8.8 per cent.

As only four studies comparing all three surgical techniques were found, a second analysis of another group of studies comparing only two of the surgical techniques was performed. Seventeen studies compared open vs closed mastoid surgery,Reference Derlacki, Baron, Beales, Bellucci, Guilford and Plester7–Reference Shirazi, Muzaffar, Leonetti and Marzo23 two studies compared open vs repair mastoid surgeryReference Tos24, Reference Lesinskas and Vainutiene25 and two studies compared closed mastoid surgery with repairing of the cavity.Reference Sanna, Zini, Gamoletti, Delogu, Russo, Scandellari and Taibah26, Reference Ojala and Palva27 All of these studies had evidence level 2 (Table II).

Table II

Outcomes of 22 studies comparing two different surgical techniques

FU = follow up (in years); S = sample size (n); R = recidivism rate (in %); pre-HL = pre-operative hearing level (in dB); post-HL = post-operative hearing level (in dB); D = post-operative ear discharge rate (in %); NA = not available

Inclusion of these 21 studies increased the patient sample size by 3112 for the closed surgical technique, 1809 for the open technique and 640 for the repair technique. The second analysis determined cholesteatoma recidivism rates of 29.4 per cent for the closed technique, 16 per cent for the open technique and 5.3 per cent for the repair group. The proportion of patients with discharging ears was 18 per cent in the closed technique group, 17 per cent in the open technique group and 11 per cent in the repair cavities group. The mean hearing levels were 23 dB pre-operatively vs 22 dB post-operatively for the closed technique, 27 dB pre-operatively vs 27 dB post-operatively for the open technique and 44 dB pre-operatively vs 39 dB post-operatively for the repair group.

In a third analysis, the cholesteatoma recidivism rate, pre- and post-operative hearing levels, and post-operative ear discharge rate were determined using data from studies which evaluated only a single surgical technique (i.e. evidence level 3; Tables III–V). Table VI provides an overall summary of evidence level 2 and 3 analyses.

Table III

Level of evidence 2 for closed mastoid surgery

FU = follow up (in years); S = sample size; R = recidivism rate; pre-HL = pre-operative hearing level (in dB); post-HL = post-operative hearing level (in dB); D = post-operative ear discharge rate

Table IV

Level of evidence 2 for open mastoid surgery

Examined were recidivism rates, pre-and post-operative hearing levels and ear discharge rates following surgery. FU = follow up (in years); S = sample size; R = recidivism rate; pre-HL = pre-operative hearing level (in dB); post-HL = post-operative hearing level (in dB); D = post-operative ear discharge rate

Table V

Level of evidence 2 for repair or reconstruction surgery

FU = follow up (in years); S = sample size (n); R = recidivism rate (in %); pre-HL = pre-operative hearing level (in dB); post-HL = post-operative hearing level (in dB); D = post-operative ear discharge rate (in %); NA = not available

Table VI

Outcomes after mastoid surgery

S = sample size (n); R = recidivism rate (in %); pre-HL = pre-operative hearing level (in dB); post-HL = post-operative hearing level (in dB); D = post-operative ear discharge rate (in %).

Discussion

Level 1 evidence for primary cholesteatoma surgery was not found in the literature search. Moreover, no prospective randomised study comparing two or more surgical techniques in mastoid surgery for cholesteatoma was identified. However, studies on primary cholesteatoma surgery with levels of evidence 2 and 3 were found.

This study analysed the published data on outcomes of primary cholesteatoma surgery and highlights an important deficiency in the available level of evidence. In addition, various methods have been used to repair the mastoid cavity, so their combined analysis may not accurately represent the outcomes associated with each method. Further, post-operative hearing assessment was not performed in all cases and various methods were used for hearing assessment: speech discrimination testing along with a pure tone audiogram may provide a standardised functional outcome assessment to enable comparisons. Ear discharge findings should also be quantified in a consistent manner (for example, as the number of days per year with ear discharge), but this was not done. These issues demonstrate the difficulties involved in defining a ‘gold standard’ treatment. Despite this, it is imperative that surgical decision-making is based on the best available evidence.

