|Year : 2014 | Volume
| Issue : 2 | Page : 45-47
Management of cholesteatoma complications: Our experience in 145 cases
Aziz Mustafa, ShkŰlzen Kuši, Arsim Behramaj
ENT Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
|Date of Web Publication||3-May-2014|
ENT Clinic, University Clinical Center of Kosova, rr. Spitalit pn, 10000 Prishtina
Source of Support: None, Conflict of Interest: None
Objectives: To assess the incidence, clinical features, diagnosis and treatm ent of complications of cholesteatomatous chronic otitis media (CCOM) seen in the ENT/Head and Neck Surgery Clinic, University Clinical Center of Kosova, Prishtina. Materials and Methods: This is a retrospective study of the medical records of patients with complications of CCOM who had undergone surgical treatment at the ENT Clinic of the University Clinical Center of Kosovo for the period time of 1994 to 2011. Results: From a total of 2765 patients suffering from COM, 502 (18.08%) had cholesteatoma. From this group, in 145 patients had complications. The mean age was 30 years. Eighty-two (56.55%) cases had extracranial complications (ECC) and 49 patients (33.79%) intracranial complications (ICC). For the ECC cases, we found that subperiostal mastoid abscess occurred in 25%, facial nerve palsy was seen in 13% and labyrinthine fistula in 9.6 %. For the ICC cases, meningitis (12%) and perisinusal abscess (11%) were the most common complications. The most frequent radiological diagnostic procedures were mastoid X-rays, which were performed in 70% of the patients, and computed tomography in 20%. Patients with ECC were treated in the ENT Clinic, whereas patients with ICC, after otologgic surgical procedures, were transferred to the Neurosurgery Clinic. In this series, 5 patients (3.4%) died as a result of complications. Conclusions: The incidence of cholesteatoma and its complications in our country still poses a challenge that requires higher dedication. Application of sophisticated diagnostic methods, CT and MRI is going to assist in choosing the adequate surgical approach, especially in cases with intracranial complications
Keywords: Cholesteatoma, Complications, Middle ear surgery
|How to cite this article:|
Mustafa A, Kuši S, Behramaj A. Management of cholesteatoma complications: Our experience in 145 cases. Indian J Otol 2014;20:45-7
| Introduction|| |
Cholestetomatous chronic otitis media (CCOM) or cholesteatoma is a long-lasting infection of the middle ear defined as a keratinizing external auditory canal epithelium intruded to the middle ear causing erosion of surrounding structures. Two main pathological distinctiveness of cholesteatoma are destruction that causes life-threatening intracranial or extracranial complications (EC) and recidivism, which means capability to recidivate after surgical intervention. After suspicion and prompt diagnosis of cholesteatoma, a surgical method has to be chosen in order to obtain eradication of disease and prevention of complications, supported by medical antibiotic and other treatment.
According to our previous report, CCOM develops complications in 30% of cases, in comparison with chronic otitis media (COM) without cholesteatoma that can be complicated in 2% of cases. There are two groups of complications: Intracranial (meningitis, dural abscesses, cerebral abscess, cerebellar abscess and lateral sinus thrombosis) and extracranial (facial nerve palsy, labyrinthine fistula, petrositis, zygomatitis, mastoiditis and neck abscesses arising from mastoid tip-Bezold's abscess). Sometimes, multiple intracranial and concomitant intracranial and extracranial complications (IC/EC) occurs. ,,
The goal of this study was to retrospectively review our 17-year experience in the diagnosis and treatment of complications of cholesteatoma and to compare with experiences of other centers.
| Materials and Methods|| |
Ethical Committee of University Clinical Center of Kosovo approved this retrospective study. All patients that underwent surgical procedures signed consent after appropriate information about procedure and possible complications of surgery and anesthesia.
In a tertiary clinical center, a retrospective chart review of all patients presented with CCOM for a period of 17 years was performed. First, all operation room protocols and charts of patients with COM are selected and then in a second selection the charts of patients with CCOM were selected. From this group, a group of 145 patients appearing with one or more complications was selected, all charts are carefully reviewed and statistical data are worked out. Symptoms and signs, ear, nose and throat (ENT) clinical examination, general examination, laboratory analyzes, imaging methods, medical and surgical treatment of each patients are reviewed and then tabulated. Patients with ear complications but without cholesteatoma were excluded from study.
| Results|| |
In a country with approximately 2 million inhabitants, University Clinical Center of Kosovo in Prishtina is the only medical center that cares about patients with cholesteatoma complications. During the period from January 1994 to December 2011, there were 2765 in-patients admitted to our clinic with COM (about 160/year). A total of 502 patients (or 30/year) had CCOM or cholesteatoma diagnosed. From this group, 145 patients experienced one are more complications and unfortunately 5 of them died because of ear cholesteatoma complications [Table 1].
