c holes tea tomas ari
TRANSCRIPT
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CHOLESTEATOMA
Dept of Otorhinolaryngology Head and Neck Surgery
Padjadjaran University
Hasan Sadikin General Hospital
20! 1
"e#ryanti P Sari
Pe$#i$#ing Uta$a%dr& Sally 'ahdiani( ')es( Sp&*H*+),
Literature Reading
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Overvie-
Definition
.nato$y
/lassification and *heories
'anage$ent
/o$plications
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Definition
Na$ed #y ohannes 'ueller in 11
& 3rroneous #elief that one of the pri$ary co$ponents
of the tu$or -as fat
2&4a pearly tu$or of fat5a$ong sheets of polyhedral
cells6
'ore appropriate na$e has #een suggested to #ekerato$a to descri#e tu$or co$position
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Definition%
/holesteato$as are e7panding lesions of the
te$poral #one that are co$posed of a stratified
s8ua$ous epithelial outer lining and a des8ua$ated
keratin center&
3pide$iology %
+ incidence of ac8uired cholesteato$a ranges fro$
appro7i$ately 9 to 2&! cases per 00(000 adults+ to : cases per 00(000 children . $ale
predo$inance of &; % in cholesteato$a incidence .
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including
& /ystic content% des8ua$ated keratin center
2& 'atri7% keratini
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Middle Ear Anatomy
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Tympanic Membrane
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TULANG-TULANG
PENDENGARAN
Ossicles
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Epitympanum
MesotympanumHipotympanum
*y$panic /avity
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EPITYMPANUM
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/lassification and *heories
=t can #e classified as one of t-o different types%
/ongenital
.c8uired
>Pri$ary
>Secondary
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/ongenital /holesteato$a
Definition ?,evenson( 919@& *hese criteria included
& >Ahite $ass $edial to nor$al ty$panic $e$#rane
2& >Nor$al pars flaccida and pars tensa
& >No prior history of otorrhea or perforations
;& >No prior otologic procedures
:& >Prior #outs of otitis $edia -ere not grounds for
$edia e7clusion as -as the case in original definition
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*-o pro$inent theories include
& the failure of the involution of ectoder$al epithelial
thickening that is present during fetal develop$ent
in pro7i$ity to the geniculate ganglion &
2& $etaplasia of the $iddle ear $ucosa&
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.c8uired /holesteato$as
/o$$on factor%
keratini
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Pri$ary .c8uired /holesteato$as
Ulti$ately for$ due to underlying 3ustachian tu#e
dysfunction that causes retraction of pars flaccida
Besults in poor aeration of epity$panic space
-hich dra-s pars flaccida $edially on top of
$alleus neck( for$ing retraction pocket &
Nor$al $igratory pattern of the ty$panic
$e$#rane epitheliu$ altered #y retraction pocket& 3nhances potential accu$ulation of keratin&
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Pri$ary .c8uired /holesteato$as
Pars flaccida retraction Pars tensa retraction
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Secondary .c8uired /holesteato$as
=$plantation theory
S8ua$ous epitheliu$ i$planted in the $iddle ear as a result of surgery(
foreign #ody( #last injury( etc&
'etaplasia theory
Des8ua$ated epitheliu$ is transfor$ed to keratini
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3pithelial invasion theory
S8ua$ous epitheliu$ $igrates along perforation edge
$edially along undersurface of ty$panic $e$#rane destroying
the colu$nar epitheliu$&
Papillary ingro-th theory
=nfla$$atory reaction in PrussackCs space -ith an intact pars
flaccida
?likely secondary to poor ventilation@ $ay cause #reak in
#asal $e$#rane
allo-ing cord of epithelial cells to start in-ard proliferation
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/holesteato$a Spread
Predicta#le in that they are channeled along
characteristic path-ays #y%
>,iga$ents
>"olds
>Ossicles
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/o$$on Sites of /holesteato$a Origin
Posterior epity$panu$
Posterior $esoty$panu$
.nterior epity$panu$
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/holesteato$a Spread