Evidence level 2 data were analysed in two different ways: the first analysis of a group of four papers compared the outcomes of all three types of surgery (Table I); and the second analysis of a group of 18 papers compared the outcomes of only two types of surgery. These two groups of papers were then pooled to determine the overall evidence level 2 on the different types of mastoid surgery for primary cholesteatoma. The pooled analysis showed that a lower cholesteatoma recidivism rate is associated with open mastoid surgery (16.9 per cent) than with closed (25.7 per cent) or reconstruction and/or repair mastoid surgery (20 per cent). Open mastoid surgery was associated with a much higher ear discharge rate (27 per cent) compared with closed (3.3 per cent) and reconstruction (8.8 per cent) mastoid surgery. Pre- and post-operative hearing levels were similar among the three groups. In the papers reporting evidence level 2 for open and closed mastoid surgery (Table II), open mastoid surgery was associated with a much lower recidivism rate (16 per cent) compared with the closed technique (29.4 per cent). The repair mastoid group had an even lower recidivism rate (5.3 per cent), although only 4 of the 22 studies examined this group. There was no difference in hearing outcome between the open and closed mastoid groups in all 22 studies. Ear discharge rates were not mentioned in many studies, so it was difficult to compare this outcome among groups.

In general, if level l evidence regarding a clinical question is available, then studies with weaker levels of evidence should not be considered: evidence level 2 should alter practice whilst evidence level 3 should inform practice. Thus, clinical practice should follow the highest level of evidence. Analysis of studies with level of evidence 2 demonstrated that open mastoid surgery is associated with a much lower cholesteatoma recidivism rate compared with closed techniques. As this is the highest level of evidence found on this subject, it should be used to inform clinical practice.

The worldwide literature on primary cholesteatoma surgery was analysed in this study. Notably, when only level 3 evidence was analysed, the differences in outcome between techniques were smaller than for level 2 evidence. Although analysis of level 3 evidence demonstrated a higher cholesteatoma recidivism rate for closed mastoid surgery compared with the open surgical technique, the difference was smaller than in the equivalent analysis of level 2 evidence (evidence level 3, 12.6 per cent vs 6.6 per cent; evidence level 2, 29.5 per cent vs 16.5 per cent). These data demonstrate that including data from individual case series or other non-experimental descriptive studies in the analysis can lead to a false view of the benefits of closed surgery. There may be a smaller difference in cholesteatoma recidivism rates between open and closed mastoid surgery in the evidence level 3 analysis because closed mastoid surgery is preferentially performed on cholesteatoma with a less extensive spread within the middle ear and mastoid cavity. Presentations at international meetings often refer to performing canal wall up surgery on patients with simpler disease and open surgery on others with more complex disease. This practice would skew results in favour of closed mastoid surgery when recidivism rates in studies with evidence level 3 are considered. It is also a reminder to avoid basing clinical practice on evidence level 4 when a higher level of evidence is available.

  • • No level 1 evidence is available for primary cholesteatoma surgery

  • • There is no difference in hearing change or discharge rate between open and closed cavity mastoid surgery

  • • The recidivism rate is much lower for open than for closed cavity mastoid surgery

  • • Low levels of evidence may inform surgical decision-making

  • • This may explain the continued use of combined approach tympanoplasty for primary cholesteatoma

The smaller difference in cholesteatoma recidivism rates between closed and open mastoid surgery in studies with evidence level 3 may persuade some surgeons that closed mastoid surgery is the best method. Closed mastoid surgery may also be falsely thought to result in a lower risk of post-operative ear discharge. Table VI provides an overall summary of level of evidence 2, showing the same rate of post-operative discharge for both open and closed mastoid surgery. Hence, it may be argued that if recidivism rates between open and closed mastoid surgery are similar and there is a reduced ear discharge rate after the latter technique, then closed mastoid surgery is the best option. However, this finding is found to be false when only studies with evidence level 2 are analysed.

This study aims to provide the highest level of evidence for primary cholesteatoma surgery and highlights the danger of relying on lower evidence levels or surgical experience alone. Whilst this article was being written, a meta-analysis of intact canal wall mastoid surgery vs open cavity surgery for primary cholesteatoma by Tomlin et al. (2013) demonstrated that the recurrence and/or recidivism rate was almost three times greater with closed mastoid surgery than for open surgery, thus supporting our findings.Reference Tomlin, Chang, McCutcheon and Harris64 However the published evidence is analysed, it is difficult to avoid the conclusion that open surgery cures more cholesteatomas compared with the other available techniques, without a significant difference in the dry ear rate or post-operative hearing level.