From a total of 145 patients with cholesteatoma complications, 85 (58.6%) were female and 60 (41.4%) male. The mean age of this series were 30 years, ranking from 5 years to 70 years. We noted that about 30% of patients were aged 10-20 years.
[Table 2] shows types of cholesteatoma complications in our patients. EC were presented in 56.55% of cases, 40% had IC and 9.65% had multiple concomitant IE/EC complications. Most often presented complication was subperiostal mastoid abscess (SMA) from EC, meningitis from IC and 5 patients had concomitant SMA and perisigmoid sinus abscess. Patients with multiple ICs (3 of them) are listed in the IC group.
Diagnostic procedures applied for this series of patients was not standardized and divers from patient to patient. For some procedures, e.g., computed tomography (CT) scans, determinative was availability. For the period 1994-2003, CT was not available in our centre in all cases and is done only in 73% of cases. Laboratory analyzes, erythrocyte sedimentation rate, white blood count and in some cases C-reactive protein was taken in all cases and elevated values indicated developing complications. Pure tone audiometry was performed in all adult conscious patients. In 70% of patients, a mastoid tip X-ray procedure were performed, as only imaging method. CT scan was performed in 20% of cases, whereas magnetic resonance imaging (MRI) only in 8 cases with severe IC, due to limited availability [Table 3].
|Table 3: Imaging procedures in patients with cholesteatoma complications|
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Treatment of these patients was combined surgical and medical (supportive). Types of surgical otological interventions are shown in [Table 4]. In all patients surgery is planned and performed according to the spread of cholesteatoma and type of complications. All cases with EC complications were treated in ENT clinic; cases with meningitis first were treated surgically in ENT clinic, then transferred to infectious disease clinic for further treatment, whereas intracranial abscesses are treated in cooperation with neurosurgeons.
|Table 4: Types of otosurgery procedures in patients with cholesteatoma complications|
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Finally, out of a total of 145 patients, 5 patients were died because of cholesteatoma complications, all with multiple IC. Rest of surviving patients healed without or with minor sequels.
| Discussion|| |
In Kosovo, middle ear surgery begins to be applied in the 50's of 20 th century, but the standardized otosurgery is established in 1977 with application of operative microscope. With an incidence of 30 new cholesteatoma cases per year and 8 new cholesteatoma complications per ear, Kosovo have similar incidence with other population of the world, according to different publications. ,
Long lasting stinking discharge from the ear, with polyps and conductive hearing loss are signs to suspect in CCOM and a diagnostic work-up have to be performed in order to establish a correct clinical diagnosis. This work-up must contain: An otoscopy and otomicroscopy with aspiration of discharge in order to differentiate between mucosal or squamous chronic middle ear infection; a microbiology swab of the discharging ear, laboratory analyzes, a pure tone audiometry, CT scan of temporal bon. In literature, all authors agree that gold standard in diagnosis of CCOM is CT scan and the early recognition of threatening complications is life-saving. , In our series, CT scan was not available in most of cases: Only 20% of patient performed CT scan that is far from the goal. As for MRI, in all cases when an intracranial cholesteatoma complication is suspect, a MRI scan is necessary, but in our series only in 5.5% of cases a MRI scan is performed.
Treatment of complications of CCOM is surgical. Antibiotics are adjuvant supportive therapy given during the course of disease according to microbiology exam results or empirically. Other treatment is required according to type of complications. Surgery is keystone of treatment. The role of surgery in complication is to drain the suppurative content and to clean cholesteatoma entirely. Different approaches and types of surgery are in use, most of them canal wall-down techniques, combined with neurosurgery operations, in case of IC complications. Otogene meningitis is treated by mastoidectomy of affected ear and to follow treatment in infectious disease setting, than other IC cases have to be treated together by otosurgeon and neurosurgeon. Data from literature gives similar conclusions concerning to treatment of cholesteatoma complications. ,, Despite a various surgical techniques used for treatment of cholesteatoma complications and the fact that surgeon can change the type of intervention during operation, but one must be clear: Cholesteatoma surgery is not adventure, but a properly planned procedure with particular goal.
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[Table 1], [Table 2], [Table 3], [Table 4]