[Middle ear cholesteatoma surgery].

UNLABELLED: To verify the efficiency of surgical techniques used by the senior author in cholesteatoma surgery, 1,048 cases operated on between 1966 and 1997 are reviewed: 739 in adults and 309 in children. In adults, the majority of cases were between 16 and 40 (64.5%) without difference between both sexes. On the contrary in children, boys were 200 and girls 109; 30 cases were less than 4. In adults only 312 cases were operated on first hand, instead in children almost all cases were operated on first hand (273 cases). The beginning of the cholesteatoma was usually the Shrapnell membrane in adults (58%) while in children the postero-superior region was as common as the Shrapnell membrane (34% 35%); the cholesteatoma was congenital in 13% of cases. Surgical techniques: Mostly two techniques were used: closed technique in two stages and obliteration technique in one or two stages. The closed technique requires remodeling of the postero-superior region of the bony canal, performing a correct posterior tympanotomy, placing a silastic sheeting in all the middle ear to prevent fibrosis and finally rebuilding all the bony defects and a large part of the tympanic membrane with thin cartilage with its perichondrium. The second stage is performed 18 months later in children, 24 months in adults. The ossiculoplasty is often performed at the first stage if the stapes arch is intact and safe. The obliteration technique requires also a precise removal of the lesions, a lowering of the facial ridge, the rebuilding of the tympanic membrane with fascia and the posterior cavities obliteration with Palva flap and free connective grafts. If the tympanic and posterior cavities are reasonably safe, and if the stapes arch is intact, one stage is performed. Otherwise a second stage is performed usually 18 months later, ossiculoplasty only or combined with a second look of posterior cavities under the flap.

RESULTS: Residual cholesteatoma was noticed in adults in 16% of first hand closed technique and 19% of second hand closed technique. It is only of 7% in first hand obliteration technique and 13% in second hand obliteration technique. It was 16% in radical cavity reconstruction. Retraction pocket was almost only observed in closed technique. In adults, an early retraction pocket was observed in 3.5% of cases and in children 12.5% of cases at the moment of the second stage. A larger cartilage more precisely fixed with fibrin glue seems to have almost suppressed the early retraction pocket. Some late retraction pockets nevertheless appeared: 6 cases in adults over 394 and 5 cases in children over 236. Hearing results in adult were the best with first hand closed technique 84% of good results if the stapes was intact and 51% if the crura were missing. If the closed technique was performed second hand, these results were only 57% if the stapes was intact and 29% if the crura were missing. For the obliteration technique these results are for the first hand 70% of good result if the stapes was intact and 60% if the crura were missing, for the second hand, only 36% if the stapes was intact and 39% if the crura were missing. In radical cavity reconstruction 63% of good results were achieved when the stapes was intact and 48% if the crura were missing. The good result is an air-bone gap between 0 and 20 dB for the three frequencies 0.5, 1 and 2 kHz.