Cholesteatoma Treatment & Management
- Author: Peter S Roland, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Virtually all cholesteatomas should be excised. The only absolute contraindications to the surgical removal of cholesteatomas are medical in nature. Some individuals have health problems of such gravity as to make the risk of surgical intervention unacceptably high.
Absence of hearing in the contralateral ear is a relative contraindication to surgery. Since, however, the cholesteatoma frequently presents a greater risk to residual hearing than surgery does, surgical removal usually remains the management option of choice in these situations.
Depending on the procedure, approximately 5-40% of cholesteatoma operations are unsuccessful, with cholesteatoma persistence or recurrence manifesting at some point in the postoperative period. Persistence may appear as early as 5-6 months postoperatively, or it may be delayed for many years. Consequently, close follow-up care is important.
The applicability of using small otoendoscopes as part of the surgical management of cholesteatomas is being explored. A study by Hunter et al in pediatric patients with cholesteatoma, comparing total endoscopic ear surgery with microscopic surgery and combined endoscopic-microscopic procedures, found that results were similar between the endoscopic and microscopic techniques with regard to hearing outcomes, complication rates, and recurrence and residual disease rates.
Medical therapy is not a viable treatment for cholesteatomas. Patients who refuse surgery or whose medical condition makes a general anesthetic too hazardous should have their ears cleaned regularly. Regular cleaning can help to control infection and may slow growth of the cholesteatoma, although it does not stop further expansion or eliminate risk. The mainstay of microbial therapy should be topical, but systemic therapy is occasionally a helpful adjunct.
Consultation with an otolaryngologist is mandatory. Rarely, advice from a neurosurgeon is required to help manage an intracranial consultation.
Surgical therapy consists of removing the cholesteatoma. In certain circumstances, the surgeon can make the decision to use a canal wall–up (closed) or canal wall–down (open) technique preoperatively.
Canal wall–down operations have the highest probability of permanently ridding the patient of a cholesteatoma. Canal wall–up procedures have the advantage of maintaining a normal appearance, but because the risk of persistent or recurrent cholesteatomas is higher with this operation, most surgeons advise an obligatory second-look tympanomastoidectomy 6 months to 1 year after the initial procedure.[24, 25]
At the time of the second look, small amounts of residual disease can frequently be removed prior to the development of either complications or massive recurrence. (Increasing evidence suggests that diffusion-weighted MRI may be able to accurately detect cholesteatoma recurrence and, in some cases, replace a second-look procedure. )
If the patient has had several episodes of recurrence of the cholesteatoma and wishes to avoid future operations, the canal wall–down technique is most applicable. In addition, it is safer for patients who are unwilling or unable to return for a second-look procedure.[6, 7, 27]
Some congenital anomalies are known to be associated with a lifelong history of eustachian tube dysfunction, and in some individuals, previous surgical procedures have irreversibly injured the eustachian tube. These again are patients in whom an open-cavity operation often is best.
Osborn et al reported the results from 420 children who underwent 700 operations and concluded that most children with cholesteatoma can be managed with an intact–canal wall technique.
Sometimes, the decision as to which procedure to use is not possible until the operation has begun and a clear understanding of the extent of the disease has been obtained.
No operation can be successful unless the goals of the procedure are kept clearly in mind. These goals include the following:
To make the ear safe by eliminating the cholesteatoma and chronic infection
To make the ear problem-free for all the usual activities of daily living, including swimming
To conserve residual hearing
To improve hearing when possible
To provide an acceptable cosmetic appearance
A careful discussion of the advantages and disadvantages of canal wall–up and canal wall–down (open) procedures is useful. If a canal wall–down procedure is considered preoperatively, showing the patient a picture of a well-crafted meatoplasty, as shown below, can help the patient form a clear understanding of the expected postoperative appearance.
Advantages and disadvantages of the canal wall–up procedure include the following:
Hearing aids easy to fit
No routine cleaning required
High tolerance for water exposure
Usually a staged procedure
Relatively high rate of recurrent or persistent cholesteatomas
Advantages and disadvantages of the canal wall–down procedure include the following:
Hearing aids difficult to fit
Annual or semiannual canal cleaning needed
Occasional problem with water exposure: Dizziness may develop after exposure to water or cold air.
