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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 27  |  Issue : 3  |  Page : 163-167

Posterior canal wall reconstruction in squamosal type of chronic otitis media: One-year follow-up study


Department of ENT, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Date of Submission29-Aug-2020
Date of Decision05-Sep-2020
Date of Acceptance21-Sep-2020
Date of Web Publication16-Dec-2021

Correspondence Address:
Dr. Abhinav Srivastava
Department of ENT, Rohilkhand Medical College and Hospital, Pilibhit Bypass Road, Bareilly - 243 006, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_192_20

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  Abstract 


Introduction: The removal of Cholesteatoma remains a matter of debate with varying opinion, but the primary objectives remain complete eradication of the disease and creation of a safe ear. Restoration of hearing is secondary objective. Reconstruction of posterior canal wall can be attempted after complete removal of cholesteatoma with different materials. Aim and Objectives: The aim of the study was to study the outcome of posterior canal wall reconstruction in patients undergoing modified radical mastoidectomy. Materials and Methods: This prospective interventional cross-sectional study has been done on forty patients in the department of otorhinolaryngology and head-neck surgery, in a tertiary care hospital in Western Uttar Pradesh with an enrolment period of 1 year and a minimum of 1-year follow-up. Results: In the present study, the success rate of canal reconstruction was 85%. The most common site of middle ear cleft which was found to be mostly affected by cholesteatoma was aditus in 94.12%, followed by posterior attic, middle ear, and sinus tympani accounting for 91.18%, 82.35%, and 79.41%, respectively. Incus was found to be the most common ear ossicle affected. A statistically significant result was found in the pre- and post-operative average hearing loss and air-bone gap. Conclusion: Canal reconstruction in patients undergoing canal wall down mastoidectomy is a good option in patients presenting with limited disease of squamosal type of chronic otitis media. A candidacy criterion has been proposed for deciding patients in whom canal reconstruction can be tried.

Keywords: Cholesteatoma, conchal cartilage, mastoidectomy, posterior canal reconstruction


How to cite this article:
Srivastava A, Mohan C. Posterior canal wall reconstruction in squamosal type of chronic otitis media: One-year follow-up study. Indian J Otol 2021;27:163-7

How to cite this URL:
Srivastava A, Mohan C. Posterior canal wall reconstruction in squamosal type of chronic otitis media: One-year follow-up study. Indian J Otol [serial online] 2021 [cited 2022 Jan 18];27:163-7. Available from: https://www.indianjotol.org/text.asp?2021/27/3/163/332649




  Introduction Top


The removal of cholesteatoma with canal wall reconstruction is always a matter of debate. Improved instrumentation has given an opportunity to consider the reconstruction. However, the primary objectives remain complete eradication of the disease and creation of a safe ear. Restoration of hearing is secondary objective. With the advancement in microscopic surgery, additional focus is being given to the reconstruction of middle ear and restoring the morphology of external auditory canal, thereby improving the quality of life. It is still a matter of debate whether posterior canal wall should be reconstructed or not.[1]

The limitation of the original intact canal wall technique, which includes posterior transmastoid facial recess approach with posterior thinning of the canal wall has been reported by various authors but has been associated with varying success rates and so not being practiced frequently. Canal wall down or open technique has been associated with low disease recurrence but less optimal functional results along with lack of self-cleaning mechanism. Canal wall up mastoidectomy offers a more physiologic approach, as it preserves anatomic structures.

In canal wall up mastoidectomy, posterior wall of external auditory canal makes exposure of some anatomic structures difficult, particularly sinus tympani and facial recess, as a result complete removal of the cholesteatoma becomes difficult and causes high recurrence rate. The recurrence rate has been reported up to 20%.[2]

Reconstruction of posterior canal wall can be attempted after complete removal of cholesteatoma with different materials. The bony defect can be reconstructed with cortical bone, bone pette, cartilage, bone cement, and glass ionomer.[3],[4]

The present study has been done with the following aim and objectives.

Aim and objectives

Aim

The aim of the study was to study the outcome of posterior canal wall reconstruction in patients undergoing modified radical mastoidectomy (MRM) in terms of hearing and integrity of reconstructed posterior canal wall and tympanic membrane.

