1/9/2019 Minimally Invasive Transcanal Removal of Attic Cholesteatoma

Korean Journal of Otorhinolaryngology-Head and Neck Surgery > Volume 60(4); 2017 > Article
Original Article
Otology
Korean J Otorhinolaryngol-Head Neck Surg 2017; 60(4): 158-163.
Published online: April 11, 2017
DOI: https://doi.org/10.3342/kjorl-hns.2016.17027

Minimally Invasive Transcanal Removal of Attic Cholesteatoma

Ji-Eun Choi , Hee Jung Kim , Byung Kil Kim , Il Joon Moon
Department of Otorhinolaryngology-Head & Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of
Medicine, Seoul, Korea

Treatment of epididymal cholesteatoma by minimally invasive endoscopic

approach
Choejieun , Kim, Hee - Jung , gimbyeonggil , muniljun
Department of Otolaryngology, Samsung Medical Center, Sungkyunkwan University School of Medicine

Address for correspondence Il Joon Moon, MD, PhD Department of OtorhinolaryngologyHead & Neck Surgery,
Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351,
Korea
Tel +82-2-3410-3578 Fax +82-2-3410-3879 E-mail iljoon.moon@gmail.com

Received August 13, 2016 Revised December 28, 2016 Accepted January 3, 2017
Copyright © 2017 Korean Society of Otorhinolaryngology-Head and Neck Surgery
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial
License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Abstract Go to :

Background and Objectives

In treating attic cholesteatoma, traditional microscopic approach provides limited exposure to the attic space. Recently,
the use of endoscope has emerged as a new treatment option for attic cholesteatoma. The aim of this study is to report the
preliminary results of transcanal endoscopic removal of attic cholesteatoma and to evaluate the feasibility of endoscopic
approach to attic cholesteatoma.

Subjects and Method

Six patients with attic cholesteatoma were enrolled in this study from Sep 2014 to Oct 2015. Cholesteatoma was removed
via transcanal endoscopic approach. We analyzed the clinical characteristics, surgical management and treatment
outcomes.

Results
All patients had attic cholesteatoma in the epitympanic space with scutum erosion. However, the disease was restricted to
the epitympanic space in three patients, whereas a limited extension of cholesteatoma to the aditus ad antrum was
observed in two patients, and mesotympanum was involved in the remaining one patient. All of the patients suffered from
conductive or mixed hearing loss with mean air-bone gap of 17.4 dB, and underwent endoscopic transcanal removal of
cholesteatoma and scutoplasty. In three patients, the incus and malleus head were removed due to ossicular erosion, and
a second-stage ossicular reconstruction was planned. No residual or recurrent diseases were noted during the follow-up
period (mean: 13 months). No surgical complications were observed postoperatively, and favorable hearing outcome was
obtained in all patients.

Conclusion
Transcanal endoscopic approach was successfully performed in patients with limited attic cholesteatoma. Further studies
involving a large number of patients with long-term follow-ups are necessary to prove the clinical efficacy of transcanal
endoscopic approach in managing limited attic cholesteatoma.

Key words: Attic cholesteatoma ㆍ Endoscope ㆍ Minimally invasive surgery ㆍ Transcanal endoscopic ear surgery

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Introduction Go to :

