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Open mastoideetomy was done in 13 of the cases in the present series. It was done in four cases for anatomical reasons e.g. far forward sigmoid sinus, low middle fossa dura, and in nine cases for pathological reasons because the disease destroyed the posterior wall of the external auditory canal, and in advanced cases of cholesteatoma with intracranial complications.

Endoscopic ear surgery has been introduced in the late eighties. While the role of the endoscopes in pre- and intra- operatire examination of the middle ear has added much to the anatomic knowledge and diagnostic capabilities ofthe otologist, the use of endoscopes in otosurgery was handicapped by the single handed approach and the continuous need for drilling and irrigation.[10,11] In the present study, the endoscope was used during microscopic ear surgery to enhance the vision during certain steps of the operation.

In FMMS, in view of the meticulous middle ear dissection and emphasis on the use of endoscopes to explore all the possible sites of pathology like anterior epyitympanic recess, sinus tympani and stapes area, staging for the possibility of residual or recurrent cholesteatoma was not done. Staging was done in 4.1 percent (5/ 120) for revising ossicular reconstruction, or to remove a silastic sheet put to provide aeration in the middle ear.

Conclusion

Due to the changing trends in the presentations of chronic ear disease, as well as the advances in its diagnosis and treatment, FMMS presents a surgical roadmap for tympano-mastoid cholesteatoma. It stresses the fact that the middle ear should be the primary target of otosurgeons to clear pathology and reconstruct the hearing mechanism. Mastoidectomy is performed, only if necessary, to approach the middle ear posteriorly and to clear pathology extensions if needed.

References

1. Tos M, Lau T. Late results of surgery in different cholesteatoma types. ORL J Otorhinolaryngol Relat Spec. 1989; 511:33-49.

2. Syms M, Luxford W. Management of cholesteatoma: status of the canal wall. Laryngoscope. 2003; 113:443-8.

3. Kos M, Castrillon R, Montandon P, Guyot J. Anatomic and functional long-term results of canal wall-down mastoidectomy. Ann Otol Rhinol Laryngol 2004; 113:872-6.

4. Olszewska E, Wagner M, Sprekelsen M. Etiopathogenesis of cholesteatoma. European arch. Otolaryngol 2004; 201: 6-24.

5. Kapur R. Causes of failure of combined approach tympanoplasty in the treatment of acquired cholesteatomas of the middle ear and the mastoid. J Laryngol Otol. 1995; 109:710-2.

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