OTO-ENDOSCOPY FOR RESIDUAL DISEASE AFTER RADICAL AND MODIFIED RADICAL MASTOIDECTOMY FOR CHOLESTEATOMA

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1 Original Article OTO-ENDOSCOPY FOR RESIDUAL DISEASE AFTER RADICAL AND MODIFIED RADICAL MASTOIDECTOMY FOR CHOLESTEATOMA *Salahuddin Ayubi, *Muhammad Zahid Rafiq Gill *Assistant Professor, University Medical Dental College, Faisalabad. ABSTRACT Introduction: Oto-endoscopy is a new and latest introduction in the middle ear and mastoid surgery. Its application has not yet gained popularity in Pakistan and our study is first of its kind in Pakistan to evaluate the utility of oto-endoscope in canal wall down procedures. Objectives: To see whether the use of oto-endoscope helps in decision making to modify the procedure preoperatively or decrease the incidence of residual disease better than microscope in radical and modified radical mastoidectomy. Study design: Case series Patients and methods: ENT Unit, Madina Teaching Hospital, Faisalabad (A tertiary care hospital). Non-probability convenience sampling. Twenty patients in total. Results: Oto-endoscopy detected five cases of residual disease after modified radical mastoidectomy and one case after radical mastoidectomy. Conclusions: 1. Oto-endoscopy does influence the detection of residual cholesteatoma in sinus tympani, anterior epitympanum and protympanum. 2. It can also modify the decision to convert modified radical to radical mastoidectomy if required. Keywords: Cholesteatoma, residual disease, oto-endoscopy. INTRODUCTION CSOM, one of the common diseases presenting in ENT clinics in developing countries still poses a great challenge due to inherent morbidity and mortality associated with its complications. 1,2 Cholesteatoma an expanding lesion of temporal bone composed of outer bone eroding stratified squamous epithilial lining and desquamated keratin centre is found to be associated with most of Corresponding Author: Salahuddin Ayubi, Assistant Professor, UMDC, Faisalabad. ayubi63@yahoo.com the complications of unsafe type of CSOM 3. The surgical treatment in management of middle ear cholesteatoma has been a matter of debate for years. 4,5,6,7,8,9 Despite advancements in surgical techniques, improved instruments and use of microscope the problem in middle ear surgery still remains residual/recurrent cholesteatoma which varies from 5.9% to 49.5% in different series necessitating second look surgery or revision mastoidectomy. 5,10,11,12,13 The anterior epitympanum, retro tympanum or protympanum are the areas which are difficult to see under operating microscope and thus are common sites for residual/recurrent cholesteatoma. 14,15,16,20 The present study aims whether the complementary use of angled endoscope helps in eliminating the residual cholesteatoma from these areas. 28 JUMDC Vol. 2, Issue 1, Jan-Jun 2011

2 MATERIALS AND METHODS A case series study of eight months duration with non-probability convenience sampling was conducted at Department of Otolaryngology, Madina Teaching Hospital, Faisalabad from 1 st January 2010 to 31 st October Madina Teaching Hospital is a 700 bed teaching, tertiary care welfare Hospital covering both rural and urban population. Twenty patients of lower and middle class between years of age both male and females having history of foul smelling and bloody chronic ear discharge and cholesteatoma confirmed on microscopy were included in the study. Inclusion criteria was patients with CSOM attico-antral type above the age of 15 years in which posterior limit of cholesteatoma cannot be seen in microscopy with no other associated ear disease and malformation. Exclusion criteria was all those patients who already had undergone any kind of surgery at any other centre, patients with dead ear or patients referred from neurosurgical department after treatment of any intracranial otogenic complication. All the patients were thoroughly interviewed and complete ENT examination including microscopy of the ear with 12X magnification microscope was done to see presence of cholesteatoma as well as site of cholesteatoma. Swab for culture and sensitivity of ear discharge was taken in all cases. Comparative skiagram of both mastoids was also obtained. Hearing assessment by tuning fork tests and pure tone audiometery was also conducted preoperatively. The surgery and the assessment of the radical and modified radical cavity were done by the same surgeon every time. After the completion of procedure under microscope the assessment for the presence or absence of cholesteatoma in three most notorious sites for residual cholesteatoma i.e. sinus tympani, anterior epitympanum and protympanum was done by 2.7 mm Hopkins rod endoscope with 0, 30 and 70 oto-endoscope. The diseases if present was again cleared by angled otoendoscope, angled pick and tailor made curved suction tip or procedure modified if required (see table) and by the end of procedure the ear was re-evaluated for any persistence of disease or otherwise. The total time taken for the procedure from the incision to the last stitch was noted and also the extra time taken for the detection of cholesteatoma by oto-endoscope to its clearance was noted. All the procedures including the otoendoscopy was done by the same surgeon to maintain the uniformity as well as reliability of the results. Descriptive statistics using Microsoft Spss software was used in the study. RESULTS Twenty patients including 13(65%) males and 7(35%) females between 15 to 55 years of age belonging to lower/middle class were included in the study. Mean age of presentation was years. 40% belonged to middle class and 60% to lower class (Graph-I). Forty five per cent presented with Graph I. Sites of Choleateatoma foul smelling aural discharge as their major complaint, 55% with deafness as well as aural discharge, whereas 45% had history of bilateral ear discharge. Mean duration of otorrhoea was 9.45 years. All the patients were admitted through outdoor. Microscopy showed attic cholesteatoma in 35% of the cases, posterosuperior perforation with cholesteatoma in 45% cases and central perforation with cholesteatoma in 20% cases. All the patients had conductive hearing loss and 8(40%) had sensorineural hearing loss also. Average AB gap was db in speech frequencies (Table-I). All the patients underwent canal wall down procedure (modified or radical mastoidectomy) under microscope by same surgeon. Oto-endoscopy by 0, 30 and mm Hopkins rod endoscope was done to detect any residual cholesteatoma at the end of procedure. Residual cholesteatoma was seen in 30% (06 cases) of cases in our series i.e. in 05 patients JUMDC Vol. 2, Issue 1, Jan-Jun