The cholesteatoma occurring in the middle ear cavity can be divided into congenital cholesteatoma and acquired
cholesteatoma, which is characterized by hyperplasia and hyperpigmentation of the epithelium. In the National Health
and Nutrition Survey conducted in Korea, middle cholesteatoma was found in 1.18% It is a relatively common disease [ 1 ].
Acquired primary cholesteatoma is classified as epitympanum cholesteatoma and mesotympanum cholestocha depending
on the initial position in the tympanic membrane. In this case, the sphincter of the upper chamomile starts from
Prussack's space and extends to the posterior chamber of the upper chamber and to the anterior chamber of the upper
chamber. It is spread through various routes to reach the mastoid through the aditus ad antrum, The patient then
descends to the lower back and reaches the posterior of the second chamber, invading the facial recess and facial recess.
The pathogenesis of acquired cholesteatoma is most common in the posterior chamber of the upper chamber, followed by
the posterior chamber of the posterior chamber and anterior to the superior chamber [ 2 , 3 ]. Endoscopy is advantageous
in that it has a wider field of view unlike conventional microscopes that have a linear field of view, and because it can
utilize various angles of endoscopes, it is convenient to perform surgery while securing the field of view in areas where
there are many square areas such as the middle ear Do. Several studies [ 4 - 9] have reported good outcomes with the use
of endoscopy to perform surgery in the area of the eye.], But the results of treatment with an endoscopic approach to the
epididymal cholesteatoma are rare and not reported in Korea [ 10 ]. The purpose of this study was to evaluate the efficacy
and early treatment results of endoscopic minimally invasive surgery through a clinical review of endoscopic treatment
outcome of the first attempted upper gastrointestinal cholesteatoma in Korea. We aim to provide basic data for expanding
the application area of endoscopic approach in surgery.

Object and method Go to :

In this study, six patients who were diagnosed as having cholangiocarcinoma by a surgeon from September 2014 to
October 2015 and who were removed by endoscopic approach were included in this study. The results were analyzed by
sex, age, physical findings, hearing results, radiologic findings ( Fig. 1 ), treatment results, and postoperative
complications. The purpose of this study was to evaluate the efficacy of endoscopic cholecystectomy in the treatment of
epididymal cholangiocarcinoma with endoscopic computed tomography. And to the hemispheres of the oviductal internal
and external canines, even though they were invaded by the ovarian canal. In addition, cases suspected of invasion into
the papillae of rabbits were excluded from the endoscopic approach.

Fig. 1.
Pre- and postoperative temporal bone computed tomography (CT) of case
1. Preoperative CT showed soft tissue density at epitympanic recess (*) (A
and B). Postoperative CT which was performed 10 months after surgery
showed clean middle ear cavity (C and D).

Surgery was performed under general anesthesia. The patient was placed in the supine position and the head was turned
to the opposite side, and the tympanomeatal flap was elevated via an aortopulmonary approach. Open the labrum and
observe lesions in middle ear and upper eyelid area and remove lesion. If the pearl paper is advanced to the anterior or
anterior part of the superior labrum or is advanced to the mastoid cavity, remove the bony annulus or part of the posterior
upper canal wall using a bone curette or an electric drill. (Instrument Set for Endoscopic Ear Surgery, Karl Storz,
Tuttlingen, Germany; Panetti Endoscopic Instrument Set, Spiggle & Theis, Overath, Germany). In all cases, the use of 0,
30, and 45-degree endoscopes was able to ensure the visual field of the lesion and to remove the granules and
surrounding tissues using the tools described above. In three cases where the pearl paper was attached to the osseous
bone, especially the head of the ankle and the vertebrae, and the erosion of the osseous and vertebrae was suspected, the
osseous osteotomy was removed after the osteotomy - Thereafter, residual lesions in the upper chamber and the distal
tongue of the pylorus were identified using 30 ° and 45 ° endoscopes, and an airway passage was established between the
used thread and upper chamber in front of the tensor tympani tendon.Fig. 2 ). The endoscope used was 0, 30, 45 or 4 mm
or 3 mm endoscopy (Karl Storz) and the light source was LED nova 100 (Karl Storz).

