In order to search for an ideal surgical treatment of middle ear cholesteatoma the following studies have been carried out,
1) Study on pathology of postoperative cholesteatoma:
In my series of 1044 tympanoplasties with preservation of the posterior canal wall, postoperative cholesteatoma was seen in 20% of preoperative cholesteatoma cases and in 2.2% of non-cholesteatoma cases. The incidence of postoperative attic retraction cholesteatoma was greater in cases with perforation of the posterosuperior quadrant without cholesteatoma than in attic cholesteatoma cases.
In many postoperative attic retraction cases. the tympanic membrane was adherent with the horizontal segment of the facial canal and cholesteatoma rested lateral to the ear drum.
As granulation was the main pathological feature in the tympanum, it was inferred that absence of the lateral attic wall and malfunction of the eustachian tube were the major contributing factors for the development of postoperative attic retraction.
The incidence of postoperative cholesteatoma decreased dramatically after corrective measures were taken for the above causes.
2) Examination of cholesteatoma which was found in planned staged tympanoplasties revealed that most of them were of residual nature, while some were considered to be implanted cholesteatoma.
3) Morphological and anatomical studies of the tympanic folds in temporal bone specimens in connection with the clinical findings indicated that attic cholesteatoma is prone to occur in poorly pneumatized temporal bones and its development appears to be related to obstruction of the tympanic isthmus, which might also be a cause of glue ear in children.
Retraction of the postero-superior quadrant of the tympanic membrane, which may be a complication of glue ear seems associated with malfunction of the eustachian tube, proliferation of granulation in the middle ear and adhesions of the tympanic membrane to the promontory.
4) The three major factors in the pathogenesis of cholesteatoma are considered to be malfunction of the eustachian tube, granulation proliferation and negative pressure in the middle ear.
By creating the three conditions in experimental animals we could produce cholesteatoma in the middle ear, which would offer a sound basis for the migration theory.
5) On the basis of our study it is concluded that prevention of postoperative recurrence of cholesteatoma can be attained by:
1. practice of staged tympanoplasty; 2. use of intact canal wall tympanoplasty; 3. utilization of silastic sheets in the tympanum; 4. reconstruction of the lateral wall of the attic; and 5. adoption of lateral grafting rather than medial grafting.
6) Survey on the status of middle ear surgery for cholesteatoma has been performed on an international basis.
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