Transcanal endoscopic ear surgery feasible and effective for the removal of Congenital cholesteatoma:JAMA
Congenital cholesteatoma (CC) is an uncommon condition. The reported incidence of CC, however, has been increasing, which might be due to early identification and increased awareness of cholesteatomas. The improvement in and widespread use of diagnostic tools, such as endoscopes and microscopes, in local clinics have likely played an important role in the early identification of CCs by primary care physicians, pediatricians, and otolaryngologists. The treatment of choice for CC is complete surgical removal, avoiding damage to the normal structures, and prevention of recurrence. The traditional method of middle ear cholesteatoma surgery is performed under a microscope
With advances in endoscopic technology, the role of transcanal endoscopic ear surgery (TEES) has gained more attention in managing cholesteatoma, particularly in pediatric populations. The angled endoscope provides wide dynamic visualization, which aids in looking for hidden areas in the middle ear cavity during CC removal. The improved visualization offered by the endoscope may also obviate a large incision (postauricular or endaural incision), which provides minimally invasive transcanal access to the middle ear.
This study by Choi JE et al assessed the outcomes of TEES for CC to determine the clinical efficacy of TEES in pediatric patients with CC.
This cohort study evaluated retrospective, multicenter data for 271 children with CC who underwent TEES at 9 tertiary referral hospitals in South Korea between January 1, 2013, and December 31, 2021, and had a follow-up of at least 6 months after surgery. Outcomes included the incidence of residual cholesteatoma and audiometric data after TEES.
- Of the 271 patients, 190 had Potsic stage I CC (70.1%), 21 (7.7%) had stage II, 57 (21.0%) had stage III, and 3 (1.1%) had stage IV.
- Thirty-six patients (13.3%) with residual cholesteatoma were found, including 15 (7.9%) with Potsic stage I, 3 (14.3%) with stage II, and 18 (31.6%) with stage III.
- In the multivariable analysis, invasion of the malleus (HR, 2.257; 95% CI, 1.074-4.743) and posterosuperior quadrant location (HR, 3.078; 95% CI, 1.540-6.151) were associated with the incidence of recidivism.
- Overall, hearing loss (>25 dB on auditory behavioral test or >30 dB of auditory evoked responses) decreased from 24.4% to 17.7% after TEES.
- This cohort study represents the largest series to date of CC removed by TEES and reveals a favorable surgical outcome, with a recidivism rate of 13.3% among 271 children with CC limited to the middle ear and/or mastoid antrum. The observed recidivism rate was lower than published estimates with microscopic techniques, which range from 20% to 52%.
Risk of residual cholesteatoma was associated with a higher Potsic stage. These rates compare favorably with those of residual cholesteatoma removed by the microscopic technique, ranging from a 13% risk in stage I to 67% in stage IV. The TEES technique improves visualization and can reduce the risk of residual cholesteatoma. The use of both hands to dissect cholesteatoma, which is difficult while using an endoscope, does not provide an advantage for resection completeness of middle ear and attic cholesteatomas.
The findings suggest that TEES may be effective in treating CC limited to the middle ear and/or mastoid antrum in children. Recidivism was low even for advanced stages. Based on findings, cholesteatoma invasion of the malleus and presence in the PSQ of the tympanic cavity may be associated with significantly higher residual rates. These results may help to guide surgeons to achieve optimal results for patients with CC.
Source: Choi JE, Kang WS, Lee JD, et al. Outcomes of Endoscopic Congenital Cholesteatoma Removal in South Korea. JAMA Otolaryngol Head Neck Surg. Published online January 19, 2023. doi:10.1001/jamaoto.2022.4660
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