**5. Endoscopic approach to cholesteatoma**

Endoscopy as a surgical tool in otosurgery is gradually evolving in daily practice when approaching middle and inner ear pathologies. Moreover, it is well known that cholesteatoma in a pediatric age, with an incidence that varies between 3 and 6 per 100,000 [26, 27], is an aggressive disease with respect to that in adults. The surgical approach is tailored according to the nature of cholesteatoma in being acquired or congenital, cystic or invasive. It often requires an extensive surgical approach, without undermining the preservation of hearing, as an attempt to eradicate the pathology due to its high rates of recidivism. The strategy to manage recidivism depends if it is residual, recurrent, or iatrogenic in nature. The standardized techniques at our disposition for such a destructive pathology, contrived upon the application of an operative microscope, are the transcanal (TC), canal wall-up (CWU), canal wall-down (CWD), and subtotal petrosectomy approaches. The surgeon should apply the indicated but least invasive and most effective approach, bearing in mind that the child will still have their entire life span ahead. Therefore, not only should

eradication of the disease be considered, but functional outcomes such as hearing, balance, and stability of the cavity must be taken into consideration.

The application of otoendoscopy in recent years has allowed otosurgery to evolve and be less invasive in reconsidering certain standardized microscope operative techniques [28–30]. The major characteristic of endoscopy is to detect and dominate blind angles during surgery. Thus, in cholesteatoma surgery, endoscopy allows improved cholesteatoma removal while decreasing the rate of recidivism.

Cholesteatoma surgery is a step by step procedure that depends upon intraoperative findings. The approach cannot be decided a priori if it should be a TC, CWU, or CWD procedure. Radiologic work-up is another important element that is needed to plan the procedure. Nonetheless, during surgery, the extension of the disease may not be as expected due to the limits of radiology in defining the propagation of the pathology. Furthermore, the time elapsed between evaluating the result of radiology and the day of surgery may allow the disease to grow further and therefore invade and extend widely. For these reasons, a programmed, solely endoscopic surgical approach is not recommended, and an operative microscope is an indispensable tool to have next to the endoscope in the operating theater.

The advantages of endoscopy in ear surgery are to eradicate surgery and decrease morbidity, especially in children. According to our experience and that reported in the literature, the exclusive use of endoscopy for cholesteatoma removal should be limited when the disease involves only the tympanic cavity [31] and more precisely the mesotympanum and hypotympanum.

When cholesteatoma extends to the epitympanum, angled endoscopes offer a valid view to that area and for the aditus ad antrum. Therefore, the otosurgeon is at ease to decide the technical approach of the surgical procedure. Surgery may proceed as a TC approach, or extend to a combined endoscopic and microscopic one; therefore, mastoidectomy may become mandatory with a CWU or CWD approach in order to ensure that the pathology has been removed.

According to our experience, two major factors determine the choice of type or approach; the condition of the ossicular chain and nature and extension of the disease. In case of intact and healthy ossicles, and cystic cholesteatoma, such as congenital colesteatoma (**Figures 12**–**14**) being either lateral or medial to the ossicular chain, with an angled endoscope, there is a good chance of removing the cholesteatoma endoscopically.

**121**

*Endoscopic Ear Surgery in Children*

**Figure 13.**

**Figure 14.**

*DOI: http://dx.doi.org/10.5772/intechopen.84563*

On the other hand, when the cholesteatoma is invasive and occupies the medial part of the head of the malleus and the body of the incus or extends to the antrum, it becomes a challenging task endoscopically. CWU mastoidectomy including antrostomy would be a plausible choice to remove the pathology and leave the ossicles intact. Conversely, in trying to approach such a pathology by an exclusive TC endoscopy, an extended atticotomy (reaching the antrum of the mastoid) and removal of the head of the malleus and the incus are required. This would determine the need to reconstruct both ossicles and the iatrogenic bony defect of the EAC with a piece of cartilage. In case of a small defect of the EAC, a small piece of cartilage may be adequate with good results in the future. If the defect is wide, a wedge of cartilage is needed to reconstruct the postero-superior part of the EAC. This closure would not be guaranteed in later years since the child is in growing phase. Therefore, an increase in the dimensions of the area of the EAC is inevitable with the consequence of a high probability of cholesteatoma recidivism, and CWD revision surgery would be necessary. As a consequence, otoendoscopy no

*Intraoperative endoscopic removal of cholesteatoma from the mesotympanum keeping the ossicles intact.*

*Radiologic pre-operative work up: coronal CT and MRI showing the mass occupying the mesotympanum.*

longer has the advantages of being less invasive with reduced morbidity.