Fig. 2.
Case 1. Operative endoscopic finding during tympanomeatal flap
elevation. Tympanic membrane shows attic area crust (A). After elevation
of a tympanomeatal flap and drilling out scutum, the structures in the
epitympanum are exposed under direct vision. Attic cholesteatoma is
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discovered (B and C). Cholesteatoma was removed and no residual lesion
in epitypanum (D). C: cholesteatoma, M: malleus, I: incus, RW: round
window, Ch: chorda tympani, S: stapes.

result Go to :

The mean age of the patients was 33.8 years, ranging from 23 to 51 years. In the physical examination performed before
surgery, there were 3 cases in which the tympanic membrane was implanted in the upper chamber and 3 cases in which
the penetration was accompanied in the upper chamber. One of these cases was associated with perforation of the
tympanic membrane. The preoperative hearing test showed an average of 17.3 dB between 7.5 and 30 dB. In order to
determine the extent and extent of the lesion, preoperative high-resolution temporal bone computed tomography showed
3 cases in the upper chamber, 2 cases in the aditus ad antrum, 2 cases in the upper chamber, The case was one case. Three
cases of suspected ossicular erosion on radiologic examination were observed. In all cases, surgery was performed under
general anesthesia. After removal of the cholesteatoma after exposing the superior arch to an endocervical approach
under endoscopy, three cases were suspected of involvement of the osopharyngeal bone by observation of the ischial
erosion Table 1 shows the results of the study.). In two cases, which extended to the entrance of the pearl diaphragm, the
end of the pearl sac was confirmed only by removing a little more of the upper and the posterior radiographs. Bone suture
and electric drill were used to remove the upper and lower radial bone sites. Curved suction dissector tools with a large tip
and large tip were very useful for peeling the pearl sac from the coronal wall. After surgery, the pearl paper was
completely removed with a 0 °, 30 °, and 45 ° endoscopy, and the defect site of the upper chamber was reconstructed
using cartilage ( Fig . The mean follow - up period was 13 months (range: 5 to 26 months). All patients had no residual
cholesteatoma or recurrence on endoscopic examination until the last follow-up. Temporomandibular computed
tomography was performed for an average of 9 months postoperatively to confirm the recurrence, which may not be seen
on physical examination No recurrence of cholesteatoma was observed in 4 cases. The recurrence of cholesteatoma was
assessed by endoscopic CT scans at 9 to 12 months after surgery with echocardiography and echocardiography at least
every 6 months until 5 years after surgery. Computed tomography is performed again. At the 3 months postoperative
follow-up, the average audiometric difference was 9.8 dB in the 4-minute method (500, 1000, 2000, 4000 Hz) and 14.9
dB in the 6 months The hearing loss of the bone was 8.6 dB, which was improved compared to the preoperative average of
17.3 dB ( Table 2). Especially, two patients with normal osseointegration who were able to perform audiometry at 1 year
postoperatively showed good results with 0 dB and 11.7 dB in airway bone hearing. In addition, two of three patients who
had undergone removal of the os- teobranous erosion and who were scheduled for removal of the os- teoic erosion
improved to less than 15 dB after the operation (Patients No 3 & 4) ( Table 2 ) After 6 months, the auditory hallucination
of the airway improved to 16.7 dB. During the follow - up period, all patients had no complications such as perforation of
the tympanic membrane, dizziness, tinnitus, sensory nerve impairment, facial nerve palsy.

Fig. 3.
Illustration of endoscopic attic reconstruction with composite cartilage
graft. After endoscopic transcanal removal of cholesteatoma, scutoplasty
was performed in our cases (A). Postoperative endoscopic finding after
transcanal endoscopic attic cholesteatoma removal (B).

Table 1.
Clinical characteristics of patients
Age Extent in Reconstruction
No. Sex TM Surgery Operative findings Tympanoplasty
(yr) imaging graft

1 23 F Only attic The entrance to Primary Trummikile the epitympanum, T1 Tragal

pocket the cave extending access to cave in composite graft
Ossicular chain intact

2 34 F Combined Limited to attic Primary Cholesteatoma in epitympanum T1 Tragal

retraction Ossicular chain intact composite graft

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Age Extent in Reconstruction

No. Sex TM Surgery Operative findings Tympanoplasty
(yr) imaging graft

3 33 F Only attic The entrance to Primary Trummikile epitympanum extending T0 Tragal sedate
pocket the cave access to the cave graft
Malleus head, incus long process