Usually a single procedure
Low rate of persistent or recurrent cholesteatomas
Often, the best plan is to reserve the decision about how to manage the canal wall until the operation has begun and a better understanding of the extent of disease has emerged. Some intraoperative findings that favor a canal wall–down, or open, technique, include the following :
Involvement of the sinus tympani
Involvement of the medial end of the canal wall, with the cholesteatoma wedged laterally between the heads of the ossicles in the epitympanum and medial canal wall
Ostitis or irremovable cholesteatoma in the area around the opening to the eustachian tube or in the most inferior portions of the middle ear space (often calls for a true radical mastoidectomy)
Large defects in the canal wall: Frequently, the best plan is to convert the operation to an open-cavity procedure (in contrast, small defects in the canal wall are readily repaired)
Labyrinthine fistula: If the cholesteatoma matrix is left over the fistula so as not to expose it, then the canal must be removed; otherwise, epithelium is trapped within the mastoid cavity, resulting in cholesteatoma recurrence; if the cholesteatoma matrix is removed from the fistula, some surgeons are comfortable leaving the canal wall up
Most surgical procedures for cholesteatomas in the United States are now performed through an incision behind the ear combined with an incision in the external auditory canal, but the procedure can be performed through an extended incision starting in the ear canal.
Regardless of which technique is used, all of the mastoid’s air cells should be removed. If ossicles are involved, they must be removed to avoid recurrence. Reconstruct the ossicular chain either at the end of the primary procedure or as part of a secondary operation.
The tympanic membrane is usually reconstructed. If a canal wall–up technique is used, missing bone is replaced with a cartilage graft. If a canal wall–down procedure is selected, a large meatoplasty is created to allow adequate air circulation into the cavity that arises as a consequence of removing the posterior canal wall. (See the image below.)
Essential features of a canal wall–up procedure include the following :
Removal of all infected air cells
A functioning eustachian tube
A well-maintained middle ear space
Adequate communication between the mastoid and the middle ear space through the aditus ad antrum or a generous facial recess
Elimination of any bony epitympanic defect with a cartilage or bone graft
Essential features of a canal wall–down procedure include the following:
Removal of all air cells, including those within the retrofacial, retrolabyrinthine, and subarcuate air cell tracts
Removal of the lateral and posterior walls of the epitympanum so that the tegmen mastoideum and tegmen tympani become a smooth, featureless plane
Amputation of the mastoid tip (usually advisable)
Saucerization of the lateral margins of the cavity
Lowering of the posterior bony external auditory wall to the level of the facial nerve
Exteriorization of the anterior epitympanic recess by removing the cog
Enlargement of the meatus (to at least twice its normal size) by removing conchal cartilage
Lowering of the medial end of the external auditory canal toward the floor of the hypotympanum
Some surgeons prefer a subcortical technique that starts by removing bone medially through the ear canal. The epitympanum is progressively enlarged, and the posterior canal wall is removed from the inside out. Bone removal is limited to that necessary to remove all of the cholesteatoma.
Such a subcortical, or inside-out, mastoidectomy combines some of the advantages of canal wall–up and canal wall–down techniques but commits the surgeon to a canal wall–down operation if the cholesteatoma has extensive mastoid involvement.[29, 30]
Canal wall-reconstruction tympanomastoidectomy
In a retrospective case review of 273 patients (mean age 35) with chronic otitis media with cholesteatoma, Walker et al found that an alternative surgical procedure, canal wall–reconstruction (CWR) tympanomastoidectomy with mastoid obliteration, produced good long-term results. The investigators, who examined the surgical outcomes on 285 ears (average follow-up 4.29 years), determined the rate of failed procedures—those requiring conversion to open cavity or subtotal petrosectomy—to be only 2.6%.
The investigators concluded that use of CWR tympanomastoidectomy avoids the long-term drawbacks of canal wall–down mastoidectomy while offering surgeons excellent exposure of the middle ear and mastoid.