**Figure 12.** *Congenital cholesteatoma with an intact tympanic membrane.*

#### **Figure 13.**

*The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy*

eradication of the disease be considered, but functional outcomes such as hearing,

and be less invasive in reconsidering certain standardized microscope operative techniques [28–30]. The major characteristic of endoscopy is to detect and dominate blind angles during surgery. Thus, in cholesteatoma surgery, endoscopy allows

Cholesteatoma surgery is a step by step procedure that depends upon intraoperative findings. The approach cannot be decided a priori if it should be a TC, CWU, or CWD procedure. Radiologic work-up is another important element that is needed to plan the procedure. Nonetheless, during surgery, the extension of the disease may not be as expected due to the limits of radiology in defining the propagation of the pathology. Furthermore, the time elapsed between evaluating the result of radiology and the day of surgery may allow the disease to grow further and therefore invade and extend widely. For these reasons, a programmed, solely endoscopic surgical approach is not recommended, and an operative microscope is an indispensable tool to have next to the endoscope in

The advantages of endoscopy in ear surgery are to eradicate surgery and decrease morbidity, especially in children. According to our experience and that reported in the literature, the exclusive use of endoscopy for cholesteatoma removal should be limited when the disease involves only the tympanic cavity [31] and more

When cholesteatoma extends to the epitympanum, angled endoscopes offer a valid view to that area and for the aditus ad antrum. Therefore, the otosurgeon is at ease to decide the technical approach of the surgical procedure. Surgery may proceed as a TC approach, or extend to a combined endoscopic and microscopic one; therefore, mastoidectomy may become mandatory with a CWU or CWD approach

According to our experience, two major factors determine the choice of type or approach; the condition of the ossicular chain and nature and extension of the disease. In case of intact and healthy ossicles, and cystic cholesteatoma, such as congenital colesteatoma (**Figures 12**–**14**) being either lateral or medial to the ossicular chain, with an angled endoscope, there is a good chance of removing the

precisely the mesotympanum and hypotympanum.

in order to ensure that the pathology has been removed.

improved cholesteatoma removal while decreasing the rate of recidivism.

The application of otoendoscopy in recent years has allowed otosurgery to evolve

balance, and stability of the cavity must be taken into consideration.

**120**

**Figure 12.**

the operating theater.

cholesteatoma endoscopically.

*Congenital cholesteatoma with an intact tympanic membrane.*

*Radiologic pre-operative work up: coronal CT and MRI showing the mass occupying the mesotympanum.*

#### **Figure 14.**

*Intraoperative endoscopic removal of cholesteatoma from the mesotympanum keeping the ossicles intact.*

On the other hand, when the cholesteatoma is invasive and occupies the medial part of the head of the malleus and the body of the incus or extends to the antrum, it becomes a challenging task endoscopically. CWU mastoidectomy including antrostomy would be a plausible choice to remove the pathology and leave the ossicles intact. Conversely, in trying to approach such a pathology by an exclusive TC endoscopy, an extended atticotomy (reaching the antrum of the mastoid) and removal of the head of the malleus and the incus are required. This would determine the need to reconstruct both ossicles and the iatrogenic bony defect of the EAC with a piece of cartilage. In case of a small defect of the EAC, a small piece of cartilage may be adequate with good results in the future. If the defect is wide, a wedge of cartilage is needed to reconstruct the postero-superior part of the EAC. This closure would not be guaranteed in later years since the child is in growing phase. Therefore, an increase in the dimensions of the area of the EAC is inevitable with the consequence of a high probability of cholesteatoma recidivism, and CWD revision surgery would be necessary. As a consequence, otoendoscopy no longer has the advantages of being less invasive with reduced morbidity.