Objectives

  • To evaluate hearing status at 3rd-month postoperative
  • To study the incidence of recurrence of cholesteatoma at 1 year
  • To see the integrity of grafted tympanic membrane at 1 year.



  Materials and Methods Top


This prospective interventional cross-sectional study has been done in the department of otorhinolaryngology and head-neck surgery, in a tertiary care hospital in Western Uttar Pradesh with an enrollment period of 1 year and a minimum of 1-year follow-up.

A total of forty clinically diagnosed cases of squamosal type of chronic otitis media (COM) were enrolled in the study who fulfilled the laid selection criteria.

Inclusion criteria

All cases undergoing reconstruction of posterior canal wall, fulfilling following criteria:

  1. Age above 18 years
  2. Willing to participate in the study
  3. Disease is limited to Attic, antrum, sinodural angle, and middle ear.


Exclusion criteria

  1. Age <18 years
  2. Not willing to participate in the study
  3. Revision mastoid surgery
  4. Invasive and extensive cholesteatoma
  5. Patients presenting with otogenic complications.


Intervention/procedure

All the clinically diagnosed cases of COM with squamosal disease underwent canal wall down MRM and in cases where disease was limited as laid down in inclusion criteria underwent canal wall reconstruction with sliced cartilage. Superficial temporalis fascia was used as graft material for reconstructing tympanic membrane in all the cases.

Surgical technique

All the patients underwent surgery under general anesthesia by postaural approach. Tympanomeatal flap was raised, and after that survey of the attic, middle ear done to know the extent of disease and status of ear ossicles. It was followed by cortical mastoidectomy. Atticotomy was done and aditus widened. Partial canal was made lowered to a varying extent depending on the visualization of the cholesteatoma completely and when satisfied by clearance of the disease from the middle ear and mastoid, reconstruction of the posterior canal along with ossiculoplasty, and repair of tympanic membrane is planned. The posterior canal is reconstructed with sliced conchal cartilage as its curvature resembles exactly the shape of posterior canal wall; it is stabilized by making groove in the superior and inferior bone which corresponds to the bone in the attic and mastoid, respectively [Figure 1] and [Figure 2]. The tympanic membrane is reconstructed with superficial temporalis fascia as graft material.
Figure 1: Figure showing superior and inferior groove for stabilization of sliced cartilage

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Figure 2: Photograph showing method of reconstruction of posterior canal wall using sliced chonchal cartilage

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Statistical analysis

The data were entered in a Pro forma generated by Epi Info version 7.0 from February 1, 2018, to January 31, 2019. The result was statistically analyzed using the software provided with Epi Info. The analysis has been done by applying frequency, percentage, mean, and standard deviation. Paired t-test has been applied for quantitative assessment of pre- and post-operative hearing loss.


  Observations Top


A total of forty ears were enrolled in the study, excluding all the dropouts who did not come for 12-month follow-up. In 1-year follow-up, there were six cases who underwent canal wall down surgery but as ear was not getting dry despite medical treatment, they underwent revision surgery, out of which four cases presented had recurrence of cholesteatoma, and remaining two cases had infected retraction pocket.

In the present study, success rate of canal reconstruction was 85%. Further analysis of outcome was done in the remaining 34 cases who presented with no recurrence [Table 1].
Table 1: Demography of the study

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The mean age of presentation was 24.5 ± 9.4 years, with 13 and 56 years as a minimum and maximum age of surgery in the study with 61.76% female [Table 1].

The most common site of middle ear cleft which was found to be mostly affected by cholesteatoma was aditus in 94.12%, followed by posterior attic, middle ear, and sinus tympani accounting for 91.18%, 82.35%, and 79.41%, respectively. Other sites of middle ear cleft which were affected were anterior attic (61.76%), antrum (52.94%), and sinodural angle (20.59%). None of the cases had involvement of digastric ridge or tip cells [Table 2].
Table 2: Extent of disease

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Incus was found to be the most common ear ossicle affected in 76.47%, followed by malleus in 46.06% and stapes with 29.41% [Table 3].
Table 3: Condition of ossicles