Management of the complications of cholesteatoma
Sometimes, the existence of a labyrinthine fistula is suggested on preoperative CT scans; at other times, the presence of a fistula is a complete surprise. Initially, the desquamated epithelium should be removed, carefully leaving the matrix over the horizontal canal. Blunt probes are used to locate the fistula by palpation. If the fistula appears to be superficial, the matrix is gently removed at the end of the case and the defect is covered with fascia.
However, if the fistula is large and it appears that the cholesteatoma matrix is attached firmly to the membranous labyrinth itself, leaving the matrix in position should be considered. Debate continues as to whether hearing loss is more likely if the matrix is removed.
If the membranous labyrinth is opened at any point during the procedure, broad-spectrum IV antibiotics and steroids should both be administered immediately. Bacterial labyrinthitis and inflammation pose the biggest risk to hearing. Fistulas involving the oval window area should be treated according to the same principles. Violation of the vestibule itself is much more likely to produce hearing loss than violation of one of the semicircular canals.
Occasionally, a canal fistula is created during the surgical procedure. If such a fistula involves one of the semicircular canals, then it should be sealed with soft tissue (preferably fascia) and IV antibiotics and steroids administered. These patients are quite likely to have significant balance disturbance in the immediate postoperative period, but a significant number recover with little or no hearing loss if appropriate antibiotic therapy and steroids are provided in the postoperative period.
Brain herniation through the tegmen of the middle fossa has a characteristic glistening, shiny appearance. The presence of clear fluid associated with such a lesion should raise suspicion of a brain hernia and cerebrospinal fluid leak. MRI and CT scanning can often help to clarify the diagnosis preoperatively.
Options for managing a brain hernia fall into 2 basic categories: reconstruction of the mastoid cavity and obliteration of the mastoid cavity. If reconstruction is chosen, glialized brain can be removed simply by sharply excising it; any viable brain can be pushed back up into the middle cranial fossa. If the defect is large, intradural and extradural repair of the dural defect should be considered.
The alternative involves obliterating the middle ear, external auditory canal, and mastoid by removing the posterior canal wall, obliterating the eustachian tube, filling the defect with abdominal fat, and over sewing the external canal. This is an especially appealing option if hearing is very poor in the afflicted ear. If all of the squamous epithelium has been removed, obliteration ensures a safe, well-healed, problem-free ear, although maximal conductive hearing loss is unavoidable.
Regular office visits are necessary following surgery. Some surgeons prefer to see the patient on the following day and remove the dressing themselves. Others prefer to wait 7-10 days; these surgeons allow the patient to remove the dressing at home after 12-48 hours. If nonabsorbable sutures or staples are used, they must be removed at 7-10 days.
If suture or staple removal is unnecessary, some surgeons delay the first postoperative visit for as long as 2-3 weeks. Open cavities heal slowly, and 12-24 weeks are often required for full epithelialization.
Postoperative treatment regimens for canal wall–down procedures vary considerably. The wick in the external auditory canal (EAC) is removed at the first postoperative visit, 7-10 days after surgery. Antibiotic otic drops are prescribed twice daily for 10 days.
The author prefers to fill cavities from the canal wall–down surgery with antibiotic ointment at the first postoperative visit.
Open cavities require variable amounts of cleaning over the first 4-8 postoperative weeks. The first cavity cleaning occurs at the postoperative visit 2-3 weeks after the procedure, and such cleaning can be accomplished regularly in an office setting every 2-3 weeks, depending on how quickly the cavity epithelializes.
Often, the patient is asked to fill the cavity with peroxide daily, starting 1-2 weeks postoperatively, or to irrigate the cavity with an alcohol-vinegar solution. This limits the amount of superficial infection.
Control of granulation tissue
Frequently, granulation tissue forms in the open cavity as it heals. Granulation tissue may be helpful because it can contract the size of the cavity, resulting in a much smaller postoperative cavity than would be the case if the initial defect epithelialized. On the other hand, granulation tissue can obliterate medial portions of the cavity, including the newly grafted drum, and compromise the hearing outcome. Exuberant granulation tissues can significantly delay epithelialization.
Steroid creams, steroid-containing drops, and regular applications of gentian violet can be used to help control the development and extent of granulation tissue.