Conclusion

A comparison of data on 5366 patients from studies with the highest available evidence level (level 2) showed a lower recidivism rate for open cavity surgery (16.0 per cent) than for closed cavity surgery (29.4 per cent), whilst there was no difference in hearing change or discharge rate among all surgical techniques. Analysis of reconstruction and/or repair mastoid surgery using a variety of non-comparable techniques in 640 patients identified a failure rate of between 5.3 per cent and 20 per cent. Combined analysis of all the available evidence suggests that reconstruction of the posterior canal wall and/or obliteration of the mastoid may in fact be the better treatment alternative, certainly in the first instance. These results (although from a much smaller patient group compared with the open or canal wall up surgery groups) suggest that this technique has the lowest recidivism rate combined with a reduced post-operative ear discharge rate.

References

1Ojala, K, Palva, A.Late results of obliterative cholesteatoma surgery. Arch Otolaryngol 1982;108:1–3CrossRefGoogle ScholarPubMed
2Patient: trusted medical information and support, 2011 Different levels of evidence. In: http://www.patient.co.uk/doctor/different-levels-of-evidence [24 July 2015]Google Scholar
3Lau, T, Tos, M.Tensa retraction cholesteatoma: treatment and long-term results. J Laryngol Otol 1989;103:149–57CrossRefGoogle ScholarPubMed
4Zorita, C, Villar, J, Bosch, J.Long-term results of cholesteatoma surgery in children. Acta Otorrinolaringol Esp 1994;45:233–6Google ScholarPubMed
5Stangerup, SE, Drozdziewicz, D, Tos, M, Trabalzini, F.Surgery for acquired cholesteatoma in children: long-term results and recurrence of cholesteatoma. J Laryngol Otol 1998;112:742–9CrossRefGoogle ScholarPubMed
6Godinho, RA, Kamil, SH, Lubianca, JN, Keogh, IJ, Eavey, RD.Pediatric cholesteatoma: canal wall window alternative to canal wall down mastoidectomy. Otol Neurotol 2005;26:466–71CrossRefGoogle ScholarPubMed
7Derlacki, EL, Baron, HS, Beales, PH, Bellucci, RJ, Guilford, FR, Plester, D et al. Selection of closed vs open technique for cholesteatomas. Arch Otolaryngol Head Neck Surg 1969;89:211–19CrossRefGoogle Scholar
8Deguine, C.Longterm results in cholesteatoma surgery. Clin Otolaryngol Allied Sci 1978;3:301–10CrossRefGoogle ScholarPubMed
9Brown, JS.A ten year statistical follow-up of 1142 consecutive cases of cholesteatoma: the closed vs. the open technique. Laryngoscope 1982;92:390–6CrossRefGoogle Scholar
10Charachon, R.Surgery of cholesteatoma in children. J Laryngol Otol 1988;102:680–4CrossRefGoogle ScholarPubMed
11Quaranta, A, Cassano, P, Carbonara, G.Cholesteatoma surgery: open vs closed tympanoplasty. Am J Otol 1988;9:229–31Google ScholarPubMed
12Marco-Algarra, J, Gimenez, F, Mallea, I, Armengot, M, de la Fuente, L.Cholesteatoma in children: results in open versus closed techniques. J Laryngol Otol 1991;105:820–4CrossRefGoogle ScholarPubMed
13Schmid, H, Dort, JC, Fisch, U.Long-term results of treatment for children's cholesteatoma. Am J Otol 1991;12:83–7Google ScholarPubMed
14Vartiainen, E, Nuutinen, J.Long-term results of surgical treatment in different cholesteatoma types. Am J Otol 1993;14:507–11Google ScholarPubMed
