Pooled analysis of the evidence for open cavity, combined approach and reconstruction of the mastoid cavity in primary cholesteatoma surgery

Background: Cholesteatoma is keratinising epithelium within the middle-ear cleft or mastoid. This disease destroys the peripheral organs of balance and hearing, with possible intracranial sequelae. The management of cholesteatoma is surgical and the primary aim is to remove the disease and prevent recurrence. Secondary aims are to obtain a non-discharging, hearing ear. Cholesteatoma surgery falls into two broad categories: open cavity surgery and combined approach surgery. A third surgical category is reconstruction of an open mastoid cavity after open surgery. This study performed a pooled analysis of the worldwide literature to compare the rates of cholesteatoma not being cured (i.e. recidivism), ear discharge and hearing change among open cavity, combined approach and reconstruction mastoid surgery for primary cholesteatoma. Methods: A literature search for all types of cholesteatoma surgery in the PubMed, Google Scholar and Medline databases and in published conference proceedings was undertaken. Results: There was no level 1 evidence for the best method of primary cholesteatoma surgery. The highest evidence level found (level 2; 5366 patients) shows no difference in hearing change or discharge rate between open and combined approach surgery; however, these methods fail to cure the cholesteatomas in 16.0 per cent and 29.4 per cent of cases, respectively. In a total of 640 patients, reconstruction and/or repair mastoid surgery using a variety of non-comparable techniques had a failure rate of between 5.3 per cent and 20 per cent. Conclusion: The available evidence suggests that reconstruction of the posterior canal wall and/or obliteration of the mastoid may be the best surgical treatment alternative. This technique appears to provide the lowest recidivism rate combined with a low post-operative ear discharge rate.