Posterior epity$panic cholesteato$a passing through
superior incudal space and aditus antru$
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Posterior $esoty$panic cholesteato$a invading the sinus
ty$pani and facial recess
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.nterior epity$panic cholesteato$a -ith e7tension to -ith
geniculate ganglion
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Patient 3valuation
Detailed otologic history
& Hearing loss
2& Otorrhea% $alodorous
& Otalgia
;& *innitus
:& ertigo
Progressive unilateral hearing loss-ith a chronic foul s$elling
otorrhea should raise suspicion&
Previous history of $iddle ear disease
& /hronic otitis $edia
2& *y$panic $e$#rane perforation% Pars flaccida
& Prior surgery
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Otologic e7a$ination
Oto$icroscopy is essential in evaluating the e7tent of disease
/lean ear thoroughly of otorrhea and de#ris -ith cotton and
cotton+tipped applicators or suction
/ulture -et( infected ears and treat -ith topical andEor oral
anti#iotics
Pneu$atic otoscopy should #e perfor$ed in every patient -ith
cholesteato$a
Positive fistula ?pneu$atic otoscopy -ill result in nystag$us
and vertigo@ response suggests erosion of the se$icircular
canals or cochlea
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Hearing evaluation
conductive hearing loss
& Pure tone audio$etry -ith air and #one conduction
2& Speech reception thresholds
& Aord recognition
:2H< tuning fork e7a$
>.l-ays correlate -ith audio$etry results
*y$pano$etry
>'ay suggest decreased co$pliance or *' perforation
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*he degree of conductive loss -ill vary considera#ly
depending on the e7tent of disease&
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Preoperative i$aging -ith co$puted to$ographies
?/*s @ of te$poral #ones ?$$ @ section -ithout
contrast in a7ial and coronal planes&
& .llo-s for evaluation of anato$y
2& 'ay reveal evidence of the e7tent
& Screen for asy$pto$atic co$plications
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/holesteato$a 'anage$ent
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Preventative 'anage$ent
*y$panosto$y tu#e for early retraction pockets
Surgical e7ploration for retraction persistence
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*reated surgically -ith rimar! goal of total
eradication of cholesteato$a to o#tain a safe to and
dry ear
& /anal+-all +do-n procedures ?/AD@
2& /anal+-all +up procedure ?/AU@
& *ranscanal anterior atticoto$y
;& Fondy $odified radical procedure
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Prior to the advent of the ty$panoplasty(
all cholesteato$a surgery -as perfor$ed using
/AD surgery approach procedure involves%
>*aking do-n posterior canal -all to level ofvertical facial nerve
>37teriori
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/lassic /AD operation is the $odified radical $astoidecto$y
in -hich $iddle ear space is preserved
Badical $astoidecto$y is /AD operation in -hich%
> 'iddle ear space is eli$inated
> 3ustachian tu#e is plugged
'eatoplasty should #e large enough to allo- good aeration of
$astoid cavity and per$it easy visuali
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=ndications for /AD approach%
/holesteato$a in an only hearing ear Significant erosion of the posterior #ony canal -all
History of vertigo suggesting a la#yrinthine fistula
Becurrent cholesteato$a after canal+-all +up
surgery
Poor eustachian tu#e function
Sclerotic $astoid -ith li$ited access to
epity$panu$
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"#$antages%
>Besidual disease is easily detected
>Becurrent disease is rare
>"acial recess is e7terioriOpen cavity created
*akes longer to heal
>'astoid #o-l $aintenance can #e a lifelong pro#le$
>Shallo- $iddle ear space $akes O/B ?Ossicular /hain
Beconstruction@ difficult
>Dry ear precautions are essential
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/anal+Aall +Do-n
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/anal +Aall +Up
/AU procedure developed to avoid pro#le$s and $aintenance
necessary -ith /AD procedures
/AU consists of preservation of posterior #ony e7ternal
auditory canal -all during si$ple $astoidecto$y -ith or
-ithout a posterior -ith ty$panoto$y