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Preoperatively, conductive and mixed hearing loss was found to be in 31 (91.18%) and 3 cases (8.82%), respectively. Postoperatively, in four cases (11.77%), hearing became normal while 27 cases (79.41%) still had varying level of conductive hearing loss. Three cases (8.82%) still had mixed hearing loss, respectively [Table 4].
Table 4: Type of hearing loss

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Average hearing loss in pre- and post-operative period was 51.47 ± 12.16 dB and 44.12 ± 15.02 dB, respectively, and it was found to be statistically significant. A statistically significant result was also found in terms of pre- and post-operative air bone gap (AB gap) with pre- and post-operative value of 29.85 ± 8.75 dB and 24.59 ± 10.94 dB, respectively [Table 5].
Table 5: Assessment of hearing loss

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Postoperatively, in all the cases, reconstructed posterior canal wall was well maintained, whereas reconstructed tympanic membrane with superficial temporalis fascia was found to be intact in 23 cases (67.64%); in rest of the 11 cases (32.36%), there was residual perforation of varying extend.

When the average hearing loss and AB gap were compared in the pre- and post-operative period then the hearing improvement was found to be significantly higher in patients with intact superficial temporalis fascia graft, whereas the same was not statistically significant in patients presenting with residual perforation in the postoperative period [Table 6] and [Table 7].
Table 6: Average hearing loss and graft condition

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Table 7: Air bone gap and graft condition

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  Discussion Top


Our study has found average age of patient to be 38 years with 61.76% were females and found our result in accordance with study done by Blanco et al.,[5] their study has found similar presentation with 32 years as the average age of patient and 60% females, whereas Cho et al.[6] have found 65% and 35% as male and female, respectively.

Failure rate of our study in terms of recurrence of cholesteatoma was 15%. The studies done by Wilson et al.[7] and Haginomori et al.[8] found recurrence rate to be 35% and 21%, respectively, on second look surgery, whereas Liu[9] found 3.2% as the rate of recurrence, Walker et al.[10] found 12% as the rate of recurrence. Wilson et al.[7] performed canal wall down in 4.1% of cases of recurrences, whereas in our study, we performed a complete canal wall down surgery in cases with recurrences because of anxiety and economic issues associated in these cases in undergoing second look with canal reconstruction.

Studies done by Wilson et al.[7] also found attic and middle ear as the most common affected site followed by mastoid. However, our study differs from their study in terms of involvement of sinus tympani, they found it involved in 26.3%, and in our study, it was 79.41%. Attic involvement as the most common site can be attributed due to the well-known fact of origin of cholesteatoma in the Prussak's space.

Study done by Mohammadi et al.[11] found incus as the most common affected ossicle followed by stapes and malleus. In our study also, the incus was found to be the most common affected ear ossicle, but malleus was next in sequence and stapes was found to be least affected. Most probable reason may be most cases presented with disease in attic and aditus region in this study.

In the study, some patients with conductive hearing loss has improved to normal, but patients with mixed hearing loss though quantitative improvement was there, but category of hearing loss was still mixed, the rationale of canal reconstruction in these cases was the ease of possible use of hearing aids in the future by maintaining canal architecture.

Average preoperative hearing loss and AB gap of 51.47 ± 12.16 dB and 29.85 ± 8.75 dB, respectively, can be attributed to involvement of the middle ear in 82.35% and sinus tympani in 79.41%, thereby causing variable destruction of incus in 76.47%, malleus in 46.06%, and stapes in 29.41%. There was a statistically significant improvement in the postoperative hearing status. Studies done by Baek et al.[12] and Mahadevaiah and Parikh[13] also found a statistically significant improvement in hearing after canal reconstruction.

Blanco et al.[5] found residual perforation in nine cases (20%) at 12-month follow–up; our study has got slightly higher incidence of residual perforation in 11 cases (32.36%), and this might be due to variable rate of healing in different patients; however, its effect on hearing was not found to be statistically significant.

One case out of 34 (2.94%) had intact ossicle continuity; the probable reason could be the presence of cholesteatoma in the attic region only. Mohammadi et al.[10] found completely intact ossicle in 5.5% of cases of cholesteatoma.

