Combined approach tympanoplasty for cholesteatoma: impact of middle-ear endoscopy.

OBJECTIVE: The aims of this study were (1) to explore whether the experience at the Radcliffe Infirmary (Oxford, UK) supported the use of combined approach tympanoplasty for cholesteatoma, by determining the rate of disease at subsequent surgery, and (2) to assess whether this rate differed from findings reported elsewhere in the literature, possibly due to the effect of using an oto-endoscope.

STUDY DESIGN: Retrospective case review, with data entered prospectively for operations performed by a single surgeon.

SETTING: Tertiary referral hospital.

PATIENTS: Between January 1998 and December 2004 inclusive, 66 patients underwent 68 primary procedures, with data available for all 'second looks'.

INTERVENTIONS: Diagnostic and therapeutic operations for cholesteatoma were performed.

MAIN OUTCOME MEASURES: All patients in this study attended follow up and underwent a second look operation, during which the rate of residual and recurrent cholesteatoma was determined. An oto-endoscope was used at all primary and subsequent surgery.

RESULTS: The mean interval between the first and second combined approach tympanoplasty procedures was 16 months, and that between the second and third such procedures was 19 months (10 patients). One patient underwent a fourth combined approach tympanoplasty procedure, 17 months after a third such procedure. The rate of cholesteatoma at second combined approach tympanoplasty was 20.6 per cent (14/68); this was judged to be residual in 10 ears (14.7 per cent) and to be recurrent, with the redevelopment of retraction pockets, in four ears (5.9 per cent). The rate of cholesteatoma at third combined approach tympanoplasty was 20 per cent (two of 10); of these two, one patient had a small pearl in the middle ear removed with the aid of a potassium titanyl phosphate laser. There was no disease present in one patient at a fourth combined approach tympanoplasty. Only four patients required a modified radical mastoidectomy.

CONCLUSION: Cholesteatoma remains a disease with significant morbidity. Endoscope-assisted surgery may decrease the morbidity of second look surgery and may improve the clearance of disease in appropriately selected patients.