Chirurgie du Cholesteatome

LA TECHNIQUE FERMEE

Retraction pocket CHOLESTEATOMA

TYMPANOPLASTY – Wullstein & Zollner

• Eradication cholesteatome matrix

• Reparation– Eardrum = Myringoplasty– Ossicles = Tympanoplasty– Ear Canal = Rehabilitation of anatomo-

physiology of the ear– Eustachian tube

Cholesteatoma

• First question:– Can we remove aall size of cholesteatoma from the

middle ear?

• Second question:– What is the best way to prevent from recurrence

• Third question:– Are we able to respect or restore the normal anatomo-

physiology of bothe external canal and middle ear?

Cholesteatoma Open Techniques

Good wound healing – Skin in a wrong place

Defective: Wrong skin in a wrong place

1677 Closed Techniques1977-1999

Unselected patients – Several Surgeons

• Children>16• 353 Cases 21%

• Adults >15• 1317 Cases 79%

Cholesteatoma removal to prevent residuesReconstruction to prevent recurrence

• Tympanic graft– Fascia 804

– Perichondrium697

– Allograft

– Xenograft

• Canal Wall

• Intact 32 %

• Partial 62 %

• Total 5%

Secon Look

• CHILDREN– 60% (214/353)

– Before 1993 78%

– After 1993 42%

• ADULTS– 44,5% (586/1317)

– Before 1993 54%

– After 1993 25%

Systematic second look versusCriteria in decision making

• OTOSCOPY

• CT SCAN

• FUNCTIONAL RESULT

Endoscopic Second Look

REQUIREMENTS

-well ventilated middle ear

LIMITATIONS

-Bony structures-Fibrous tissue-Bleeding-Visual limitation to differentiate pathology-Ossicular chain

18% endoscopicSecond look

Short term results during second look

• CHILDREN 353

• Recurrence 18%• Residual 20%

• ADULTS

• Recurrence 16,5%• Residual 8,5%

Short term results regarding only the second stages

• CHILDREN 214

• Recurrence 29%• Residual 32%

• ADULTS 586

• Recurrence 37%• Residual 20%

Out of 1670 cases498 reviewed over 10 years

• 5 years follow-up– 60 cases 12 % 3rd revision– 11 cases 2% 2nd revision

• Including 48 cases 8% children cholesteatoma

conclusions

• The purpose of the surgery is not to performe a closed or an open technique but to get a safe ear.

• Residual cholesteatoma means we have to improve the exeresis of the disease.

• Recurrence means we have to improve the reparation of the ear

OTITE CHRONIQUE

• OTORRHEE

• PERFORATION

• MALADIE

• Abondante, muqueuse

• pars tensa, antero-inf.

• non marginale• tubo-tympanique• pneumatisée• simple• SAFE EAR• non dangereux

• Epaisse, fétide, peu abondante

• Shrapnell, postero-sup

• marginale• antro-atticale• éburnée• cholesteatome• UNSAFE EAR• dangereux

TYMPAN• PERFORATION : absence des 3 couches.

• RETRACTION : absence de la fibreuse, épiderme stable.

• ADHESIF : absence de la fibreuse et de la muqueuse, épiderme stable.

• CHOLESTEATOME :absence de la fibreuse et de la muqueuse, épiderme instable

POCHES DE RETRACTION

• S. d ’appel

• Localisation

• Epiderme

• Os

• ABSENT

• NON MARG

• NORMAL

• MOBILE

• SAFE

• PRESENT

• MARGINALE

• DYSKERATOSE

• FIXEE

• UNSAFE

metaplasia

migration

retraction

TYMPAN

• Absence lamina propris – myringomalacia, retraction, collapsus

• Absence LP et absence muq – atelectasie, otite adhésive

• Absence LP et absence muq et proliferation epiderme - cholesteatome

POCHES DE RETRACTION TYMPANIQUE

• Tympan flaccide

• Attraction mediale du tympan

• Collapsus tympanique

• Tympanum atelectasique