Silver nitrate cautery effectively eliminates or reduces granulation tissue. However, silver nitrate produces a chemical burn, the depth of which is difficult to control, so extra caution must be used around delicate or sensitive structures such as the horizontal semicircular and facial nerve in order to avoid injury.
Often, a superficial infection develops that can be effectively controlled using topical antibiotic drops. The causative organisms are predominantly gram negative, with Pseudomonas species as the single most common pathogens, but gram-positive organisms, including Streptococcus and Staphylococcus species, account for 20-30% of recovered organisms.
Aminoglycoside and fluoroquinolone topical preparations provide appropriate antibacterial spectra for these organisms. The complete absence of potential ototoxicity among the fluoroquinolones makes them appealing. If a nonsteroidal otic preparation is desired, either ciprofloxacin or ofloxacin solution is an excellent choice.
If granulation tissue is present, steroid-containing drops may be preferred. In such cases, ciprofloxacin/dexamethasone (Ciprodex) is an excellent choice. Antibacterial creams containing fluoroquinolones can also be used. Occasionally, if granulation tissue appears to be overwhelming, steroid creams alone are useful.
If a superficial fungal infection or candidiasis develops, nystatin-triamcinolone (Mycolog) or clotrimazole (Mycelex) cream is usually sufficient to eradicate it.
Postoperative stenosis is usually a consequence of exuberant granulation tissue and is more likely to occur when a postoperative infection is present. Principles of prevention include control of the infection and suppression of the granulation tissue.
Surprisingly, the gentle pressure of expanded packing often slowly increases the size of the canal. By keeping the packing in place for several months, a 1- to 2-mm nonfunctional medial canal can be expanded to 4-5 mm, which is large enough to conduct sound efficiently and prevent additional conductive hearing loss.
If postoperative stenosis completely obliterates the cavity, revision of the cavity in an attempt to restore patency and improve hearing may be necessary. Split-thickness skin grafts limit the recurrence of postoperative stenosis.
Facial nerve damage
The most dreaded complication of tympanomastoid surgery is injury to the facial nerve. The incidence of permanent facial nerve injury following cholesteatoma surgery is not entirely certain, but it appears to be 1% or less, and it probably is much less than 1% in the hands of experienced otologists who perform the operation regularly. Controversy exists as to whether or not facial nerve monitoring is helpful in reducing the risk of postoperative facial nerve injury.
Because even the suggestion of intraoperative facial nerve injury may produce in the surgeon in pronounced sympathetic discharge with high levels of circulating catecholamines, technical skills may be degraded and judgment impaired. Therefore, the surgeon should stop operating to assess the situation, and, if at all possible, a consultant opinion should be obtained immediately.
The first step in managing a possible or recognized facial nerve injury is to decompress the nerve around the area thought to be injured. Bone should be removed a few millimeters proximal and distal to the damaged segment so that the injury can be clearly visualized.
Evaluation of the severity of injury is extremely difficult if the injured segment is in the middle ear, where the space in which the surgeon can operate is very limited. The horizontal semicircular canal limits exposure posteriorly, and the superstructure of the stapes limits exposure anteriorly. Consequently, accurate assessment of the severity of injury is especially difficult in this area.
If injury to the facial nerve is not recognized during the operation and the patient awakens with facial paralysis, the surgeon should wait several hours to make sure that this is not a consequence of the local anesthetic. If facial paralysis persists 3-4 hours beyond recovery from anesthesia, the packing should be removed.
If the surgeon is not absolutely sure that the facial nerve is anatomically intact, the patient should be taken back to surgery immediately, the nerve decompressed around the area of injury, and the severity of the injury assessed. Based on the assessment, the surgeon must decide whether or not to excise the injured segment. A consultation should be obtained if possible, and consultants should document their assessment and opinion.
If the facial nerve was clearly visualized at the time of surgery and the operating surgeon is absolutely certain that the nerve is anatomically intact, treat the injury like any other posttraumatic nerve paralysis. Begin electroneuronography testing approximately 72 hours postoperatively. If, within the first 2-3 weeks, the compound action potential on the affected side drops to less than 10% of the compound action potential on the normal side, the patient should be taken back to the operating room for exploration.
If more than 50% of the diameter of a facial nerve is deemed nonviable because it has been cut, crushed, or stretched, then the injured segment should be resected and the nerve should be anastomosed or grafted.
