|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 2 | Page : 92-93
An oblivious cholesteatoma
Arvind Kumar Kairo, Kapil Sikka, Rakesh Kumar, Krishan Kudawla
Departments of ENT and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||3-May-2014|
Department of ENT and Head and Neck Surgery, Room No. 4057, ENT Office, Teaching Block, Ansari Nagar, New Delhi - 111 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kairo AK, Sikka K, Kumar R, Kudawla K. An oblivious cholesteatoma. Indian J Otol 2014;20:92-3
We are reporting an interesting and unusual case of primary acquired cholesteatoma of epitympanum. This case is about the unusual pattern of spread, which defies the usual well documented pathway of cholesteatoma spread. Cholesteatoma tends to follow embryological planes that were formed during development of middle ear cleft.
According to embryological bases of temporal bone pneumatization, tympanic cavity gets pneumatized by different out pouching which are formed as extension of first pharyngeal pouch  [Figure 1]. When saccus superior (squamous) and saccus medius (petrous) pneumatizes, the bony plate left between these two developing saccus is called Korner's septum (petrosquamous lamina). 
|Figure 1: Embryologically, tympanic cavity gets pneumatised by different out pouching which are formed as extension of first pharyngeal pouch 1. Chart to show the fate of these different out pouching (saccus)|
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Most acquired cholesteatoma are formed by invagination of the pars flaccida into the lateral most portion of the epitympanum (The Prussak's space). Their spread is limited by these mucosal folds around the ossicles. These folds along with suspensory ligaments guide the cholesteatoma sac into the recesses of the epitympanum which are formed by saccus medius. Posteriorly it may spread lateral to the body of the incus (superior incudal space), inferiorly into the middle ear through pouch of von Troltsch or anteriorly into the protympanum.
A 17-year-old male patient presented to our out-patient department with the complaints of right sided impairment of hearing since early childhood without any significant ear discharge. On evaluation, patient was having bulge in posterior canal wall. Audiometry revealed moderate conductive hearing loss in right ear. High resolution computerized tomography temporal bone revealed a peculiar finding. The cholesteatoma sac arising from Prussak's space was filling an enlarged cell lateral to Korner's septum. Mastoid antrum was normal [Figure 2]a and b. Patient underwent canal wall down outside in modified radical mastoidectomy. During surgery cholesteatoma sac arising from Prussak's space was found which was not spreading toward antrum (along superior incudal space) but involved air cells lateral to Koerner's septum  [Figure 2]a and b. As it is arising from Prussak's space, by convention, it spreads via posterior route, where cholesteatoma sac spreads through the superior incudal space lateral to the body of incus and then it reaches the aditus and antum, thereby gaining access to mastoid [Figure 3]. In this case, the cholesteatoma spread is unusual.
|Figure 2: (a) Axial view of high resolution temporal bone computerized tomography scan of patient. (1) Koerner's septum, (2) cholesteatoma sac, (3) ossicular chain in epitympanum, (4) antrum, (5) horizontal part of facial nerve (b) Axial view of high resolution temporal bone computerized tomography scan of patient. (1) Cholesteatoma sac, (2) head of Malleus in epitympanum, (3) horizontal part of facial nerve|
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|Figure 3: Intraoperative photograph of middle ear cleft with intact Koerner's septum and cholesteatoma sac (lateral wall of sac removed). (1) Posterior pouch of von Troltsch, (2) pars tensa, (3) head of Malleus in epitympanum, (4) horizontal part of facial nerve, (5) Koerner's septum|
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Post-operatively, the patient's recovery was uneventful.
| References|| |
|1.||Hammar YES. Study Concerning the development of the Vonderdarma and some ranger forming organs. Arch Anat Mikrosk 1902; 59:471-628. |
|2.||Proctor B. The development of the middle ear spaces and their surgical significance. J Laryngol Otol 1964;78:631-48. |
|3.||Proctor B. Surgical Anatomy of the Ear and Temporal Bone. New York: Thieme Medical Publishers; 1989. p. 66-84. |
[Figure 1], [Figure 2], [Figure 3]