4 51 M Combined Mesotympanum Primary Cholesteatoma in epitympanum & T0 Tragal cartilage

perforation mesotympanum (stapes tendon, malleus
handle)

Malleus head, incus body partial erosion

5 25 F Only attic Limited to attic Primary Cholesteatoma in epitympanum T0 Tragal
pocket Incus partially eroded composite graft

6 37 M Combined Limited to attic Primary Cholesteatoma in epitympanum T1 Tragal

retraction Ossicular chain intact composite graft

T0: tympanoplasty type 0, TM: tympanic membrane

Table 2.
Postoperative results of endoscopic attic cholesteatoma removal
F/U periods Preop Postop ABG* (3 Postop ABG (6 Postop ABG (12
No. Recurrence‡ Complications
(m) ABG* months†) months) months)

1 26 21.7 0 0 0 (-) (-)

2 15 17.5 14 18.3 11.7 (-) (-)

3 16 30 20 20.8 12.5 (-) (-)

4 14 13.3 10 15 10 (-) (-)

5 6 7.5 5 16.7 (-) (-)

6 5 14.2 (-) (-)

Average 13.66 17.36 9.8 14.16 8.55
* in pure tone audiogram,
† follow up ABG 3 months after,
‡ follow up computed tomography image of temporal bone.
ABG: airbone gap

Review Go to :

Primary acquired cholesteatoma is characterized by the formation of middle ear pressure due to dysfunction of the duct,
resulting in intracorporeal intramuscular infiltration, resulting in retraction pockets mainly in the relaxed part of the
eardrum, And the formation of keratin accumulates into the space within the tympanic membrane, which is the type of
cholesteatoma that has developed [ 11 ]. Tos [ 12 ] classified the acquired middle ear cholesteatoma as upper
cholesteatoma, choledocholaryngomoma, and transthoracic cholesteatoma. Upper cholesteatoma is defined as depression
or perforation of the eardrum. The epididymis is transmitted to the mastoid through the upper chamber and the aditus ad
antrum in Prussack's space and surgical removal is necessary for cure.
The most common procedure for removal of these cholesteatoma is the use of anatomical opening and attic
reconstruction in the case of early ascontained cholesteatoma, and mastoid decompression in case of ascending
cholesteatoma. . It is important to completely remove the cholesteatoma lesion through surgery. In addition, securing the
ventilation passageway through the superior canal is necessary to prevent recurrence [ 13 ].
Recently, the concept of minimally invasive surgery has been introduced into medicine due to the development of
endoscopy, and has been applied to various fields and interest is increasing. Endoscopy has been actively used in sinus
surgery in otolaryngology, and microscopic surgery is common in the field of surgery. Although endoscopy was primarily
used for diagnostic purposes at the initial stage of the disease, Nomura [ 14 ] and Mer et al. [ 15 ] introduced an attempt to
search the middle ear cavity using the endoscope through the eardrum for the first time. Thereafter, Poe and Bottrill [ 16 ]
reported the effectiveness of the endoscopy for the diagnosis of external lymphatic fistula. However, in recent years, there
has been an increasing interest in the use of endoscopy in middle-ear surgery worldwide [ 17 ], and research papers have