3 Table I. Patient Duration of Average AB gap on PTA Site of Age Sex No. otorrhoea in speech frequencies db cholesteatoma M 4 years 20 Attic M 12 years 35 Posterosuperior F 15 years 30 Central+chol M 7 years 25 Attic M 3 years 35 Attic M 5 years 40 Attic F 9 years 35 Posterosuperior F 18 years 30 Central+chol M 4 years 40 Attic M 6 years 20 Posterosuperior M 3 years 45 Posterosuperior M 10 years 30 Posterosuperior M 5 years 35 Posterosuperior F 20 years 20 Central+chol M 7 years 25 Posterosuperior F 25 years 35 Central+chol F 9 years 30 Attic F 10 years 35 Attic M 12 years 30 Posterosuperior M 5 years 40 Posterosuperior Mean Central+chol = cholesteatoma with central perforation who underwent modified radical mastoidectomy and in 01 patient after radical mastoidectomy (see table). The disease was then cleared by use of angled otoendoscope, curved pick and tailor made curved suction tip in two cases (i.e. in 40% of cases with residual disease after modified radical mastoidectomy) while in three cases we had to convert modified radical to radical mastoidectomy because either the sinus tympani was too deep or there was invasion of supra-structure of stapes and it was not possible to remove the disease completely without removing the supra structure of stapes thus otoendoscope modified our earlier decision of modified radical mastoidectomy in 20% of our cases in our series. We also analyzed the site of residual disease in our study and found the sinus tympani the most notorious site for residual cholesteatoma (83.3%) followed by anterior epitympanum (50%) and protympanum (16.67%) just above opening of Eustachian tube. 50% of our cases had residual disease at more than one site. In one of our patient who had residual disease after radical mastoidectomy, the sinus tympani was too deep and we were unable to clear the cholesteatoma despite the use of angled otoendoscope, curved pick and tailor made suction tube (see table). The average time taken for the procedure to complete was minutes and the average extra time taken for oto-endoscopy and clearance of residual disease was 10 minutes (Table-II). DISCUSSION Surgical management of choleasteatoma remains controversial. 4,5,6,7,8,9 The canal wall down procedures (Radical or modified radical mastoidectomy) are considered by many otologists as gold standard despite their attentend problems 4,5,10,17,18 (i.e. recurrent ear infections, necessity for periodic life long medical attention for cavity clearance, restrictions on social activity) for advanced disease, complicating otitis media or in patients who are likely to be lost in follow-up. The reason for their preference is canal wall down procedure provides better eradications of disease and are thus safe for the patient. 5,10,17,18,19 The persistence of wet ear is one of the main concern of the patients leading to revision surgery. One of the main 30 JUMDC Vol. 2, Issue 1, Jan-Jun 2011