Children have an extremely active metabolism, and the risk of recidivism is higher than in adults. For this reason, children need closer follow-up and for a longer period, almost their entire lifespan. Non-EPI-DWI MRI is a very helpful tool in monitoring the disease and trying to avoid unnecessary surgical revisions. Most authors would consider MRI at 1 year postoperatively, otherwise explorative tympanoplasty in recommended [32].

In case of recurrence of disease, endoscopy plays an interesting role. If cholesteatoma is limited to the tympanic cavity such as the epitympanum, endoscopy grants fully transcanal removal of the disease without resorting to an post-aural approach (**Figures 15** and **16**).

#### **Figure 15.**

*Non-EPI-DWI MRI follow-up after 1 year of a 9-year-old child who underwent a CWU for cholesteatoma. Note the presence of the mass in the tympanic cavity.*

#### **Figure 16.**

*Endoscopic transcanal of cholesteatoma removal for epitympanum.*

In the case that cholesteatoma recurrence is in the mastoid cavity (**Figure 17**), endoscopy can also be an interesting tool for removal of cholesteatoma in a less invasive fashion, as shown in **Figure 18**.

Instrumentation for endoscopic cholesteatoma removal should include dedicated tools to better control its dissection and removal. The ones that really are helpful, besides being elongated and curved shafts, include a suction duct. They can be dissectors, knives, and suctions with sharp edges (**Figure 19**).

**123**

**Figure 19.**

**Figure 18.**

*after positioning the ear speculum.*

*Endoscopic Ear Surgery in Children*

*proximity of the lateral semicircular canal.*

**Figure 17.**

*DOI: http://dx.doi.org/10.5772/intechopen.84563*

*MRI at 1 year follow-up in CWU in a 7-year-old child showing recurrence of disease in the mastoid cavity in* 

*Intraoperative removal of cholesteatoma through a small 1 cm post-aural incision to gain access to the mastoid* 

*On the left, standard surgical tools for otosurgery; on the right, Panetti Endoscopic Instrument Set (Spiggle and* 

*Theis, Overath, Germany) of dedicated tools containing curved sharp tips containing suction ducts.*

#### **Figure 17.**

*The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy*

Children have an extremely active metabolism, and the risk of recidivism is higher than in adults. For this reason, children need closer follow-up and for a longer period, almost their entire lifespan. Non-EPI-DWI MRI is a very helpful tool in monitoring the disease and trying to avoid unnecessary surgical revisions. Most authors would consider MRI at 1 year postoperatively, otherwise explorative

In case of recurrence of disease, endoscopy plays an interesting role. If cholesteatoma is limited to the tympanic cavity such as the epitympanum, endoscopy grants fully transcanal removal of the disease without resorting to an post-aural approach

tympanoplasty in recommended [32].

(**Figures 15** and **16**).

**122**

**Figure 16.**

**Figure 15.**

*Endoscopic transcanal of cholesteatoma removal for epitympanum.*

invasive fashion, as shown in **Figure 18**.

*Note the presence of the mass in the tympanic cavity.*

In the case that cholesteatoma recurrence is in the mastoid cavity (**Figure 17**), endoscopy can also be an interesting tool for removal of cholesteatoma in a less

*Non-EPI-DWI MRI follow-up after 1 year of a 9-year-old child who underwent a CWU for cholesteatoma.* 

Instrumentation for endoscopic cholesteatoma removal should include dedicated tools to better control its dissection and removal. The ones that really are helpful, besides being elongated and curved shafts, include a suction duct. They can

be dissectors, knives, and suctions with sharp edges (**Figure 19**).

*MRI at 1 year follow-up in CWU in a 7-year-old child showing recurrence of disease in the mastoid cavity in proximity of the lateral semicircular canal.*

#### **Figure 18.**

*Intraoperative removal of cholesteatoma through a small 1 cm post-aural incision to gain access to the mastoid after positioning the ear speculum.*

### **Figure 19.**

*On the left, standard surgical tools for otosurgery; on the right, Panetti Endoscopic Instrument Set (Spiggle and Theis, Overath, Germany) of dedicated tools containing curved sharp tips containing suction ducts.*
