c Holes Tea Tomas Ari

8/18/2019 c Holes Tea Tomas Ari

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CHOLESTEATOMA

Dept of Otorhinolaryngology Head and Neck Surgery

Padjadjaran University

Hasan Sadikin General Hospital

20! 1

"e#ryanti P Sari

Pe$#i$#ing Uta$a%dr& Sally 'ahdiani( ')es( Sp&*H*+),

Literature Reading


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Overvie-

Definition

.nato$y

/lassification and *heories

'anage$ent

/o$plications


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Definition

Na$ed #y ohannes 'ueller in 11

& 3rroneous #elief that one of the pri$ary co$ponents

of the tu$or -as fat

2&4a pearly tu$or of fat5a$ong sheets of polyhedral

cells6

'ore appropriate na$e has #een suggested to #ekerato$a to descri#e tu$or co$position


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Definition%

/holesteato$as are e7panding lesions of the

te$poral #one that are co$posed of a stratified

s8ua$ous epithelial outer lining and a des8ua$ated

keratin center&

3pide$iology %

+ incidence of ac8uired cholesteato$a ranges fro$

appro7i$ately 9 to 2&! cases per 00(000 adults+ to : cases per 00(000 children . $ale

predo$inance of &; % in cholesteato$a incidence .


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including

& /ystic content% des8ua$ated keratin center

2& 'atri7% keratini


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Middle Ear Anatomy


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Tympanic Membrane


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TULANG-TULANG

PENDENGARAN

Ossicles


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Epitympanum

MesotympanumHipotympanum

*y$panic /avity


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EPITYMPANUM


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/lassification and *heories

=t can #e classified as one of t-o different types%

/ongenital

.c8uired

>Pri$ary

>Secondary


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/ongenital /holesteato$a

Definition ?,evenson( 919@& *hese criteria included

& >Ahite $ass $edial to nor$al ty$panic $e$#rane

2& >Nor$al pars flaccida and pars tensa

& >No prior history of otorrhea or perforations

;& >No prior otologic procedures

:& >Prior #outs of otitis $edia -ere not grounds for

$edia e7clusion as -as the case in original definition


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*-o pro$inent theories include

& the failure of the involution of ectoder$al epithelial

thickening that is present during fetal develop$ent

in pro7i$ity to the geniculate ganglion &

2& $etaplasia of the $iddle ear $ucosa&


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.c8uired /holesteato$as

/o$$on factor%

keratini


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Pri$ary .c8uired /holesteato$as

Ulti$ately for$ due to underlying 3ustachian tu#e

dysfunction that causes retraction of pars flaccida

Besults in poor aeration of epity$panic space

-hich dra-s pars flaccida $edially on top of

$alleus neck( for$ing retraction pocket &

Nor$al $igratory pattern of the ty$panic

$e$#rane epitheliu$ altered #y retraction pocket& 3nhances potential accu$ulation of keratin&


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Pri$ary .c8uired /holesteato$as

Pars flaccida retraction Pars tensa retraction


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Secondary .c8uired /holesteato$as

=$plantation theory

S8ua$ous epitheliu$ i$planted in the $iddle ear as a result of surgery(

foreign #ody( #last injury( etc&

'etaplasia theory

Des8ua$ated epitheliu$ is transfor$ed to keratini


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3pithelial invasion theory

S8ua$ous epitheliu$ $igrates along perforation edge

$edially along undersurface of ty$panic $e$#rane destroying

the colu$nar epitheliu$&

Papillary ingro-th theory

=nfla$$atory reaction in PrussackCs space -ith an intact pars

flaccida

?likely secondary to poor ventilation@ $ay cause #reak in

#asal $e$#rane

allo-ing cord of epithelial cells to start in-ard proliferation


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/holesteato$a Spread

Predicta#le in that they are channeled along

characteristic path-ays #y%

>,iga$ents

>"olds

>Ossicles


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/o$$on Sites of /holesteato$a Origin