If a primary anastomosis can be achieved without tension, this is probably the best method of repair. A primary anastomosis with small segments of missing nerve is possible, but only if the nerve can be mobilized and rerouted over a substantial portion of its length. This is not usually possible when surgery is limited to the mastoid and tympanic segment. If a primary anastomosis without tension cannot be achieved, then an interposition graft should be placed.
Controversy exists as to whether or not facial nerve monitoring is helpful in reducing the risk of postoperative facial nerve injury.
The routine use of facial nerve monitoring remains controversial. A 1990 survey showed that most experienced otologists do not believe that facial nerve monitoring is obligatory. Indeed, a large percentage of surgeons use such monitoring only in selected cases. These include patients requiring revision surgery, patients who have had perioperative facial nerve weakness in the past, or patients in whom imaging studies show facial nerve anomalies.
On the other hand, some surgeons believe that predicting the cases in which the facial nerve is at risk is impossible and, consequently, believe monitoring should be performed in every case. These surgeons see facial nerve monitoring as a precaution, much like electrocardiographic monitoring, that can potentially be useful in any given case.
Total neurosensory hearing loss
A 1-2% chance of total neurosensory hearing loss is associated with cholesteatoma removal. A cholesteatoma that has produced a labyrinthine fistula or that lies directly over the footplate is more likely to produce permanent neurosensory loss.
In approximately 10-15% of patients undergoing cholesteatoma removal, the surgical graft fails, and a tympanic membrane perforation occurs that, if untreated, will be permanent. Such perforations, however, frequently can be eliminated with a revision operation.
Long-term balance disturbance can occur because of labyrinthine or middle ear injury but is uncommon, occurring in less than 1% of patients.
Chondritis and perichondritis
Perichondritis or chondritis occurs in less than 1% of patients. Care should be taken at the time of surgery to minimize the amount of exposed cartilage because exposure and devascularization render the cartilage more susceptible to infection.
Perichondritis develops slowly and has the following symptoms: (1) increasing pain, erythema, and edema of the skin over the involved conchal or auricular cartilage and (2) occasional fluctuance.
Fluoroquinolones offer excellent coverage for these infections, achieving blood levels equal to those achieved with oral or IV antibiotic administration. Because the blood supply to cartilage is relatively sparse, however, perichondritis and chondritis are slow to respond to antibiotic therapy.
Antibiotic therapy must be continued for a minimum of 3-4 weeks; often, 6 weeks of oral antibiotic therapy is required. If fragments of devitalized cartilage become sequestered, they require operative removal.
If no clinical response to antibiotic therapy occurs within 2-3 weeks or if the infection worsens during that period, operative drainage should be considered. Drains should be left in place for several weeks. A semicircular incision that parallels the margin of the antihelix minimizes the cosmetic impact.
Persistent drainage from a canal wall–down cavity can arise for a number of reasons. Most commonly, persistent drainage results from either a sequestered air cell that continues to harbor infection or a small area of osteitis. In such cases, the cavity as a whole heals up quite well except for a small area that remains covered with granulation tissue. The only solution is to remove the involved area.
If the area of osteitis is large and postoperative otorrhea has persisted for months or years, skin grafting should be considered. Skin grafts are especially useful in cavities that have developed mucosal (as opposed to squamous) epithelial linings on at least 1 occasion.
Sometimes, persistent or recurrent drainage is due to a residual cholesteatoma, in which case the only viable solution is reoperation to remove residual disease.
Foreign bodies retained within the mastoid cavity or wound must be removed if they have become the focus for inflammation or infection. The most common foreign bodies are small metal fragments that result from the burr hitting the end of the suction irrigation during surgery. Retained pieces or fragments of packing and/or shreds of cotton can similarly serve as a nidus of infection but can usually be removed in the office.
Many patients have alteration of taste on the anterior ipsilateral tongue for weeks after an otologic procedure. This condition, however, usually resolves within a few months after surgery.