15Karmarkar, S, Bhatia, S, Saleh, E, DeDonato, G, Taibah, A, Russo, A et al. Cholesteatoma surgery: the individualized technique. Ann Otol Rhinol Laryngol 1995;104:591–5Google ScholarPubMed
16Parisier, SC, Hanson, MB, Han, JC, Cohen, AJ, Selkin, BA.Pediatric cholesteatoma: an individualized, single-stage approach. Otolaryngol Head Neck Surg 1996;115:107–14CrossRefGoogle ScholarPubMed
17Roden, D, Honrubia, VF, Wiet, R.Outcome of residual cholesteatoma and hearing in mastoid surgery. J Otolaryngol 1996;25:178–81Google ScholarPubMed
18Dodson, EE, Hashisaki, GT, Hobgood, TC, Lambert, PR.Intact canal wall mastoidectomy with tympanoplasty for cholesteatoma in children. Laryngoscope 1998;108:977–83CrossRefGoogle ScholarPubMed
19Darrouzet, V, Duclos, JY, Portmann, D, Bebear, JP.Preference for the closed technique in the management of cholesteatoma of the middle ear in children: a retrospective study of 215 consecutive patients treated over 10 years. Am J Otol 2000;21:474–81Google ScholarPubMed
20Rondini-Gilli, E, Mosnier, I, Julien, N, Gouin, JM, Aïdan, P, Rufat, P, Sterkers, O.One-stage surgery of middle ear cholesteatoma in adults: apropos of 180 cases. Rev Laryngol Otol Rhinol (Bord) 2001;122:75–9Google ScholarPubMed
21Göçmen, H, Kiliç, R, Ozdek, A, Kizilkaya, Z, Safak, MA, Samim, E.Surgical treatment of cholesteatoma in children. Int J Pediatr Otorhinolaryngol 2003;67:867–72CrossRefGoogle ScholarPubMed
22Siddiqui, R.Surgery for otitis media with cholesteatoma: canal up versus canal down procedures. Liaquat J Uni Med Health Sci 2005;44:64–7Google Scholar
23Shirazi, MA, Muzaffar, K, Leonetti, JP, Marzo, S.Surgical treatment of pediatric cholesteatomas. Laryngoscope 2006;116:1603–7CrossRefGoogle ScholarPubMed
24Tos, M.Modification of combined-approach tympanoplasty in attic cholesteatoma. Arch Otolaryngol 1982;108:772–8CrossRefGoogle ScholarPubMed
25Lesinskas, E, Vainutiene, V.Closed tympanoplasty in middle ear cholesteatoma surgery. Medicina (Kaunas) 2004;40:856–9Google ScholarPubMed
26Sanna, M, Zini, C, Gamoletti, R, Delogu, P, Russo, A, Scandellari, R, Taibah, A.The surgical management of childhood cholesteatoma. J Laryngol Otol 1987;101:1221–6CrossRefGoogle ScholarPubMed
27Ojala, K, Palva, A.Late results of obliterative cholesteatoma surgery. Arch Otolaryngol 1982;108:1–3CrossRefGoogle ScholarPubMed
28Barakate, M, Bottrill, I.Combined approach tympanoplasty for cholesteatoma: impact of middle-ear endoscopy. J Laryngol Otol 2008;122:120–4CrossRefGoogle ScholarPubMed
29He, Y, Liang, Y, Liu, X, Li, G, Hu, Y.Intact canal wall mastoidectomy and tympanoplasty in treating patients with cholesteatoma of the middle ear and mastoid [in Chinese]. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2008;22:740–1Google ScholarPubMed
30Hinohira, Y, Yanagihara, N, Gyo, K.Improvements to staged canal wall up tympanoplasty for middle ear cholesteatoma. Otolaryngol Head Neck Surg 2007;137:913–17CrossRefGoogle ScholarPubMed
31Ho, SY, Kveton, JF.Efficacy of the 2-staged procedure in the management of cholesteatoma. Arch Otolaryngol Head Neck Surg 2003;129:541–5CrossRefGoogle ScholarPubMed
32Quaranta, N, Fernandez-Vega Feijoo, S, Piazza, F, Zini, C.Closed tympanoplasty in cholesteatoma surgery: long-term (10 years) hearing results using cartilage ossiculoplasty. Eur Arch Otorhinolaryngol 2001;258:20–4CrossRefGoogle ScholarPubMed
