| [Background]The earliest description of cholesteatoma of the middle ear dates back to the1880 s.At that time,doctors noticed that some patients had ear discharge without signs of inflammation.Under the microscope,these secretions appeared as creamy,fatty substances,hence the term "cholesteatoma." Cholesteatoma is composed of three layers of tissue(matrix,perimatrix,and cystic contents).The matrix is composed of highly proliferative epithelial cells,while the contents are a mixture of non-nucleated skin keratin debris,oil secreted by the epithelium,and purulent and necrotic material.According to the EANO/JOS joint statement,middle ear cholesteatoma can be divided into three types: 1.Congenital middle ear cholesteatoma,2.Acquired middle ear cholesteatoma,and 3.Unclassifiable middle ear cholesteatoma.Acquired cholesteatoma is further classified into two types: the retraction pocket cholesteatoma and the non-retraction pocket cholesteatoma.Postoperative cholesteatoma of the middle ear includes recurrent cholesteatoma and residual cholesteatoma.The smooth ventilation of the middle ear is one of the important factors that prevent the formation of cholesteatoma.The ventilation of the middle ear is determined by four factors,namely,the eardrum,the eustachian tube,the mastoid air cells,and the central and peripheral neural regulation of the middle ear mucosa,which all work together to maintain airflow and drainage.Currently,research has found that the most common cause of middle ear cholesteatoma is the formation of a pouch in the relaxed part of the eardrum,which is caused by negative pressure in the upper part of the ear.Luntz discovered that the relaxed part of the eardrum contains less collagen fibers and has a greater contractile force than the tensile part,making it more compliant and prone to forming a relaxed inward pouch.The mechanisms that regulate middle ear pressure include:(1)the gas reservoir in the mastoid cavity for buffering the middle ear;(2)the ventilation regulation mechanism of the Eustachian tube;(3)the respiratory regulation mechanism of the middle ear mucosa;and(4)the neural regulation mechanism of middle ear pressure.The first two mechanisms are particularly important.There are two pathways for middle ear airflow:(1)the Eustachian tube → middle ear cavity→ posterior ear cavity;(2)the Eustachian tube → superior sinus tympani →superior ear cavity → entrance of the tympanic sinus → mastoid.In theory,for cholesteatoma patients with normal Eustachian tube function,releasing the obstruction of the middle ear ventilation pathway during mastoidectomy can improve the ventilation and drainage of the middle ear.This can stabilize the pressure within the middle ear and reduce the recurrence of middle ear cholesteatoma.At present,there are few domestic and foreign literatures on the regression analysis of the recurrence rate and treatment effect after SRO,and there is no literature reporting the phenomenon of comparison of the curative effects of SRO and BOT.Using BOT technology,it is believed that this method can fill the upper tympanic cavity and mastoid pneumoperitoneum,so that the elastic part of the tympanic membrane cannot be shrunk back,thereby reducing the recovery rate of bile coagulation.But theoretically speaking,improving middle ear ventilation and stabilizing the middle ear flow is the most effective way to reduce the recurrence rate of choline in the middle ear.Therefore,the effect of SRO technology is better,and it will not cause complications related to occlusion.This study will compare scarring and recurrence by various technical methods to determine the most suitable method.[Objective](1)To evaluate the clinical efficacy of supratubal recess opened in the treatment of acquired middle ear cholesteatoma.(2)To investigate the effect of supratubal recess opened on the recurrence rate of acquired middle ear cholesteatoma.(3)To compare the difference of supratubal recess opened and Bony Obliteration Tympanoplasty in the treatment of acquired middle ear cholesteatoma.[Method]A total of 166 patients with middle ear cholesteatoma who underwent surgical treatment in the Department of Otorhinolaryngology of Guangzhou 12 th People’s Hospital from December 2008 to December 2017 were collected.After approval by the Medical Research Ethics Committee,all patients signed an informed consent.Excluding congenital cholesteatoma cases,138 ears were enrolled,including three groups.One group,45 ears,underwent supracapsular recess opening combined with radical mastoidectomy(CWU-SRO);The other 47 ears were treated with bone powder packing combined with complete wall mastoidectomy(CWU-BOT).The last group consisted of 45 ears undergoing simple round wall mastoidectomy(Simple CWU).