Review ArticleCan endoscopic ear surgery replace microscopic surgery in the treatment of acquired cholesteatoma? A contemporary review
Introduction
Acquired cholesteatoma is a non-neoplastic lesion consisting of keratinizing squamous epithelium in the temporal bone. This could be primary, arising from a retraction pocket, or secondary, due to migration of squamous epithelium via a tympanic membrane perforation [1,2]. Acquired cholesteatoma can gradually expand and erode adjacent structures by bone resorption, which may lead to intratemporal complications, such as hearing loss, vestibular dysfunction, facial paralysis, and intracranial complications [3,4]. Cholesteatoma is a surgical disease that requires meticulous surgical clearance [5].
The primary goal of cholesteatoma surgery is to provide a safe, dry ear. The traditional approach uses a microscope and includes canal wall up (CWU) and canal wall down (CWD) techniques; either performed via postauricular, endaural or transcanal approach [6]. The CWU technique, or closed cavity, retains more anatomy at the expense of higher risk of residual disease and need for possible second-look middle ear exploration. In contrast, the CWD technique, or open cavity, presents with lower recurrence rates but results in a mastoid cavity that requires life-long follow-up [7,8]. The choice between the two techniques remains an ongoing debate, and depends on disease status, patient factors, surgeon's skill and expertise level.
The use of endoscopes has revolutionized our approach to middle ear surgery [9]. Since the 1990s, endoscopic ear surgery (EES) has reported encouraging outcomes in tympanoplasty, ossiculoplasty, cochlear implantation, and neurotologic procedures [7,[10], [11], [12], [13], [14]]. For cholesteatoma, EES is primarily used as an adjunct to microscopes for diagnostic purposes. Thomassin et al. [15] first reported the use of the endoscope for the identification of residual cholesteatoma. Since then, various studies have shown the addition of endoscope use has significantly reduced residual and recurrence rates of cholesteatoma compared to microscope use alone, especially for CWU procedures [7]. In fact, there has been a shift towards exclusive EES without a microscope in the management of cholesteatoma [4,16,17].
Can EES replace traditional microscopic ear surgery (MES) in the treatment of acquired cholesteatoma? Here, we discuss the evidence behind EES in adult and pediatric cholesteatoma, advantages and disadvantages of EES as well as current challenges.
Section snippets
Methods
A literature review was performed in PubMed database from its inception to September 2019. Keywords “endoscopic surgery” and “acquired cholesteatoma” were searched. Relevant articles in the English language comparing the use of transcanal EES versus exclusive microscopic surgery in the treatment of acquired cholesteatoma in adult or pediatric populations were identified (Table 1). Publications that presented the outcomes of exclusive EES for management of acquired cholesteatoma without control
Adult cholesteatoma
The indication of EES includes cholesteatoma limited to the tympanic space and its sub-sites (e.g, epitympanum, mesotympanum, retrotympanum, protympanum, and hypotympanum) and antrum [[17], [18], [19], [20], [21], [22], [23]]. Where mastoid is involved, treatment options become controversial. Some suggest conversion to the microscope with CWD, or a combined endoscopic and microscopic approach with mastoidectomy [17]; whilst others claim that an exclusive endoscopic approach is possible [22,24,25
Benefits of EES
EES has significantly changed our traditional mindset and surgical approach [26,38]. Acquired cholesteatoma due to retraction of the tympanic membrane has its bulk in the middle ear, with more advanced cases reaching the mastoid cavity. The majority of failures with MES occurred within the tympanic space instead of the mastoid. EES redirects surgeons’ attention away from mastoid towards the tympanic space and subsites [26,28]. In fact, transcanal approach follows the rational route of
Current challenges
Worldwide, there has been a slow acceptance of this new technique, partly due to the adequacy of microscopes, the need to acquire new skills, and the perception of no added benefits to patients or surgeons [39]. Moreover, endoscopes have their inherent limitations that make it technically challenging, especially for novice surgeons at their ‘learning curve’ [26,38].
Limited cholesteatoma
The main indications for EES are limited cholesteatoma within the tympanic cavity and attic without significant mastoid involvement [26,38]; since disease that does not extend beyond the lateral semicircular canal can still be dissected with endoscopic equipment. Following transcanal elevation of tympanomeatal flap and atticotomy, the sac and matrix can be removed completely under direct visualization (Fig. 1). Tympanic membrane, ossicular chain and attic defect can be reconstructed using
Conclusion
EES represents a new frontier in our perception, understanding, and approach in middle ear surgery. Compared to the microscope, the endoscope is minimally invasive, has less morbidities, less recurrence rate compared to CWU mastoidectomies, results in better hearing outcomes with greater preservation of normal anatomy, as well as improves visualization and ability to look “around the corners”. However, the use of an endoscope can be technically difficult and has its learning curve. The
Funding
This work was supported by the National Natural Science Foundation of China (grant number 81670920); Natural Science Foundation of Zhejiang Province (grant number LY15H130003); Medical and Health Science Research Foundation of Zhejiang Province (grant numbers 2016KYB272, 2020RC107); Natural Science Foundation of Ningbo (grant number 2018A610363); and Huimin Research and Development Foundation of Ningbo (grant number 2015C50026).
Declaration of competing interest
The authors have no conflict of interest to disclose.
Acknowledgements
None.
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