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Middle Ear Cholesteatoma: Surgical Treatment, Follow-up and Hearing Restoration
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Otolaryngology and Head and Neck Surgery.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Although middle-ear cholesteatoma is a major topic in otological research, its etiology and pathogenesis remain unclear. Pediatric cholesteatoma is considered more aggressive than adult cholesteatoma, as it has a higher rate of growth, is more often infected and exhibits wider extension. Higher incidence of residual and recurrent disease after surgical treatment of pediatric cholesteatoma has been observed in most studies. In this study, the results are presented from a canal wall down (CWD) obliteration technique used in 330 adult patients (Paper I) with cholesteatoma, evaluated at 1, 3 and 6 years following surgery. Additionally, results are offered from 57 pediatric patients (Paper II) using identical surgical technique and compared with adults. The surgical and hearing outcomes in both groups showed a low incidence of residual and recurrent disease and a high rate of ear water resistance without infection. The results were unrelated to the severity and extension of disease, as well as to age and previous surgery. No differences were found in outcomes between adult and pediatric cholesteatoma patients.

The thesis also describes the use of diffusion-weighted magnetic resonance imaging (DW-MRI) (Paper III) in follow-up examinations of adult cholesteatoma patients undergoing surgical treatment. Non-echo planar diffusion-weighted imaging (Non-EPI DW-MRI)increased the accuracy of clinical examinations. It is concluded that the use of non-EPI DW-MRI should be mandatory in clinical follow-ups after cholesteatoma surgery. In Paper IV a relatively new mode of hearing rehabilitation was investigated, with an active middle ear implant (AMEI), in patients with chronically disabled ears. Functional hearing results were compared with the previous use of conventional hearing aids before and after AMEI implantation. Moreover, the consequences of positioning of the implant in the middle ear were evaluated using cone beam computed tomography (CBCT), a modification of conventional computed tomography. The hearing results, assessed with AMEI, were found to be less dependent on the precise positioning of the floating mass transducer(FMT) against the round window membrane (RWM) than was anticipated. Further, the hearing results were noted to be comparable with those with conventional hearing aids and even superior at high frequencies.

 

 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. , 48 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 905
National Category
Medical and Health Sciences
Research subject
Oto-Rhino-Laryngology
Identifiers
URN: urn:nbn:se:uu:diva-198121ISBN: 978-91-554-8672-3 (print)OAI: oai:DiVA.org:uu-198121DiVA: diva2:615659
Public defence
2013-06-12, Enghoffsalen, ingång 50, Akademiska Sjukhuset, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2013-05-22 Created: 2013-04-09 Last updated: 2013-08-30Bibliographically approved
List of papers
1. Surgical treatment of adult cholesteatoma: long-term follow-up using total reconstruction procedure without staging
Open this publication in new window or tab >>Surgical treatment of adult cholesteatoma: long-term follow-up using total reconstruction procedure without staging
2013 (English)In: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 133, no 1, 28-34 p.Article in journal (Refereed) Published
Abstract [en]

Conclusions:

A total of 330 cases of adult cholesteatoma were operated with canal-wall down (CWD) and total reconstruction procedure (TRP) without staging. Independent of preoperative middle ear conditions, cholesteatoma extent and localization, long-term improvement of hearing with a low incidence of residual and recurrent disease were achieved.

Objectives:

To evaluate long-term surgical and hearing results using a well-defined surgical technique without staging in adult cholesteatoma.

Methods:

The same CWD surgical technique, including obliteration of the mastoid cavity, reconstruction of the canal wall, and ossiculoplasty with autologous bone, was used by three senior surgeons (1982-2004). Preoperative and postoperative pure tone average (PTA) for air conduction (AC), bone conduction (BC), and air-bone gap (ABG) were assessed and compared 1, 3, and 6 years after surgery. Various prognostic factors with potential influence on long-term hearing outcome were evaluated.

Results:

Recurrence of AC occurred in 10%, residual disease in 3%. Six years after surgery all patients except one had a dry ear and over 92% of all cases were water resistant. Three patients developed complete deafness. Long-lasting improvement and/or preservation of hearing, with maintenance of PTA-ABG closure in 68% of all cases within 20 dB, were obtained. Sixty-four (19%) ossicular revisions were performed.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-188875 (URN)10.3109/00016489.2012.707333 (DOI)000312525800004 ()23113656 (PubMedID)
Available from: 2012-12-20 Created: 2012-12-20 Last updated: 2017-12-06Bibliographically approved
2. Surgical treatment of paediatric cholesteatoma: Long-term follow up in comparison with adults
Open this publication in new window or tab >>Surgical treatment of paediatric cholesteatoma: Long-term follow up in comparison with adults
Show others...
2012 (English)In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 76, no 8, 1091-1097 p.Article in journal (Refereed) Published
Abstract [en]

Objective: This study was designed to analyse long-term results after surgery of acquired (ACH) and congenital cholesteatoma (CCH) of the middle ear in children and compare these with adults.