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been published that report good outcomes in middle ear surgery by using endoscopy alone Has been published [ 8 , 18 , 19
].
In particular, since the microscope has a linear field of view, it is difficult to obtain a field of view for lesions located in
various rectangular regions of the middle ear. By using an endoscope, it is possible to obtain a wider field of view than a
microscope and a variety of endoscopes (0, 30, 45, The endoscope is used as a good approach to replace the disadvantages
of the microscope. In this study, we investigated the clinical features of the middle ear, the facial recess, the tympanic
sinus, and the upper jaw of the middle ear, which are the main structures of the middle ear, 18 , 20 ], it is difficult to
completely remove the lesion. Therefore, if endoscopy is used to obtain various angle and wide field of view for removal of
cholesteatoma, removal of residual cholesteatoma and recurrence of cholesteatoma , Respectively [ 19 , 21 ].
Marchioni et al. [ 22 ] and Tarabichi [ 20 ] selected the aortic approach as the primary surgical procedure for middle ear
cholesteatomas and found that the preservation of the ossicles with the complete removal of cholesteatoma lesions was
easier in the endoscopic approach [ 4 ] In addition, Migirov et al. [ 9 ] reported on the success of the endoscopic approach
to secondary recurrence of residual or recurrent cholesteatoma, and reported the results of removing recurrence and
residual cholesteatoma, emphasizing the efficacy of endoscopy. Marchioni et al. [ 22 , 23 ] reported that endoscopy could
be useful in cases where the middle ear pouch is difficult to access In the case of pediatric cholesteatoma, endoscopic
approach alone has been reported to be an easy method for the treatment of pediatric cholesteatoma restricted to middle
ear in terms of complete invasion as well as complete invasion [ 7 , 23 ]. In Korea, Jang et al. [ 8]. The efficacy of
endoscopy in terms of lowering the probability of residual or recurrent cholesteatoma in patients with endoscopic
mucosal approach to the existing microscopic approach during mastoidectomy was introduced. The results of the study
showed that the results of the plastic surgery are less invasive and have good results [ 4 ].
However, endoscopic surgery has disadvantages, but the biggest disadvantage is that the procedure is carried out with one
hand because the operation is carried out with one hand. This is a limitation in ensuring clear vision by removing bleeding
from the surgical field as appropriate. To overcome this, it is helpful to use tools designed to allow a clear view of the
operation, even with one hand, with a suction hole at the end of the instrument. Other disadvantages are that heat from
the lens located at the end of the endoscope can damage the inner ear and facial nerve. Therefore, it is recommended to
place the endoscope on the outer part of the bony annulus and perform the surgery unless necessary. do. In addition,
since the endoscope has a two-dimensional plane view, many exercises are necessary in order to have an accurate depth of
view during operation. In the process of positioning the endoscope in the middle ear cavity and performing surgery,
unexpected patient movements There is a risk that they may be damaged, so it is always good to be careful and to proceed
with the operation.
In this study, we could obtain good hearing results of about 10 dB of airway bone hearing loss in three cases in which
removal of cholesteatoma was possible by preserving the ossicular chain without ossicular invasion by cholesteatoma. In 3
cases, osseous erosion was observed and removal of the osteochondral and osteochondral head was planned. Secondary
hearing improvement was planned in all 3 cases. . After 3 uneventful good hearing results, we analyzed the postoperative
endoscopic findings and temporal bone CT findings. We suspected that 2 of them had contact with the ears of the
tympanic membrane, It is presumed that the inserted cartilage plate was moved slightly downward and connected to the
spine. All patients with a few eardrum recesses were not observed in the reconstruction site of the superior labyrinth, but
it is presumed that the function of the eardrum is poor. Therefore, it is necessary to continuously monitor the recurrence
of the earticular lesion due to the eardrum recession. In the case of the removal of the ossicle during endoscopic
choledochotomy, it is possible to plan secondary hearing as in this study. However, the ossicular reconstruction that
reconstructs the ossicular chain between the spine and the vertebra can be performed immediately. Individual access is
required.
In this study, which was first attempted in Korea, endoscopic removal of epididymal cholesteatoma was successfully
performed in all cases through an aortopulmonary approach without skin incision. All patients were discharged on the
next day after surgery, which is considered to be another advantage of the endoscopic approach. Although the follow - up
period was short, no residual lesions or recurrences were observed in any of the cases, no complications related to the
operation were observed, and excellent hearing improvement was obtained. In other words, it was confirmed that
endoscopic surgery through an extrauterine approach is a useful and effective method for removing cholesteatoma in a
relatively early epididymis, which is not advanced into the mastoid cavity, We believe that prospective studies will be
needed for long - term follow - up of more patients.

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