An open cavity should be problem-free once it is fully healed, provided that the patient returns every 6-12 months for microscopic cleaning in the office. At the cleanings, variable amounts of desquamated epithelium and/or cerumen fill the depths of the cavity. Occasional areas of crusting may be present, behind which superficial areas of infection will have developed. Usually, removing the crust and exposing these areas to circulating air is sufficient to resolve the infection.
Home care may consist of regular installations of hydrogen peroxide or a one-to-one mixture of alcohol and white vinegar. Such installations may be administered daily, every other day, or weekly. The alcohol-vinegar combination is desiccating.
Because the skin of the epithelialized cavity is normal squamous epithelium, filling the cavity once or twice a month with an emollient is sometimes helpful. Baby oil or any other mineral oil product is effective. This may help to soften cerumen and reduce itching.
Most patients swim comfortably with an open cavity, but some develop vertigo when cold water enters the ear and stimulates the exposed horizontal semicircular canal. In such circumstances, the use of an earplug can effectively the block circulation of water over the exposed canal and eliminate vertigo. Children should be watched carefully the first several times they swim to make sure that they do not develop dysequilibrium and vertigo while in the water.
Each patient must be monitored for many years. Recurrence can occur long after the initial surgical excision. Follow-up care should include semiannual or annual evaluations, even in patients who are asymptomatic.
The frequency with which a patient with a canal wall–down mastoidectomy cavity needs to be seen in order to keep the ear free of desquamated epithelium and cerumen becomes readily apparent. Some patients may require follow-up evaluations as often as every 3 months for cavity cleaning, while other patients may need to be seen only once a year.
Patients who have had canal wall–up operations generally need a second-look procedure 6-9 months after the original operation. Once the second-look operation is healed, regular follow-up care at intervals of 6 months to 1 year are necessary in order to identify persistence or recurrence of the cholesteatoma.
De la Cruz A, Fayad JN. Detection and management of childhood cholesteatoma. Pediatr Ann. 1999 Jun. 28(6):370-3. [Medline].
Janet C, L CS, L JA, A GK, C PB. Congenital cholesteatoma and cochlear implantation: Implications for management. Cochlear Implants Int. 2012 Mar 2. [Medline].
Lim HW, Yoon TH, Kang WS. Congenital cholesteatoma: clinical features and growth patterns. Am J Otolaryngol. 2012 Feb 21. [Medline].
Stapleton AL, Egloff AM, Yellon RF. Congenital cholesteatoma: predictors for residual disease and hearing outcomes. Arch Otolaryngol Head Neck Surg. 2012 Mar. 138(3):280-5. [Medline].
Joel Swartz, H. Harnsberger. Imaging of the Temporal Bone. 3 Sub edition. New York: George Thieme Verlag; Oct 1, 1997.
Roland PS, Meyerhoff WL. Open-cavity tympanomastoidectomy. Otolaryngol Clin North Am. 1999 Jun. 32(3):525-46. [Medline].
Graham MD, Delap TG, Goldsmith MM. Closed tympanomastoidectomy. Otolaryngol Clin North Am. 1999 Jun. 32(3):547-54. [Medline].
Potsic WP, Korman SB, Samadi DS, Wetmore RF. Congenital cholesteatoma: 20 years' experience at The Children's Hospital of Philadelphia. Otolaryngol Head Neck Surg. 2002 Apr. 126(4):409-14. [Medline].
Kemppainen HO, Puhakka HJ, Laippala PJ, et al. Epidemiology and aetiology of middle ear cholesteatoma. Acta Otolaryngol. 1999. 119(5):568-72. [Medline].
Golz A, Goldenberg D, Netzer A, et al. Cholesteatomas associated with ventilation tube insertion. Arch Otolaryngol Head Neck Surg. 1999 Jul. 125(7):754-7. [Medline].
Drahy A, De Barros A, Lerosey Y, Choussy O, Dehesdin D, Marie JP. Acquired cholesteatoma in children: Strategies and medium-term results. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Apr 2. [Medline].
Rosito LS, Netto LS, Teixeira AR, Costa SS. Sensorineural Hearing Loss in Cholesteatoma. Otol Neurotol. 2016 Mar. 37 (3):214-7. [Medline].
Yehudai N, Most T, Luntz M. Risk factors for sensorineural hearing loss in pediatric chronic otitis media. Int J Pediatr Otorhinolaryngol. 2015 Jan. 79(1):26-30. [Medline].