33Mutlu, C, Khashaba, A, Saleh, E, Karmarkar, S, Bhatia, S, DeDonato, G et al. Surgical treatment of cholesteatoma in children. Otolaryngol Head Neck Surg 1995;113:56–60CrossRefGoogle ScholarPubMed
34Schwaber, MK.Intact canal wall mastoidectomy. Am J Otol 1979;1:45–8Google ScholarPubMed
35Sun, J, Sun, J, Hu, Y, Lv, Q, Wang, Y, Li, X, et al. Canal wall-down mastoidectomy with mastoid obliteration for pediatric cholesteatoma. Acta Otolaryngol 2010;130:259–62CrossRefGoogle ScholarPubMed
36Redaelli de Zinis, LO.Titanium vs hydroxyapatite ossiculoplasty in canal wall down mastoidectomy. Arch Otolaryngol Head Neck Surg 2008;134:1283–7CrossRefGoogle ScholarPubMed
37Ajalloueyan, M.Experience with surgical management of cholesteatomas. Arch Otolaryngol Head Neck Surg 2006;132:931–3CrossRefGoogle ScholarPubMed
38Mukherjee, P, Saunders, N, Liu, R, Fagan, P.Long-term outcome of modified radical mastoidectomy. J Laryngol Otol 2004;118:612–16CrossRefGoogle ScholarPubMed
39Berrettini, S, Ravecca, F, de Vito, A, Forli, F, Valori, S, Franceschini, SS.Modified Bondy radical mastoidectomy: long-term personal experience. J Laryngol Otol 2004;118:333–7CrossRefGoogle ScholarPubMed
40Kos, MI, Castrillon, R, Montandon, P, Guyot, JP.Anatomic and functional long-term results of canal wall-down mastoidectomy. Ann Otol Rhinol Laryngol 2004;113:872–6CrossRefGoogle ScholarPubMed
41Ramsey, MJ, Merchant, SN, McKenna, MJ.Postauricular periosteal-pericranial flap for mastoid obliteration and canal wall down tympanomastoidectomy. Otol Neurotol 2004;25:873–8CrossRefGoogle ScholarPubMed
42Vartiainen, E.Ten-year results of canal wall down mastoidectomy for acquired cholesteatoma. Auris Nasus Larynx 2000;27:227–9CrossRefGoogle ScholarPubMed
43Castrillon, R, Kos, I, Montandon, P, Guyot, JP.Long-term results of canal wall down mastoidectomy [in French]. Schweiz Med Wochenschr 2000;125:58S–61SGoogle Scholar
44Mills, RP, Padgham, ND.Management of childhood cholesteatoma. J Laryngol Otol 1991;105:343–5CrossRefGoogle ScholarPubMed
45Kronenberg, J, Shapira, Y, Migirov, L.Mastoidectomy reconstruction of the posterior wall and obliteration (MAPRO): preliminary results. Acta Otolaryngol 2012;132:400–3CrossRefGoogle Scholar
46Dornhoffer, JL.Retrograde mastoidectomy. Otolaryngol Clin North Am 2006;39:1115–27CrossRefGoogle ScholarPubMed
47El Sharkawy, A, Mekbel, K, Emam, H, Abdel Razek, M.The use of cartilage and pedicles perichondrial flap for primary reconstruction of posterior canal wall. EJENTAS 2010;10:75–8Google Scholar
48Zhang, ZG, Liu, X, Chen, SJ, Chen, B, Zheng, YQ.Modification of closed tympanoplasty in middle ear cholesteatoma. Chin Med J (Engl) 2010;123:447–51Google ScholarPubMed
49Kang, MK, Ahn, JK, Gu, TW, Han, CS.Epitympanoplasty with mastoid obliteration technique: a long-term study of results. Otolaryngol Head Neck Surg 2009;140:687–91CrossRefGoogle ScholarPubMed
50Abramovich, S, Hannan, SA, Huins, CT, Georgalas, C, McGuinness, J, Vats, A, Thompson, I.Prospective cohort comparison of bioactive glass implants and conchal cartilage in reconstruction of the posterior canal wall during tympanomastoidectomy. Clin Otolaryngol 2008;33:553–9CrossRefGoogle ScholarPubMed
