Canal Wall-up Tympanomastoidectomy: Recurrence Factors

Objective: Canal wall-up tympanomastoidectomy is gaining popularity in the treatment for cholesteatoma. The choice remains controversial because of the significant recurrence rate of this disease. We aimed to analyze tympanomastoidectomy success rate, to establish eventual predictive factors for failure, and to evaluate the computed tomography (CT) scan’s value in this pathology. Method: We performed a retrospective cohort study regarding all patients submitted to tympanomastoidectomy for cholesteatoma at the otolaryngology department of Hospital São José, Lisbon, from January 1, 2005, to December 31, 2009. Clinical and demographic data were obtained from medical records. Results: One hundred nineteen patients were submitted to tympanomastoidectomy. In most cases, preoperative CT scans showed cholesteatoma in the attic (50%) and large extension of the disease (tegmen, semicircular or fallopian canal erosion in 51%), not always confirmed during surgery (75%). Sixty percent had a canal wall-down procedure. The overall postoperative air-bone gap was within 20 dB in 44%. Second-look surgery was performed in 24 patients: the overall recurrence rate was 23%, with conversion to canal wall-down procedure in 67%. Factors identified as related to failure: cholesteatoma in the sinus tympani (33%), scutum erosion (29%), and large extension of disease (40%). Conclusion: The recurrence rate was significant, despite the high percentage of canal wall-down procedures. Factors for failure remain uncertain and CT scans presented limited value in the diagnosis and evaluation of cholesteatoma, especially postoperatively. In the absence of better diagnostic procedures, we recommend second look surgery to control cholesteatoma’s recurrence.

目的：上鼓室外侧壁保留的鼓室乳突切除术在胆脂瘤治疗中越来越受欢迎。由于该疾病的复发率较高，这种手术方式的选择仍存在争议。我们旨在分析鼓室乳突切除术的成功率，确定可能导致失败的预测因素，并评估计算机断层扫描（CT）在这种病理情况下的价值。 方法：我们对2005年1月1日至2009年12月31日在里斯本圣若泽医院耳鼻喉科因胆脂瘤接受鼓室乳突切除术的所有患者进行了一项回顾性队列研究。临床和人口统计学数据从病历中获取。 结果：119名患者接受了鼓室乳突切除术。在大多数病例中，术前CT扫描显示胆脂瘤位于上鼓室（50%）且病变范围较大（鼓室盖、半规管或面神经管侵蚀占51%），但在手术中并不总是能得到证实（75%）。60%的患者接受了开放式乳突根治术（即去除外耳道后壁的手术）。术后总体气骨导差在20分贝以内的占44%。24名患者接受了二次探查手术：总体复发率为23%，其中67%转为开放式乳突根治术。确定与失败相关的因素包括：鼓室窦胆脂瘤（33%）、盾板侵蚀（29%）以及病变范围大（40%）。 结论：尽管开放式乳突根治术的比例较高，但复发率仍然显著。失败的因素仍不确定，CT扫描在胆脂瘤的诊断和评估中价值有限，尤其是在术后。在缺乏更好的诊断方法的情况下，我们建议进行二次探查手术以控制胆脂瘤的复发。