Endoscopic Control of Hard-to-Access Sites During Microscopic Cholesteatoma Surgery

PURPOSE: Residual cholesteatoma poses a great challenge in middle ear surgery. Considering that microscopes only offer line-of-sight vision, it was suggested earlier that endoscopes might prove useful to control difficult-to-visualize areas during surgery to ensure total evacuation of squamous epithelium. In this retrospective chart study, we evaluated intraoperative endoscopic findings of difficult-to-access sites in the tympanic cavity and postoperative cholesteatoma recidivism rate in these areas in a patient cohort who underwent primarily microscopic surgery. MAIN FINDINGS: Residual cholesteatoma mass was intraoperatively detected in difficult-to-visualize areas using an endoscope during 50% of the procedures (10 cases), mostly in the sinus tympani (6 cases), but also in the supratubal recess (3 cases). During a mean follow-up of 36.1 months (range: 20-59 months, targeted magnetic resonance imaging [MRI] mean follow-up: 31.3 [range: 12-59]), recurrent attic cholesteatoma was found in 2 patients (10%), and residual disease was detected with dedicated MRI sequences in another 2 cases (10%). None of the residual cholesteatomas developed in the endoscopically controlled areas. The mean air-bone gap closure at 1 year was 1.9 ± 10.2 dB (range: -18.3-21.7). CONCLUSIONS: Intraoperative endoscopic surveillance helps uncovering hidden cholesteatoma mass during routine microscopic surgery and thus offers an effective control of residual disease in these areas during a medium-term follow-up.