Cholesteatoma

•  For cholesteatoma

Principles

(1) Squamous epithelium must be excised in Toto or Exteriorized.

A Cholesteatoma is an epithelial cyst in the mastoid. The treatment of a cyst is total excision but if complete excision is not possible incomplete excision will result in recurrence so exteriorization (Marsupialisation) has to be done.

(2) Endothelium must be excised in toto or interiorized i.e. put into communication with the Eustachian tube.

Unaerated endothelium will secrete mucus as in serous otitis media. If endothelium is buried under the skin lining of an open mastoid cavity, or under the muscle secretion will result in a discharging cavity. In a well-pneumatized mastoid as in invasive cholesteatoma in a child it is impossible to eliminate all the endothelia (perilabyrinthine cells) so an open mastoid cavity or an Obliterative Muscleplasty is not the solution.

(3) Va./s Ratio

Squamous epithelium of the ear canal must be adequately aerated. The ratio of volume of air (Va.) circulating in the ear canal to the surface area (s) of the skin of the ear canal must be correct- if not, the skin will repeatedly break down. In an open cavity (canal wall down technique) the Va. can be increased by a meatoplasty or a conchoplasty & the S decreased by an obliteration muscleplasty.

(4) Skin can only grow from skin & Endothelium can only grow from endothelium.

Raw area will granulate.

Raw area in the ear canal if large must be grafted. Small raw areas can be covered by silastic or teflon sheeting raw areas in the middle ear must be covered with silastic if large or gelfilm if small.

Polypoidal metaplastic mucosa of the promontory must be removed with gelfilm there is no risk of extrusion but it if get absorbed in a few days, adhension will form with silastic there is a 2-3 % risk of extrusion. This risk can be minimized by

•  Wash the silastic in acctone

•  With my cartilage technique, silastic cannot come in contact with the fascia.

•  Purulent sinusity must be treated & caused before tympanosplasty.

I use .005 or .01 silastic

Thick silastic to the removed at a 2 nd stage reinforced silastic (dacron mesh) will not curl up with adramcing fibrosis because granulation grow into the dacron mash but in case of extrusion, removal requires surgery.