51Uzun, C, Yagiz, R, Tas, A, Adali, MK, Koten, M, Karasalihoglu, AR.Combined Heermann and Tos (CHAT) technique in cholesteatoma surgery: surgical technique and preliminary results. J Laryngol Otol 2005;119:429–35CrossRefGoogle ScholarPubMed
52Ikeda, M, Yoshida, S, Ikui, A, Shigihara, S.Canal wall down tympanoplasty with canal reconstruction for middle-ear cholesteatoma: post-operative hearing, cholesteatoma recurrence, and status of re-aeration of reconstructed middle-ear cavity. J Laryngol Otol 2003;117:249–55CrossRefGoogle ScholarPubMed
53Paparella, MM, Jung, TT.Intact bridge tympanomastoidectomy (I.B.M.) – combining essential features of open vs closed procedures. J Laryngol Otol 1983;97:579–85CrossRefGoogle ScholarPubMed
54Hatano, M, Ito, M, Yoshizaki, T.Retrograde mastoidectomy on demand with soft-wall reconstruction in pediatric cholesteatoma. Acta Otolaryngol 2010;130:1113–18CrossRefGoogle ScholarPubMed
55Haginomori, S, Takamaki, A, Nonaka, R, Takenaka, H.Residual cholesteatoma: incidence and localization in canal wall down tympanoplasty with soft-wall reconstruction. Arch Otolaryngol Head Neck Surg 2008;134:652–7CrossRefGoogle ScholarPubMed
56Della Santina, CC, Lee, SC.Ceravital reconstruction of canal wall down mastoidectomy: long-term results. Arch Otolaryngol Head Neck Surg 2006;132:617–23CrossRefGoogle ScholarPubMed
57Cho, SW, Cho, YB, Cho, HH.Mastoid obliteration with silicone blocks after canal wall down mastoidectomy. Clin Exp Otorhinolaryngol 2012;5:23–7CrossRefGoogle ScholarPubMed
58Lee, WS, Kim, SH, Lee, WS, Kim, SH, Moon, IS, Byeon, HK.Canal wall reconstruction and mastoid obliteration in canal wall down tympanomastoidectomized patients. Acta Otolaryngol 2009 Sep;129:955–61CrossRefGoogle ScholarPubMed
59Takahashi, H, Iwanaga, T, Kaieda, S, Fukuda, T, Kumagami, H, Takasaki, K et al. Mastoid obliteration combined with soft-wall reconstruction of posterior ear canal. Eur Arch Otorhinolaryngol 2007;264:867–71CrossRefGoogle ScholarPubMed
60Leonetti, JP, Marzo, SJ, Beauchamp, MM, Jellish, WS.Long-term results with operated sinus tympani retraction cholesteatoma. Otolaryngol Head Neck Surg 2006;135:152–4CrossRefGoogle ScholarPubMed
61Gantz, BJ, Wilkinson, EP, Hansen, MR.Canal wall reconstruction tympanomastoidectomy with mastoid obliteration. Laryngoscope 2005;115:1734–40CrossRefGoogle ScholarPubMed
62Lee, WS, Choi, JY, Song, MH, Son, EJ, Jung, SH, Kim, SH.Mastoid and epitympanic obliteration in canal wall up mastoidectomy for prevention of retraction pocket. Otol Neurotol 2005;26:1107–11CrossRefGoogle ScholarPubMed
63Dornhoffer, JL.Retrograde mastoidectomy with canal wall reconstruction: a single-stage technique for cholesteatoma removal. Ann Otol Rhinol Laryngol 2000;109:1033–9CrossRefGoogle ScholarPubMed
64Tomlin, J, Chang, D, McCutcheon, B, Harris, J.Surgical technique and recurrence in cholesteatoma: a meta-analysis. Audiol Neurootol 2013;18:135–42CrossRefGoogle ScholarPubMed
Figure 0

Table I Outcomes of all three surgical techniques in four retrospective studies

Figure 1

Table II Outcomes of 22 studies comparing two different surgical techniques

Figure 2

Table III Level of evidence 2 for closed mastoid surgery

Figure 3

Table IV Level of evidence 2 for open mastoid surgery

Figure 4

Table V Level of evidence 2 for repair or reconstruction surgery

Figure 5

Table VI Outcomes after mastoid surgery