Surgery is the mainstay of cholesteatoma treatment. Disease clearance and a safe ear take priority over preservation or reconstruction of hearing.
Treatment priorities
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The primary aim is to remove the disease and render the ear safe.
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Hearing preservation or reconstruction is secondary and must never compromise the primary aim.
Canal wall down procedures
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These procedures leave the mastoid cavity open into the external auditory canal, fully exteriorizing the diseased area.
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Operations used for atticoantral disease include atticotomy, modified radical mastoidectomy and, rarely, radical mastoidectomy.
Canal wall up procedures
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Disease is removed through a combined meatal and mastoid approach while preserving the posterior bony meatal wall and avoiding an open mastoid cavity.
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The procedure gives a dry ear and permits easy reconstruction of the hearing mechanism, but some cholesteatoma may be left behind.
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Residual or recurrent cholesteatoma has a very high incidence, requiring long-term follow-up. Some surgeons advise routine re-exploration after about six months.
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Canal wall up procedures are advised only in selected cases.
Combined approach access
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In combined approach or intact canal wall mastoidectomy, disease is removed permeatally and through cortical mastoidectomy and posterior tympanotomy.
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Posterior tympanotomy creates a window through the facial recess between the mastoid and middle ear to reach the sinus tympani.