Management of anterior epitympanic cholesteatoma: Expectations after epitympanic approach and canal wall reconstruction

Background: The epitympanic approach to cholesteatoma provides excellent access to the anterior epitympanic space. When it is combined with reconstruction of the scutum. it is tempting to propose that the approach may offer the patient the advantage of both canal wall up and canal wall down techniques and the disadvantages of neither. In theory. then, the incidence of residual/recurrent cholesteatoma should be no greater than that for canal wall down surgery, and the need for a second look often associated with the canal wall up procedure should be less compelling. However. validation of this theory is lacking. Objective: To test this theory, we sought to establish the incidence of recidivism in patients undergoing cholesteatoma removal via the epitympanic approach followed by canal wall reconstruction, to identify anatomic factors predisposing to persistent disease, and to identify technical features or problems associated with recurrent cholesteatoma. Study Design: A retrospective case series. Setting: A tertiary referral center. Patients: Fifty-four adults and I I children with extensive cholesteatoma involving but not limited to the anterior epitympanic space. Intervention: All patents underwent removal of cholesteatoma via the epitympanic approach with canal wall reconstruction followed by reexploration I year later. Results: Recurrent/residual disease was observed in 6 adults (11%) and 5 of 11 children (45%). The anterior epitympanic space harbored cholesteatoma in 100% of adults and 80% of children with recurrent disease. Conclusion: The epitympanic approach does not eliminate the need for reexploration in cases of extensive cholesteatoma involving the anterior epitympanic space, The anterior epitympanic space is highly likely to harbor residual disease. Features of the canal wall reconstruction can be identified that predispose to recurrence. Long-term follow-up and close surveillance are mandatory, especially in children.