78 J I M D C 2 0 1 7 78 Op e n Ac c e ss F u l l L e n g t h A r t i c l e Comparison of Efficacy of Canal Wall up Mastoidectomy with Canal Wall Down Mastoidectomy in Surgical Management of Otitis Media with Cholesteatoma Sadaf Raffat Mustafa Assistant Professor, Department of ENT, Railway Hospital, Rawalpindi A B S T R A C T Objectives: To compare the efficacy of Canal Wall Up (CWU) Mastoidectomy with Canal Wall Down (CWD) Mastoidectomy in the surgical management of chronic otitis media with cholesteatoma in local population. Patients and Methods: A total of sixty patients with chronic otitis media, cholesteatoma and granulation tissue were enrolled. Patients were randomly divided into two groups; Group A patients underwent CWU Mastoidectomy while Group B patients underwent CWD Mastoidectomy. Both groups were followed for 6 months, for recurrence of the disease and associated complications. Chi-square test was applied as a test of significance, to compare the outcomes of CWU Mastoidectomy and CWD Mastoidectomy. a p-value <0.05 was considered as statistically significant Results: Disease recurrence rate was significantly higher in group A (CWU) while complications rates were higher in group B (CWD) patients. Persistent discharge, conductive deafness, and development of mastoid cutaneous fistula were reportedly higher in group B patients (P<0.05). Conclusion: CWD operations have a higher probability of permanently curing the patient of the cholesteatoma but with higher rates of post-surgical complications. CWU procedures have the advantage of maintaining a near normal anatomy but with a higher risk of residual or recurrent cholesteatomas. Choice of a particular surgical procedure depends on the preference of the surgeon, the nature, and extent of the pathology and the general health of the patient. Key Words: Cholesteatoma, Chronic Otitis Media, Mastoidectomy, Otitis media. Author`s Contribution 1,2Conception, Synthesis and Planning of the research, Discussion & Analysis Address of Correspondence Dr. Sadaf Raffat Mustafa drsadafrafat@yahoo.com Article info. Received: Mar 24, 2017 Accepted: May 14, 2017 Cite this article: Mustafa SR. Comparison of Efficacy of Canal Wall Up Mastoidectomy with Canal Wall Down Mastoidectomy in Surgical Management of Otitis Media. JIMDC. 2017; 6(2):78-82. Funding Source: Nil Conflict of Interest: Nil I n t r o d u c t i o n Chronic Otitis media (COM) is an inflammatory disease of the middle ear, that lasts for more than three months.1 When associated with cholesteatoma, it is characterized by the presence of keratinized stratified squamous epithelium within the cavities of the middle ear. The incidence of cholesteatoma has been reported in between 1.0-12.6 cases per 100,000 inhabitants.2,3 Cholesteatomas may grow large enough to erode the middle ear structures and the mastoid bone behind the middle ear.4 Problems with the middle ear, such as fluid in the middle ear, a hole in the eardrum, or injury to the small, middle ear bones, can cause hearing loss.5 In rare situations, infections in the middle ear can spread deep inside the inner ear, causing a sensorineural hearing loss and dizziness.6 Rare, but serious, complications include brain infections, such as an abscess or meningitis. A chronic infection and a cholesteatoma can also cause injury to the facial nerves and facial paralysis.7 Surgical management of chronic otitis media with and without cholesteatoma has been a matter of debate for years.8,9The primary goal of surgery for COM is to eradicate disease and obtain a dry and safe ear. Restoration of hearing is by necessity, a secondary consideration because any attempt at middle ear O R I G I N A L A R T I C L E 79 J I M D C 2 0 1 7 79 reconstruction will fail in the setting of persistent inflammation and otorrhea.10 There are two major types of mastoidectomies: canal wall down (CWD) and canal wall up (CWU), and the debate as which technique is to be adopted still exists in 21st century.11 The mastoid bowl or cavity created by a CWD technique often fills with earwax and need frequent ear canal cleaning, protection from water and possible hearing changes. Another disadvantage of the CWD mastoidectomy is that the operation changes the architecture of the ear canal. Therefore, the hearing may be diminished to some degree as a result of this change of architecture. The CWU mastoidectomy was developed to address some of the limitations of CWD mastoidectomy but is associated with higher rates of recurrence.12 Recent publications