My 13 year old daughter recently had a right ventilating tube inserted by her
ENT. During surgery the doctor discovered a cholesteatoma, previously unseen
due to ear canal debris. I have several questions relating to the surgical
treatment of the cholesteatoma.
Thank you in advance for your answers.
1.) What preoperative tests/studies are performed and why?
2.) We live in a rural area, so how do I ascertain the ENT's expertise with this particular surgery? I plan on consulting with the pediatrician and interviewing the ENT, however, I am foggy as how to measure adequate "expertise."
3.) What is current theory as to when to perform canal wall up versus canal wall down?
Reply: ---------------------------------
1) Pre-operative assessment typically involves assessing the history - presence of pain, drainage, subjective hearing loss, dysequilibrium; careful microscopic examination of the ear and removal of debris; audiometric evaluation (detailed hearing measurement); and usually CAT scan imaging of the ear.
2) The best advice I can give you here is to seek the opinion of your child's pediatrician and to ask the ENT physician directly about his/her expertise and experience in this area. The frequency of mastoid surgery in the last couple of decades has declined considerably due to advances in the treatment of otitis media including antibiotic therapy and tympanostomy tubes. Still, all ENT training programs in the US are obligated to provide sufficient surgical training in mastoid surgery. There are sub-specialists in ENT who limit their practice to ear medicine and surgery (otologists or neuro-otologists) - typically they deal with more complicated problems often referred to them by other ENT specialists.
3) Canal wall down procedures are mastoid operations in which the posterior bony ear canal wall is removed - this wall separates the mastoid air cell system from the ear canal. Removing the canal wall results in a large open cavity that may have a tendency to periodically accumulate epithelial debris which requires removal. Additionally, there is some loss of efficiency in sound transfer from the ear drum and ear bones into the inner ear when the canal wall is removed. Canal wall down procedures are typically advised when there is extensive cholesteatoma - removing the canal wall improves exposure thus increasing the confidence that cholesteatoma has been completely removed which in turn reduces the risk of recurrent cholesteatoma.
Canal wall up procedures are mastoid operations in which the posterior bony canal wall is preserved. Preservation of the canal wall eliminates mastoid debris problems and can potentially provide somewhat better overall hearing results. The limitation of this approach has to do with exposure in an area that separates the middle ear from the mastoid. If there is cholesteatoma in this area that is difficult to visualize - canal wall down procedures may be more appropriate. An alternative approach is to do a canal wall up procedure with the intent to do a simple re-exploration of the ear 1 year later to verify complete removal of cholesteatoma - a so-called 2nd look procedure.
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Steve Dankle, MD
Otolaryngology-Head and Neck Surgery
Milwaukee, Wis
NOTICE: OFCN is not engaged in the rendering of professional medical services. The information contained on this system or any other OFCN system should not supplant individual professional consultation. It is offered exclusively as a community education service. Advice on individual problems must be obtained directly from a professional.
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