The Effect of the Status of the Ossicular Chain and Choice of Graft Material on Hearing Outcomes in Pediatric Cholesteatoma Surgery

OBJECTIVE: Compare hearing benefit of incus preservation in primary cholesteatoma surgery versus cartilage-myringostapediopexy. METHODS: Prospective cohort study in a tertiary referral center. Tympanoplasty utilizing cartilage or other grafts, with or without intact incus was performed in 195 ears (187 children) with intact stapes. Outcome measures were pre and post-operative four-tone air conduction (AC) threshold (0.5, 1, 2, 4 kHz) and proportion with normal hearing (AC <= 30 dB HL) at 12 months. RESULTS: Ears with intact ossicles had better post-operative AC thresholds than those with incus eroded or removed (median 20 dB HL vs. 30 dB HL, Mann-Whitney P <.001). The normal hearing rate was 81/106 (74%) with intact incus and 46/89 (52%) without (Fisher's exact P =.001). Ears without intact incus and a cartilage-myringostapediopexy had better post-operative thresholds than those with a non-cartilage graft (28.8 dB HL vs. 36.3 dB HL, Mann-Whitney P =.005). Of ears without intact incus, 37/59 (63%) with a cartilage-myringostapediopexy and 9/30 (30%) with a non-cartilage graft had normal hearing post-operatively (Fisher's exact P =.007). By preserving the incus in 12 ears, 1 more ear would have normal hearing than with incus removal plus cartilage-myringostapediopexy (NNT = 12 (CI 3.6-); Fisher's exact = 0.1). CONCLUSION: Preserving an intact ossicular chain conveys a small but significant hearing benefit in cholesteatoma surgery, the magnitude of which should be considered before deciding to remove the intact incus. Cartilage-myringostapediopexy provides a significant gain in hearing when the incus is absent, even without a partial ossicular replacement prosthesis.