Staged procedure often necessary -ith a scheduled second
look operation at ! to 1 $onths for%
>Be$oval of residual cholesteato$a
>Ossicular chain reconstruction if necessary
Procedure should #e adapted to e7tent of disease as -ell as
skill of otologist
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/AU $ay #e indicated in patients -ith large pneu$atiSuggests good eustachian tu#e function
/AU procedures are contraindicated in%
>Only hearing ear
>Patients -ith la#yrinthine fistula
>,ong+standing ear disease
>Poor eustachian tu#e function
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/anal+Aall +Up
.dvantages%
>Bapid healing ti$e
>3asier long+ter$ care
>Hearing aids easier to fit
>No -ater precautions
Disadvantages%
>*echnically $ore difficult
>Staged operation often necessary
>Becurrent disease possi#le >Besidual disease harder to detect
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/anal+Aall +Up
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Novel *echni8ues
=n 200: Gant
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Novel *echni8ues
/anal Aall Beconstruction techni8ue
>/o$plete cortical $astoidecto$y -ith opening of -ith facial
recess and re$oval of incus and $alleus head
>Posterior canal -all skin elevated( annulus elevated
>'icrosagittal sa- used to cut posterior canal -all
>/holesteato$a re$oved
>Posterior canal -all #one replaced
>/ortical #one chips used to #lock attic and $astoid fro$
ty$panu$
>Fone pateC holds #one chips in place
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/o$plications
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*he e7pansion of cholesteato$as
=nfection(otorrhea(#one destruction
& e7tracranial co$plications
Hearing loss
"acial nerve paresis or paralysis
,a#yrinthine fistula% se$icircularis canal erosion
e7tradural or perisinus a#scess
serous or suppurative la#yrinthitis
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2& =ntracranial co$plications
potentially life+threatening
Periosteal a#scess
,ateral sinus thro$#osis% sig$oid sinus
*hro$#osisEphle#itis
'eningitis
3pidural (su#dural( or parenchy$al #rain a#scess
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Hearing ,oss
/onductive hearing loss% ossicular chain erosion ?0@
>& 3rosion of lenticular process andEor stapes superstructure
process $ay produce :0dF conductive hearing loss
>2& Hearing loss varies despite disease e7tent ?natural
$yringostapediope7y( trans$ission of sound through (
cholesteato$a sac@
Sensorineural hearing loss% involve$ent of la#yrinth
"ollo-ing surgery( 0 have further i$pair$ent due to%
>37tent of disease present
>/o$plications in healing process
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,a#yrinthine "istula
(nci#ence% as high as 0
)!mtom% Sensorineural hearing loss andEor
vertigo induced #y noise or pressure change
.#sence of a positive fistula test does not rule out this
co$plication&
*ommon site% hori
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"acial Paralysis
+a! #e$elo%
>.cutely secondary to infection
>Slo-ly fro$ chronic e7pansion of cholesteato$a
,emoral 'one *, % locali
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=ntracranial /o$plications
Potentially life+threatening
=ncidence% as high as
*omlications
& Periosteal a#scess
2& ,ateral sinus thro$#osis
& =ntracranial a#scess
;& 'eningitis
)!mtom%
& Suppurative $alodorous otorrhea2& /hronic headache
& "ever
;& Otalgia
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'anage$ent%
>Presence of $ental status changes -ith nuchal rigi#it! or
cranial neuropathies -arrant consultation -ith urgent
intervention
>3pidural a#scess( su#dural e$pye$a( $eningitis and (
cere#ral a#scesses should #e treated i$$ediately prior to
definitive otologic $anage$ent of ear disease&
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*onclusions
Pathogenesis of cholesteato$a re$ains uncertain
3ssential to possess #asic kno-ledge of the i$portant
anato$ic and functional characteristics of the $iddle ear for
successful $anage$ent of cholesteato$as
/areful and thorough evaluations are the key to early diagnosisand treat$ent
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*reat$ent is surgical -ith pri$ary goal to eradicate disease
and provide a safe and dry ear Surgical approaches $ust #e custo$i
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Thanks