4 Patient No. Type of Procedure after microscopical surgery Procedure Time Table II. Extra time for otoendo Site of residual disease Final procedure Residual disease status at of the end S.T A.ET PRO 1. MRM 2:00 hrs 10 mins MRM - 2. MRM 2:05 hrs 14 mins MRM - 3. MRM 1:25 hrs 15 mins RM - 4. MRM 1:47 hrs 05 mins MRM - 5. MRM 1:55 hrs 08 mins MRM - 6. MRM 1:52 hrs 11 mins MRM - 7. MRM 1:50 hrs 07 mins MRM - 8. MRM 1:58 hrs 09 mins MRM - 9. RM 1:49 hrs 09 mins RM MRM 1:52 hrs 12 mins MRM RM 1:46 hrs 05 mins RM MRM 1:48 hrs 07 mins MRM MRM 2:10 hrs 08 mins MRM RM 1:40 hrs 09 mins RM MRM 1:58 hrs 09 mins MRM MRM 1:39 hrs 15 mins RM RM 1:36 hrs 15 mins RM MRM 2:07 hrs 09 mins MRM RM 1:35 hrs 08 mins RM MRM 1:44 hrs 15 mins RM - Mean RM=Radical mastoidectomy MRM=Modified Radical mastoidectomy hrs=hours mins=minutes S.T=Sinus tympani PRO=Protympanum A.ET=Anterior epitympanum Otoendo=Oto-endoscopy reasons for discharging ear after such a surgery is persistent cholesteatoma 11,12,13 and the common sites of residual/recurrent disease is sinus tympani or anterior epitympanum. 7 16,20,22 We in our study on 20 patients after completing the drill work under microscope did complementary endoscopy with 2.7mm 0, 30 and 70 telescope (Hopkins rod) and looked for the presence or absence of cholesteatoma in sinus tympanic/ anterior epitympanum and protympanum and noticed that 30% of patients still had residual disease in these areas. El-Meselaty et al. 8 in his series on use of endoscope in canal wall down and canal wall up procedures after drill work under microscope also noticed 30% incidence of residual cholesteatoma in canal wall down procedures while 50% incidence of residual cholesteatoma in canal wall up procedures. Pressutt et al. 20 had noticed 37% incidence of residual cholesteatoma with otoendoscope after microscopical work in his series. The commonest site of residual cholesteatoma was sinus tympani (83.3%) followed by anterior epitympanum (50%) and protympanum (16.67%) in our series. Ayeche et al. 16 in a similar study noticed 76% incidence of residual cholesteatoma in sinus tympani and 44% in anterior epitympanum. The sinus tympani was also the most common site of residual cholesteatoma in a series by Presutt et al. 20. The reason for such a high incidence of recurrent/residual disease in sinus tympanum is that it is one of the most difficult areas to see by microscope. 14,15,16,20,21,22 The otologists had used CT scan 24 to preview the difficult areas and plan an ideal approach for better eradication of disease. The use of oto-endoscope is a step forward in this direction. The sinus tympani is classified into type A B C 22 according to its depth and difficulty index to remove the disease from it. Morchinoi et al. 22 had noticed that otoendoscope is quite helpful to eradicate the disease in type A B while in type C even the oto-endoscope is unable to remove the disease completely. Thomassin et al. 22 in their study on use of oto-endoscope in middle ear had divided sinus tympani into type I, II and III and noticed that in type III which in his JUMDC Vol. 2, Issue 1, Jan-Jun

5 series accounted for 25% of cases, the removal of disease is not without the risk of damage to the vital structures and recommended retrofacial approach for such cases. We in one of our cases were unable to clear the disease from sinus tympani despite the use of angled oto-endoscope. However we have not used the retro-facial approach recommended by Thomassin et al. 23 and kept the patient on follow-up without any significant complication. We also measured the additional time taken by the use of otoendoscope after the completion of drill work under microscope and noticed that additional time taken was 10±5 minutes which was not a long time considering the benefits attained by the use of oto-endoscope. In our series we have to convert three of our cases from modified radical to radical mastoidectomy because the disease was involving the crura of stapes and sinus tympani was too deep that it was not possible to remove the disease from sinus tympani without removing the supra structures of stapes and thus oto-endoscope helped us in changing our decision in 20% of our cases and we agree with the similar work done previously 8,9,15,16 that use of otoendoscope plays an important role in decision making and helps in decreasing the incidence of residual disease and thus may decrease the recurrent disease. In our series we followed our patient for 6 months and attained dry ear in 90% of cases with no incidence of residual/ recurrent disease except in one of our patients in whom we were unable to remove the cholesteatoma from deep sinus tympani at the time of surgery even with the help of otoendoscope. However the patient is symptom free after 8 months of follow-up and kept on regular suction clearance under otoendoscope. We didn t come across any significant complication associated with the use of oto-endoscope in our series and conclude that oto-endoscope is useful complimentary instrument in ear surgery especially in cases of chronic otitis media with cholesteatoma and can play an important role in better disease control. However further bigger studies in future are needed. Graph II. Condition of the cavity CONCLUSIONS 1. Oto-endoscopy does influence the detection of residual cholesteatoma in sinus tympani, anterior epitympanum and protympanum. 2. It can also modify the decision to convert modified radical to radical mastoidectomy if required. REFERENCES 1. Akinpelu OV, Amusa YB, Komolafe EO, Adeolu AA, Oladele AO, Ameye SA. Challenges in management of chronic suppurative otitis media in a developing country. J Laryngol Otol. 2008; 122(1): Dubey SP, Larawin V. Complications of chronic suppurative otitis media and their management. Laryngoscope. 2007; 117(2): Memon, MA, Matiullah S, Ahmed Z, Marfani MS. Frequency of un-safe chronic suppurative otitis media in patient with discharging ear. J Liaquat Uni Med Health Sci. 2008; 7(2): Sade J. Surgical planning of the treatment of cholesteatoma and postoperative follow-up. Ann Otol Rhinol Laryngol. 2000; 109(4): Tauno Palva. Surgical treatment of chlesteatomatous ear disease. The Journal of Laryngology and Otology. 1985; 99: JUMDC Vol. 2, Issue 1, Jan-Jun 2011

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