have emphasized the need for clinicians to take note of the outcomes of their surgery, not just in terms of technical success, but also in relation to the impact of the treatment upon the patient's lifestyle and wellbeing.13 Currents study rationale was based on authors’ experience and belief for a need of individualized treatment in these patients. This study aims to compare the efficacy of CWU mastoidectomy with CWD mastoidectomy in the surgical management of chronic otitis media with cholesteatoma in the local population. P a t i e n t s a n d M e t h o d s This experimental study was conducted after ethical approval and informed consent from all the enrolled patients. The study was carried out at ENT department, PIMS, Islamabad from July 2007- July 2008. A total of sixty patients with chronic otitis media, cholesteatoma and granulation tissue were enrolled. Patients were randomly divided in two groups; Group A patients underwent CWU mastoidectomy while Group B patients underwent CWD mastoidectomy. Both the groups were followed for 6 months (monthly basis) and observed for hearing outcome, recurrence of disease including cholesteatoma, granulation tissue and complications such as facial paralysis, meningitis, suppurative labyrinthitis, persistent ear discharge, conductive deafness and mastoid cutaneous fistula. Data was analyzed using SPSS software version 20.0. Chi-square test was used as a test of significance to compare the outcomes of CWU mastoidectomy and CWD mastoidectomy. p-value <0.05 was considered as statistically significant. R e s u l t s The present study includes 60 patients; 30 in each group. Demographic data is presented in table 1. As shown in the table, mean age of the patients in group A was 27.10+2.29 SD and in group B it was 27.33+2.95 SD. There were 70 males and 30 females in group A and in group B there were 63 males and 37 females. Disease recurrence rate was significantly higher in group A (CWU) (p<0.05), however complication rate was found higher in group B (CWD) patients. Persistent discharge, conductive deafness, and mastoid cutaneous fistula were reportedly significantly higher in group B patients (p<0.05) (Table 2). Table 1: Demographic profile of study population (N=60) Gender Group A (n=30) N (%) Age (years) Mean ± SD Group B (n=30) N (%) Age (years) Mean ± SD Male 21 (70) 26.64 ± 1.91 19 (63) 28.18 ± 2.48 Females 9 (30) 27.67 ± 2.06 11 (37) 26.18 ± 3.63 Total 30 (100) 27.10 ± 2.29 30 (100) 27.33 ± 2.95 Table 2: Comparison of recurrence and complications of disease in both groups (N=60) Variables Group A (n =30) N (%) Group B (n=30) N (%) p-value Recurrence 25(83.33) 12 (40) 0.001 Complications Facial Paralysis 01(3.33) 5 (16.67) 0.085 Meningitis 07(23.33) 2 (6.67) 0.071 Suppurative Labyrinthitis 0(0) 2 (6.67) 0.150 Persistent Discharge 03(10) 12 (40) 0.007 Conductive Deafness 09(30) 18 (60) 0.020 Fistula 1(3.33) 07(23.33) 0.023 80 J I M D C 2 0 1 7 80 D i s c u s s i o n The objectives of mastoidectomy in cholesteatoma are to get a disease-free and dry ear, the prevention of recurrent disease and the maintenance of hearing or the possibility to reconstruct an affected hearing mechanism. The choice of the surgical technique for chronic ear disease depends on a number of factors including preference of the surgeon, nature of the pathology and the general health of the patient. Our results showed that with canal wall up technique the rate of recurrence of disease is significantly higher as compared to those in canal wall down technique. Our results are comparable with the published data by Hulka and Mc Elveen et al. In their randomized, blinded study, they suggested that with canal wall up mastoidectomy rate of recurrence was significantly higher as compared to the rate after canal wall down surgery.14 The results of a national comparative audit of 611 mastoidectomies by 55 consultants were published by the Royal College of Surgeons of England in 1995. The study also showed the higher rate of recurrence after canal wall up mastoidectomies.15 A recent paper by Sadé et al which examined the strategies used in cholesteatoma surgery, presented data on 200 CWD procedures found the same higher rates of recurrence after canal wall up procedures.16 Gantz et al analyzed 130 cases studied in 2005, and according to his results the recurrence rate after canal wall reconstruction technique was significantly higher and the patients required a repeat surgery.17 A possible explanation of the increased rate of recurrence in CWU technique