A candidacy criterion is proposed here for patients selected for reconstructing posterior canal wall who undergo canal wall down mastoidectomy for squamosal disease (disease means squamosal pathology in the form of cholesteatoma, retraction pocket, granulation tissue, or combination of these):

Disease factors

  1. Limited disease: Disease should be confined to attic, antrum, middle ear, sinodural angle with the absence of any dural or sinus breach
  2. Posterior canal wall should not be involved by disease causing erosion
  3. Absence of otogenic complications
  4. Absence of gross osteitis
  5. Absence of involvement of digastric and tip cells.


Patient factors

  1. Patient ready for weekly follow-up in initial 2 month and monthly follow-up for a year and 6 monthly for the next 3 years
  2. Surgeon's satisfaction about disease clearance
  3. Patient must be explained about the possibility of canal reconstruction which will be decided only intraoperatively after assessing the extent and nature of disease
  4. Patient must be explained about the possibility of recurrence and need for regular follow-up.



  Conclusion Top


In the modern era, with advancement in surgical tool and technique along with improvement in health-care awareness and early presentation of ear diseases, the changing trend is limited disease in middle ear cleft. Hence, canal reconstruction in patients undergoing canal wall down mastoidectomy is a good option, as it maintains the ear canal contour, eliminates long-term cavity problem, and provides better hearing gain. Furthermore, in cases with mixed hearing loss, use of hearing aid continues to be an option. One concern of disease recurrence on long-term follow-up is still there and is the scope of future research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Heo KW, Kang MK, Park JY. Alternative to canal wall-down mastoidectomy for sclerotic mastoid cavities: Epitympanoplasty with mastoid obliteration. Ann Otol Rhinol Laryngol 2014;123:47-52.  Back to cited text no. 1
    
2.
Dornhoffer JL. Retrograde mastoidectomy with canal wall reconstruction: A single-stage technique for cholesteatoma removal. Ann Otol Rhinol Laryngol 2000;109:1033-9.  Back to cited text no. 2
    
3.
Yu Z, Yang B, Wang Z, Han D, Zhang L. Reconstruction of lateral attic wall using autogenous mastoid cortical bone. Am J Otolaryngol 2011;32:361-5.  Back to cited text no. 3
    
4.
Zanetti D, Nassif N, Antonelli AR. Surgical repair of bone defects of the ear canal wall with flexible hydroxylapatite sheets: A pilot study. Otol Neurotol 2001;22:745-53.  Back to cited text no. 4
    
5.
Blanco P, González F, Holguín J, Guerra C. Surgical management of middle ear cholesteatoma and reconstruction at the same time. Colomb Med (Cali) 2014;45:127-31.  Back to cited text no. 5
    
6.
Cho YS, Hong SD, Chung KW, Hong SH, Chung WH, Park SH. Revision surgery for chronic otitis media: Characteristics and outcomes in comparison with primary surgery. Auris Nasus Larynx 2010;37:18-22.  Back to cited text no. 6
    
7.
Wilson KF, Hoggan RN, Shelton C. Tympanoplasty with intact canal wall mastoidectomy for cholesteatoma: Long-term surgical outcomes. Otolaryngol Head Neck Surg 2013;149:292-5.  Back to cited text no. 7
    
8.
Haginomori 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;134:652-7.  Back to cited text no. 8
    
9.
Liu W. Canal wall reconstruction mastoidectomy. J Otol 2007;2:52-5.  Back to cited text no. 9
    
10.
Walker PC, Mowry SE, Hansen MR, Gantz BJ. Long-term results of canal wall reconstruction tympanomastoidectomy. Otol Neurotol 2014;35:e24-30.  Back to cited text no. 10
    
11.
Mohammadi G, Naderpour M, Mousaviagdas M. Ossicular erosion in patients requiring surgery for cholesteatoma. Iran J Otorhinolaryngol 2012;24:125-8.  Back to cited text no. 11
    
12.
Baek MK, Choi SH, Kim DY, Cho CH, Kim YW, Moon KH, et al. Efficacy of posterior canal wall reconstruction using autologous auricular cartilage and bone pâté in chronic otitis media with cholesteatoma. J Int Adv Otol 2016;12:247-51.  Back to cited text no. 12
    
13.
Mahadevaiah A, Parikh B. Modified intact canal wall mastoidectomy-Long term results in hearing and healing. Indian J Otolaryngol Head Neck Surg 2008;60:317-23.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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