chirurgie du cholesteatome la technique fermee
TRANSCRIPT
Chirurgie du Cholesteatome
LA TECHNIQUE FERMEE
Retraction pocket CHOLESTEATOMA
TYMPANOPLASTY – Wullstein & Zollner
• Eradication cholesteatome matrix
• Reparation– Eardrum = Myringoplasty– Ossicles = Tympanoplasty– Ear Canal = Rehabilitation of anatomo-
physiology of the ear– Eustachian tube
Cholesteatoma
• First question:– Can we remove aall size of cholesteatoma from the
middle ear?
• Second question:– What is the best way to prevent from recurrence
• Third question:– Are we able to respect or restore the normal anatomo-
physiology of bothe external canal and middle ear?
Cholesteatoma Open Techniques
Good wound healing – Skin in a wrong place
Defective: Wrong skin in a wrong place
1677 Closed Techniques1977-1999
Unselected patients – Several Surgeons
• Children>16• 353 Cases 21%
• Adults >15• 1317 Cases 79%
Cholesteatoma removal to prevent residuesReconstruction to prevent recurrence
• Tympanic graft– Fascia 804
– Perichondrium697
– Allograft
– Xenograft
• Canal Wall
• Intact 32 %
• Partial 62 %
• Total 5%
Secon Look
• CHILDREN– 60% (214/353)
– Before 1993 78%
– After 1993 42%
• ADULTS– 44,5% (586/1317)
– Before 1993 54%
– After 1993 25%
Systematic second look versusCriteria in decision making
• OTOSCOPY
• CT SCAN
• FUNCTIONAL RESULT
Endoscopic Second Look
REQUIREMENTS
-well ventilated middle ear
LIMITATIONS
-Bony structures-Fibrous tissue-Bleeding-Visual limitation to differentiate pathology-Ossicular chain
18% endoscopicSecond look
Short term results during second look
• CHILDREN 353
• Recurrence 18%• Residual 20%
• ADULTS
• Recurrence 16,5%• Residual 8,5%
Short term results regarding only the second stages
• CHILDREN 214
• Recurrence 29%• Residual 32%
• ADULTS 586
• Recurrence 37%• Residual 20%
Out of 1670 cases498 reviewed over 10 years
• 5 years follow-up– 60 cases 12 % 3rd revision– 11 cases 2% 2nd revision
• Including 48 cases 8% children cholesteatoma
conclusions
• The purpose of the surgery is not to performe a closed or an open technique but to get a safe ear.
• Residual cholesteatoma means we have to improve the exeresis of the disease.
• Recurrence means we have to improve the reparation of the ear
OTITE CHRONIQUE
• OTORRHEE
• PERFORATION
• MALADIE
• Abondante, muqueuse
• pars tensa, antero-inf.
• non marginale• tubo-tympanique• pneumatisée• simple• SAFE EAR• non dangereux
• Epaisse, fétide, peu abondante
• Shrapnell, postero-sup
• marginale• antro-atticale• éburnée• cholesteatome• UNSAFE EAR• dangereux
TYMPAN• PERFORATION : absence des 3 couches.
• RETRACTION : absence de la fibreuse, épiderme stable.
• ADHESIF : absence de la fibreuse et de la muqueuse, épiderme stable.
• CHOLESTEATOME :absence de la fibreuse et de la muqueuse, épiderme instable
POCHES DE RETRACTION
• S. d ’appel
• Localisation
• Epiderme
• Os
• ABSENT
• NON MARG
• NORMAL
• MOBILE
• SAFE
• PRESENT
• MARGINALE
• DYSKERATOSE
• FIXEE
• UNSAFE
metaplasia
migration
retraction
TYMPAN
• Absence lamina propris – myringomalacia, retraction, collapsus
• Absence LP et absence muq – atelectasie, otite adhésive
• Absence LP et absence muq et proliferation epiderme - cholesteatome
POCHES DE RETRACTION TYMPANIQUE
• Tympan flaccide
• Attraction mediale du tympan
• Collapsus tympanique
• Tympanum atelectasique