may due to the fact that external auditory canal wall is conserved. However, preservation of the pneumatized epitympanum and mastoid cavity creates conditions conducive to the development of tympanic retraction pockets and recurrence of cholesteatoma. As pointed out by Palva and Virtanen, the more air-filled spaces there are, the higher the probability of retraction pockets.18 Accordingly, there have been several efforts aimed at reducing the air-filled mastoid cavity. Several surgeons have attempted obliteration of the mastoid cavity with abdominal fat or soft tissue after a CWU mastoidectomy and have reported slightly better results with respect to hearing and drum retraction compared with the air space reservoir technique.19 However, a retraction pocket is still developed in the remaining epitympanic space in these techniques. Other surgeons have attempted to seal off the mastoid cavity with a bony septum at the antrum level, but the functional result was disappointing because of the absorption of bony septum, which resulted in an incomplete block between the middle ear and the mastoid cavity.20 Others also tried combination of canal wall up mastoidectomy and type I tympanoplasty to evaluate the therapeutic effects in terms of disease clearance and hearing improvement, and reported better outcomes.21 Our results also showed that with canal wall down technique, the rate of developing complications (conductive deafness, persistent ear discharge and developing a fistula) was significantly higher when compared with those in canal wall up technique. With CWD mastoidectomy, the operation changes the architecture of the ear canal which results in diminished hearing to some degree as a result of this change of architecture. Similar findings were observed by Kos MI et al, who reported that complication rate was higher with canal wall down surgery.22 Hulka and McElveen in their study concluded that canal wall down mastoidectomy was significantly superior to the intact canal wall technique in visualizing middle ear pathology and in getting permanent eradication of the disease.14 However, they reported significantly higher rate of complications after canal wall down procedure. A national comparative audit published by the Royal College of Surgeons of England in 1995, reported significantly greater number of "wet" ears with canal wall down than with canal wall up mastoidectomies.15 Findings of persistent ear discharge after canal wall down technique reported by Sadé et al are comparable to our results.16 Gantz BJ in his study of 130 cases, reported the same higher rates of complications after canal wall down surgeries.19 Several surgeons have improvised to get slightly better results. They reported that the use of endoscope has improved visualization in CWU techniques with better outcomes.23-25 others tried mastoid obliteration with autologous bone and reported it to be safe, low-cost, with low recurrence rates - similar to traditional canal wall down procedures and with greater water resistance and quality of life improvements.26-27 In summary, numerous factors help in determining which technique is best. Sometimes, this decision is not possible 81 J I M D C 2 0 1 7 81 until the operation has begun and a clear understanding of the extent of disease has been obtained. Canal-wall- down operations have the highest probability of permanently curing the patient of cholesteatoma but with higher rates of post-surgical complications. Canal-wall-up procedures have the advantage of maintaining a near normal anatomy, but they have a higher risk of persistent or recurrent cholesteatomas. The risk of recurrence is sufficiently high so that most surgeons advise an obligatory second-look tympanomastoidectomy, 6 months to 1 year following the initial operation. Our study results are similar. Keeping in view all the arguments in favor and against different types of surgical techniques, it is difficult to recommend one type as a technique of choice. What surgical procedure would be best for the patient depends on the preference of the surgeon, the nature and extent of the pathology, and the general health of the patient. Furthermore, surgeons have personal beliefs regarding specific techniques which are largely based on their own area of expertise. We recommend, that for patients who are difficult to follow, have the extensive disease, or have the disease in an ear with severe to profound hearing loss, CWU surgery may be preferred. 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