Summary
Introduction. Cholesteatoma is characterized by the proliferation of keratinized squamous epithelium in the middle ear or mastoid process. Its annual incidence is 6–9 cases per 100,000 individuals, with higher prevalence in children. Surgical treatment is crucial for disease eradication, ensuring a safe and dry middle ear. Two surgical approaches are available: canal wall up and canal wall down. The canal wall down technique provides superior visualization and is preferred in cases of extensive disease or high recurrence risk, especially when combined with mastoid obliteration using autologous materials, like bone pate, for improved long-term outcomes.
Clinical Case. An 11-year-old male with recurrent left-sided purulent otorrhea and progressive hearing loss underwent multiple ear surgeries for chronic atticoantral suppurative otitis media. Despite surgical management, cholesteatoma persisted, necessitating a revision antromastoidectomy with mastoid obliteration. Intraoperatively, the mastoid cavity was filled with cholesteatoma extending into the attic, sinus tympani, and aditus ad antrum, with severe ossicular erosion. Cholesteatoma and granulation tissue were excised, and tympanic membrane repair was completed using tragal cartilage and perichondrium. The mastoid cavity was obliterated with bone pate harvested from the mastoid cortex, secured with hemostatic materials and covered with free skin grafts.
Discussion. The canal wall down technique is effective in cholesteatoma management, offering enhanced visualization of middle ear structures, enabling complete cholesteatoma removal, and reducing recurrence rates. However, it presents challenges related to cavity maintenance, including persistent otorrhea. Mastoid obliteration reduces cavity size, lowers infection risk, and promotes a dry and self-cleaning ear. Various autologous, allogenic and heterologous materials can be used for obliteration. Autologous materials, such as bone pate, are biocompatible, provide long-term structural stability, and ensure effective cavity closure, thereby reducing the risk of recurrence and the need for revision surgery.
Conclusions. Cholesteatoma is a highly recurrent and destructive disease, often requiring multiple surgical interventions. Canal wall down mastoidectomy is the preferred approach in recurrent cholesteatoma, as it allows for thorough disease clearance and reduced recurrence risk. Mastoid obliteration, particularly with autologous bone pate, significantly improves long-term outcomes by reducing cavity size and minimizing infection risk.