Methods: Computer-based analysis of consecutively operated paediatric patients for ACH and CCH in a tertiary referral centre was made in 57 cases under the age of 12 operated 1983-2004 by three surgeons using identical technique. A canal wall down and total reconstruction procedure (TRP) with obliteration of the mastoid cavity, canal wall reconstruction, ossiculoplasty with consistent use of autologous bone and an "aeration enhancement procedure" (AEP) with silicon sheet in selected cases were used. Pre- and post-operative PTA (0.5-3 kHz) and pure-tone average air-bone gap (PTA-ABG) together with surgical parameters were assessed 1, 3 and 6 years following surgery.

Results: Results showed stable hearing over 6 years with low incidence of persistent and recurrent disease comparable with results from adult patients. In nearly half of the cases, silastic sheeting was used. In 21 cases, stapes was eroded. Bone conduction thresholds levels remained unaffected 6 years after surgery. No deaf ears, postoperative facial dysfunction or other lesions related to surgery were observed. Six years after surgery every evaluated ear was found to be water-resistant and infection-free.

Conclusion: Our results suggest that one-stage eradication of ACH and CCH in children using total reconstruction procedure (TRP) provide long-term improvement or preservation of hearing, with a low incidence of persistent or recurrent disease. No difference in surgical outcome between children and adults was found.

Keyword
Cholesteatoma surgery, Children, Silastic sheeting, Hearing results, Surgical results, Staging, Long-time follow-up
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-179557 (URN)10.1016/j.ijporl.2012.04.006 (DOI)000306449300005 ()
Available from: 2012-08-20 Created: 2012-08-20 Last updated: 2017-12-07Bibliographically approved
3. Non-echo planar diffusion-weighted MRI increases follow-up accuracy after one-step step canal wall-down obliteration surgery for cholesteatoma
Open this publication in new window or tab >>Non-echo planar diffusion-weighted MRI increases follow-up accuracy after one-step step canal wall-down obliteration surgery for cholesteatoma
Show others...
2013 (English)In: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 133, no 6, 574-583 p.Article in journal (Refereed) Published
Abstract [en]

Conclusion:

Non-echo planar (non-EPI) diffusion-weighted (DW) magnetic resonance imaging (MRI) increases the number of detected cholesteatoma after one-step canal-wall down (CWD) obliteration surgery for cholesteatoma compared with clinical evaluation alone.

Objective:

To evaluate the use of DW-MRI for detection of cholesteatoma after surgical treatment using CWD obliteration technique.

Methods:

Thirty-eight adult patients (41 ears) treated with identical one-step canal-wall down obliteration surgical technique were included in a prospective and blinded study. All patients were investigated with non-EPI and EPI DW-MRI 1-9 months after the clinical examination. Follow-up time after primary surgery varied between 10 and 234 months. DW-MRI were assessed by two neuroradiologists and compared with clinical results. Inter-rater agreement was calculated. Positive non-EPI DW-MRI cases underwent revision surgery within 18-159 days after imaging.

Results:

Out of 41 cases seven were evaluated as positive for cholesteatoma on non-EPI DW-MRI. Since one patient refused surgery six of these seven cases underwent surgical revision and all were verified. There was agreement between clinical and non-EPI findings in five of eight cases. EPI findings correlated poorly with non-EPI and clinical findings. Inter-rater agreement (Cohen´s kappa) was 0.91 for non-EPIDW-MRI (p<0.001) and -0.062 for EPI DW-MRI (p=0.43)

 

National Category
Neurology
Identifiers
urn:nbn:se:uu:diva-198119 (URN)10.3109/00016489.2012.762118 (DOI)000319011800003 ()23675808 (PubMedID)
Available from: 2013-04-09 Created: 2013-04-09 Last updated: 2017-12-06Bibliographically approved
4. Round window vibroplasty in chronic ear surgery: Comparison with conventional hearing rehabilitation
Open this publication in new window or tab >>Round window vibroplasty in chronic ear surgery: Comparison with conventional hearing rehabilitation
2013 (English)In: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 138, no 8, 814-825 p.Article in journal (Refereed) Published
Abstract [en]

Conclusion:

Functional hearing results with round window vibroplasty in chronically disabled middle ears were comparable and, at high frequencies, superior to the results achieved with previously used conventional hearing aids even after extended surgery. Soft tissue transfer appears to be more important than floating mass transducer (FMT) alignment with the round window membrane (RWM) for efficient coupling or sonoinversion.

Objectives:

To evaluate the functional hearing results of an active middle ear implant (AMEI) to the round window niche (RWN). The results were compared with previously used conventional hearing aids. The position of the FMT was determined by cone-beam computed tomography (CBCT).

Study design:

Prospective cohort study

Setting:

Tertiary referral center

Material and Methods:

Seven patients with severe middle ear disease were implanted with an AMEI with round window application. The postoperative hearing outcome was compared with preoperative hearing using unaided and conventionally aided conditions. The results were correlated with the physical/geometric relation of the FMT to the RWM as determined with CBCT.

Results:

Dislocation of the FMT was not observed. One patient was re-implanted due to accidental damage to the electrode. In all patients, the pertinent functional hearing results were achieved and were comparable to previous rehabilitation results.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-198120 (URN)10.3109/00016489.2013.780294 (DOI)000321791700004 ()
Available from: 2013-04-09 Created: 2013-04-09 Last updated: 2017-12-06Bibliographically approved

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