Posterior epity$panu$

Posterior $esoty$panu$

.nterior epity$panu$


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/holesteato$a Spread

Posterior epity$panic cholesteato$a passing through

superior incudal space and aditus antru$


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Posterior $esoty$panic cholesteato$a invading the sinus

ty$pani and facial recess


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.nterior epity$panic cholesteato$a -ith e7tension to -ith

geniculate ganglion


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Patient 3valuation

Detailed otologic history

& Hearing loss

2& Otorrhea% $alodorous

& Otalgia

;& *innitus

:& ertigo

Progressive unilateral hearing loss-ith a chronic foul s$elling

otorrhea should raise suspicion&

Previous history of $iddle ear disease

& /hronic otitis $edia

2& *y$panic $e$#rane perforation% Pars flaccida

& Prior surgery


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Otologic e7a$ination

Oto$icroscopy is essential in evaluating the e7tent of disease

/lean ear thoroughly of otorrhea and de#ris -ith cotton and

cotton+tipped applicators or suction

/ulture -et( infected ears and treat -ith topical andEor oral

anti#iotics

Pneu$atic otoscopy should #e perfor$ed in every patient -ith

cholesteato$a

Positive fistula ?pneu$atic otoscopy -ill result in nystag$us

and vertigo@ response suggests erosion of the se$icircular

canals or cochlea


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Hearing evaluation

conductive hearing loss

& Pure tone audio$etry -ith air and #one conduction

2& Speech reception thresholds

& Aord recognition

:2H< tuning fork e7a$

>.l-ays correlate -ith audio$etry results

*y$pano$etry

>'ay suggest decreased co$pliance or *' perforation


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*he degree of conductive loss -ill vary considera#ly

depending on the e7tent of disease&


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Preoperative i$aging -ith co$puted to$ographies

?/*s @ of te$poral #ones ?$$ @ section -ithout

contrast in a7ial and coronal planes&

& .llo-s for evaluation of anato$y

2& 'ay reveal evidence of the e7tent

& Screen for asy$pto$atic co$plications


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/holesteato$a 'anage$ent


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Preventative 'anage$ent

*y$panosto$y tu#e for early retraction pockets

Surgical e7ploration for retraction persistence


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*reated surgically -ith rimar! goal of total

eradication of cholesteato$a to o#tain a safe to and

dry ear

& /anal+-all +do-n procedures ?/AD@

2& /anal+-all +up procedure ?/AU@

& *ranscanal anterior atticoto$y

;& Fondy $odified radical procedure


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Prior to the advent of the ty$panoplasty(

all cholesteato$a surgery -as perfor$ed using

/AD surgery approach procedure involves%

>*aking do-n posterior canal -all to level ofvertical facial nerve

>37teriori


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/lassic /AD operation is the $odified radical $astoidecto$y

in -hich $iddle ear space is preserved

Badical $astoidecto$y is /AD operation in -hich%

> 'iddle ear space is eli$inated

> 3ustachian tu#e is plugged

'eatoplasty should #e large enough to allo- good aeration of

$astoid cavity and per$it easy visuali


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=ndications for /AD approach%

/holesteato$a in an only hearing ear Significant erosion of the posterior #ony canal -all

History of vertigo suggesting a la#yrinthine fistula

Becurrent cholesteato$a after canal+-all +up

surgery

Poor eustachian tu#e function

Sclerotic $astoid -ith li$ited access to

epity$panu$


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"#$antages%

>Besidual disease is easily detected

>Becurrent disease is rare

>"acial recess is e7terioriOpen cavity created

*akes longer to heal

>'astoid #o-l $aintenance can #e a lifelong pro#le$

>Shallo- $iddle ear space $akes O/B ?Ossicular /hain

Beconstruction@ difficult

>Dry ear precautions are essential


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/anal+Aall +Do-n


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/anal +Aall +Up

/AU procedure developed to avoid pro#le$s and $aintenance

necessary -ith /AD procedures

/AU consists of preservation of posterior #ony e7ternal

auditory canal -all during si$ple $astoidecto$y -ith or

-ithout a posterior -ith ty$panoto$y

Staged procedure often necessary -ith a scheduled second

look operation at ! to 1 $onths for%

>Be$oval of residual cholesteato$a

>Ossicular chain reconstruction if necessary

Procedure should #e adapted to e7tent of disease as -ell as

skill of otologist


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/AU $ay #e indicated in patients -ith large pneu$atiSuggests good eustachian tu#e function

