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Advanced Otology:
Discussion
There are three ways that determines the surgical strategy of cholesteatoma. First, patient’s factors like bilaterality, and hearing level in diseased and contralateral ear. Second, surgeon’s choice that depends on his practice and experience. This choice obviously changes from time to time according to his added experience. The third choice, is the most logical in our view, depends on pathology of cholesteatoma, namely its site of origin, ways of spread, biological behavior and growth rate, and histological characteristics.
TMC staging system (Belal, 2005) outlines a simple clinico- radiological staging of the disease that allows us to have a road map for the surgical approaches meant to remove completely the pathology and reconstruct the hearing mechanism. We have called this surgical approach system, which is based on pathological staging: Functional Middle ear and Mastoid Surgery (FMMS). It is meant to replace mastoidectomy as the classical surgical approach to remove cholesteatoma. It emphasizes the fact that cholesteatoma almost always starts in the middle ear, then spreads in the temporal bone according to its site of origin, biological behavior and lines of least resistance . This means that we need to clear the middle ear first by proper anterior exposure that may include canaloplasty, retro-tympanotomy, hypo-tympanotomy, anterior atticotomy and anterior epi-tympanotomy.
Then, the decision of doing mastoideetomy is taken based on pre-operative staging of the disease as well as intra-operative findings . In most of the cases, intact canal wall mastoidectomy suffices to completely clear mastoid disease as well as to approach the middle ear from the posterior route. This includes posterior atticotomy and posterior epi-tympanotomy. Posterior tympanotomy was only done in six cases in this series, probably because of proper anterior clearance of the disease from the facial recess with the help of endoscopes.