Manolidis S, Kutz JW Jr. Diagnosis and management of lateral sinus thrombosis. Otol Neurotol. 2005 Sep. 26(5):1045-51. [Medline].
Djurhuus BD, Skytthe A, Faber CE, et al. Cholesteatoma risk in 8,593 orofacial cleft cases and 6,989 siblings: A nationwide study. Laryngoscope. 2014 Nov 12. [Medline].
Thompson JW. Cholesteatomas. Pediatr Rev. 1999 Apr. 20(4):134-6. [Medline].
Tierney PA, Pracy P, Blaney SP, Bowdler DA. An assessment of the value of the preoperative computed tomography scans prior to otoendoscopic 'second look' in intact canal wall mastoid surgery. Clin Otolaryngol Allied Sci. 1999 Aug. 24(4):274-6. [Medline].
Gaurano JL, Joharjy IA. Middle ear cholesteatoma: characteristic CT findings in 64 patients. Ann Saudi Med. 2004 Nov-Dec. 24(6):442-7. [Medline].
Manasawala M, Cunnane ME, Curtin HD, Moonis G. Imaging Findings in Auto-Atticotomy. AJNR Am J Neuroradiol. 2013 Nov 14. [Medline].
Vercruysse JP, De Foer B, Pouillon M, et al. The value of diffusion-weighted MR imaging in the diagnosis of primary acquired and residual cholesteatoma: a surgical verified study of 100 patients. Eur Radiol. 2006 Mar 3. [Medline].
Dubrulle F, Souillard R, Chechin D, et al. Diffusion-weighted MR imaging sequence in the detection of postoperative recurrent cholesteatoma. Radiology. 2006 Feb. 238(2):604-10.
Yamashita K, Hiwatashi A, Togao O, et al. High-resolution three-dimensional diffusion-weighted MRI/CT image data fusion for cholesteatoma surgical planning: a feasibility study. Eur Arch Otorhinolaryngol. 2014 Dec 28. [Medline].
Hunter JB, Zuniga MG, Sweeney AD, et al. Pediatric Endoscopic Cholesteatoma Surgery. Otolaryngol Head Neck Surg. 2016 Mar 1. [Medline].
Dawes PJ, Leaper M. Paediatric small cavity mastoid surgery: second look tympanotomy. Int J Pediatr Otorhinolaryngol. 2004 Feb. 68(2):143-8. [Medline].
Prinsley P. An audit of 'dead ear' after ear surgery. J Laryngol Otol. 2013 Nov 11. 1-7. [Medline].
Jindal M, Riskalla A, Jiang D, Connor S, O'Connor AF. A systematic review of diffusion-weighted magnetic resonance imaging in the assessment of postoperative cholesteatoma. Otol Neurotol. 2011 Oct. 32(8):1243-9. [Medline].
Visvanathan V, Kubba H, Morrissey MS. Cholesteatoma surgery in children: 10-year retrospective review. J Laryngol Otol. 2012 Feb 6. 1-4. [Medline].
Osborn AJ, Papsin BC, James AL. Clinical indications for canal wall-down mastoidectomy in a pediatric population. Otolaryngol Head Neck Surg. 2012 Aug. 147(2):316-22. [Medline].
Roth TN, Haeusler R. Inside-out technique cholesteatoma surgery: a retrospective long-term analysis of 604 operated ears between 1992 and 2006. Otol Neurotol. 2009 Jan. 30(1):59-63. [Medline].
Sanna M, Facharzt AA, Russo A, Lauda L, Pasanisi E, Bacciu A. Modified Bondy's technique: refinements of the surgical technique and long-term results. Otol Neurotol. 2009 Jan. 30(1):64-9. [Medline].
Walker PC, Mowry SE, Hansen MR, Gantz BJ. Long-Term Results of Canal Wall Reconstruction Tympanomastoidectomy. Otol Neurotol. 2013 Oct 16. [Medline].
Busaba NY. Clinical presentation and management of labyrinthine fistula caused by chronic otitis media. Ann Otol Rhinol Laryngol. 1999 May. 108(5):435-9. [Medline].