(1)Otoscopy was performed 6 months after operation to evaluate the anatomical state of the tympanic membrane,and to observe whether there was retraction of the tympanic membrane,retraction bag,rupture of the tympanic membrane,survival of the transplanted tympanic membrane,external auditory canal and the state of the external auditory canal.(2)Half a year after operation,high-resolution CT of temporal bone was performed to evaluate the middle ear sinus,to understand the invasion range of cholesteatoma and the situation of ossicular chain,to evaluate the recurrence,and tp evaluate the hearing.(3)All patients were followed up by Pure Tone audiometry(air conduction,bone conduction,air-bone gap)at 0.5/1/2/4 k Hz and tympanometry(type A,B and C)six months to evaluate the postoperative hearing after operation.[Results](1)The recurrence rate of cholesteatoma: all patients were followed up for 5years,and the median follow-up time was 44(6-60)months.In the CWU-SRO group,43 ears(95.6%)were dry,1 ear(2.2%)had cholesteatoma recurrence.The total recurrence rate of CWU-BOT group was 14.9%(7/47),and 3 cases(6.38%)had postoperative infection.The recurrence rate of CWU group was 19.6%(9/46),and 1 case(2.22%)had postoperative infection.(2)Recurrence site of cholesteatoma: in CWU-SRO group,we observed 1case(100%)of recurrent cholesteatoma extending to the tympanic sinus(S2).The recurrence sites of cholesteatoma in CWU-BOT group were S1(3 cases,42.8%),S2(2 cases,26.8%),T(2 cases,26.8%),Site A and M were not founded recurrence cholesteatoma.In CWU group,the recurrence sites of cholesteatoma were S1(2cases,22.2%),S2(2 cases,22.2%),T(1 case,11.1%),A(3 cases,33.4%)and M(1case,11.1%).(3)Postoperative hearing: hearing was improved in 32 ears(71.1%)in CWU-SRO group.The median AC hearing threshold was 27(23-48)d BHL,and the median ABG was 14.5(12.5-16.7)d BHL.In the CWU-BOT group,28 cases(28/46,60.9%)had postoperative hearing improvement.The median AC was 43(30-53)d BHL,and the median ABG was 20(19-22.8)d BHL.In the CWU group,postoperative hearing was improved in 28 ears(60.9%).The median AC was 27.5(19-48.3)d BHL,and the median ABG was 15(12.3-19.4)d BHL.Mann-Whitney U test showed that there was a significant effect on ABG change(p <0.001).(4)Postoperative acoustic immittance: each group was followed up for 5 years.In CWU-SRO group,32 ears(71.2%)were type A,11 ears(24.4%)were type B,and 2 ears(4.4%)were type C.In CWU-BOT group,33 ears(70.2%)had type A,6ears(12.8%)had type B,and 8 ears(17%)had type C tympanic impedance.In CWU group,20 ears(43.5%)had type A tympanic impedance,24 ears(52.2%)had type B tympanic impedance,and 2 ears(4.3%)had type C tympanic impedance.(5)In CWU-SRO group,the volume of external auditory canal increased in 8ears,perforation of tympanic membrane at 6 o ’clock tension was found in 3 ears,superior semicircular canal fistula was found in 1 ear,and the tympanic membrane was not active during Valsalva maneuver in 2 ears.In the CWU-BOT group,otoendoscopy showed that the tension part was completely restored.The Angle between the tympanic membrane and the external auditory canal is small and easy to accumulate fluid for 1 ear.4 ears had no movement of the tympanic membrane during the Valsalva maneuver.In CWU group,otoendoscopy showed that the loose part of the tympanic membrane was inverted pocket in 7 ears,the implanted temporalis fascia formed a thin area in 6 ears,and the tympanic membrane did not move during Valsalva maneuver in 2 ears.[Conclusion]Opening the supratubal recess to ensure the patency of the attic is beneficial to the gas exchange between the mastoid and the middle ear and reduces the possibility of cholesteatoma recurrence.(1)Supratubal Recess Opened of acquired middle ear cholesteatoma has a lower recurrence rate and better reconstruction of postoperative hearing in patients with cholesteatoma.(2)Supratubal Recess Opened in the treatment of acquired middle ear cholesteatoma is to reduce postoperative recurrence rate by improving postoperative middle ear ventilation and drainage.(3)The theoretical basis for the supratubal recess opened is to improve middle ear ventilation;while Bony Obliteration Tympanoplasty uses the filling theory.According to the results of retrospective analysis,the recurrence rate of CWU-SRO is lower than that of CWU-BOT;the hearing recovery rate of CWU-SRO is better than that of CWU-BOT. |
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