/AU procedures are contraindicated in%

>Only hearing ear

>Patients -ith la#yrinthine fistula

>,ong+standing ear disease

>Poor eustachian tu#e function


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/anal+Aall +Up

.dvantages%

>Bapid healing ti$e

>3asier long+ter$ care

>Hearing aids easier to fit

>No -ater precautions

Disadvantages%

>*echnically $ore difficult

>Staged operation often necessary

>Becurrent disease possi#le >Besidual disease harder to detect


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/anal+Aall +Up


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Novel *echni8ues

=n 200: Gant


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Novel *echni8ues

/anal Aall Beconstruction techni8ue

>/o$plete cortical $astoidecto$y -ith opening of -ith facial

recess and re$oval of incus and $alleus head

>Posterior canal -all skin elevated( annulus elevated

>'icrosagittal sa- used to cut posterior canal -all

>/holesteato$a re$oved

>Posterior canal -all #one replaced

>/ortical #one chips used to #lock attic and $astoid fro$

ty$panu$

>Fone pateC holds #one chips in place


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/o$plications


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*he e7pansion of cholesteato$as

=nfection(otorrhea(#one destruction

& e7tracranial co$plications

Hearing loss

"acial nerve paresis or paralysis

,a#yrinthine fistula% se$icircularis canal erosion

e7tradural or perisinus a#scess

serous or suppurative la#yrinthitis


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2& =ntracranial co$plications

potentially life+threatening

Periosteal a#scess

,ateral sinus thro$#osis% sig$oid sinus

*hro$#osisEphle#itis

'eningitis

3pidural (su#dural( or parenchy$al #rain a#scess


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Hearing ,oss

/onductive hearing loss% ossicular chain erosion ?0@

>& 3rosion of lenticular process andEor stapes superstructure

process $ay produce :0dF conductive hearing loss

>2& Hearing loss varies despite disease e7tent ?natural

$yringostapediope7y( trans$ission of sound through (

cholesteato$a sac@

Sensorineural hearing loss% involve$ent of la#yrinth

"ollo-ing surgery( 0 have further i$pair$ent due to%

>37tent of disease present

>/o$plications in healing process


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,a#yrinthine "istula

(nci#ence% as high as 0

)!mtom% Sensorineural hearing loss andEor

vertigo induced #y noise or pressure change

.#sence of a positive fistula test does not rule out this

co$plication&

*ommon site% hori


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"acial Paralysis

+a! #e$elo%

>.cutely secondary to infection

>Slo-ly fro$ chronic e7pansion of cholesteato$a

,emoral 'one *, % locali


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=ntracranial /o$plications

Potentially life+threatening

=ncidence% as high as

*omlications

& Periosteal a#scess

2& ,ateral sinus thro$#osis

& =ntracranial a#scess

;& 'eningitis

)!mtom%

& Suppurative $alodorous otorrhea2& /hronic headache

& "ever

;& Otalgia


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'anage$ent%

>Presence of $ental status changes -ith nuchal rigi#it! or

cranial neuropathies -arrant consultation -ith urgent

intervention

>3pidural a#scess( su#dural e$pye$a( $eningitis and (

cere#ral a#scesses should #e treated i$$ediately prior to

definitive otologic $anage$ent of ear disease&


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*onclusions

Pathogenesis of cholesteato$a re$ains uncertain

3ssential to possess #asic kno-ledge of the i$portant

anato$ic and functional characteristics of the $iddle ear for

successful $anage$ent of cholesteato$as

/areful and thorough evaluations are the key to early diagnosisand treat$ent


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*reat$ent is surgical -ith pri$ary goal to eradicate disease

and provide a safe and dry ear Surgical approaches $ust #e custo$i


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