Cholesteatomas in children have a more aggressive growth pattern compared to adults, which leads to a higher incidence of both residual and recurrent disease. A staged canal wall-up or a canal wall-down tympanomastoidectomy (CWUT and CWDT, respectively) is selected depending on the extent of the disease and condition of the middle ear (ME) cleft and mastoid. Endoscopic ear surgery (EES) has been recently introduced as an adjuvant tool for the treatment of this pathology even in the pediatric population.

Objectives

To analyze long term outcomes of CWUT and CWDT in the pediatric population, focusing on residual and recurrence rates of cholesteatoma and hearing results. A literature review including cases treated with EES were discussed.

Material and methods

Pediatric patients treated for cholesteatoma involving both the ME and mastoid with a follow-up (FU) of at least 4 years were retrospectively analyzed in a quaternary referral center for otology and lateral skull base surgery. Patients were grouped according to the surgical technique (CWUT versus CWDT). Rates of residual and recurrent cholesteatoma after each surgical technique were reported and compared. Mean Air-Bone Gap (ABG) of 0.5-1-2-4 KHz was measured and reported before the first surgery and at the last post-operative FU.

Results

Two-hundred and thirty-six cases fulfilled our inclusion criteria. The mean FU was 100.4 ± 44.2 months (median 89 months). One-hundred and five (44.5%) cases underwent a CWUT, whereas 131 (55.5%) a CWDT. A second stage surgery was performed in 73.5% of CWUT and 58.7% of CWDT. Among the CWUT group, residual cholesteatoma occurred in 22 (21%) ears and recurrence in 24 (22.9%). Patients undergoing CWDT showed lower rates of both residual and recurrent cholesteatoma (7.6% and 2.3%, respectively). ABG improvement was noted for both groups, even though CWUT showed better post-operative hearing results.

Conclusions

The CWDT technique offers a definite surgical therapy, with minimal residual and recurrence rates and audiological results comparable to the CWUT technique. EES must still prove its added benefit or equivalence to pure microscopic approaches.

中文翻译：

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小儿胆脂瘤中管壁向上和管壁向下鼓膜切除术的长期结果

与成人相比，儿童胆脂瘤的生长模式更具侵略性，这导致残留和复发疾病的发生率更高。根据疾病的程度和中耳 (ME) 裂隙和乳突的状况，选择分期的管壁向上或管壁向下的鼓室乳突切除术（分别为 CWUT 和 CWDT）。最近引入内窥镜耳手术 (EES) 作为治疗这种病理的辅助工具，即使在儿科人群中也是如此。

目标

分析 CWUT 和 CWDT 在儿科人群中的长期结果，重点关注胆脂瘤的残留和复发率以及听力结果。讨论了包括用 EES 治疗的病例的文献综述。

材料与方法

在四级转诊中心进行耳科和外侧颅底手术，回顾性分析了接受 ME 和乳突胆脂瘤治疗且随访 (FU) 至少 4 年的儿科患者。根据手术技术（CWUT 与 CWDT）对患者进行分组。报告并比较了每种手术技术后胆脂瘤的残留率和复发率。在第一次手术前和最后一次术后 FU 时测量并报告了 0.5-1-2-4 KHz 的平均气骨间隙 (ABG)。

结果

236 个案例符合我们的纳入标准。平均 FU 为 100.4 ± 44.2 个月（中位数 89 个月）。105 例 (44.5%) 例接受了 CWUT，而 131 例 (55.5%) 例接受了 CWDT。73.5% 的 CWUT 和 58.7% 的 CWDT 进行了二期手术。在 CWUT 组中，残余胆脂瘤发生在 22 个（21%）耳中，24 个（22.9%）出现复发。接受 CWDT 的患者的胆脂瘤残留率和复发率均较低（分别为 7.6% 和 2.3%）。尽管 CWUT 显示出更好的术后听力结果，但两组的 ABG 均有所改善。

结论

CWDT 技术提供了明确的手术治疗，具有与 CWUT 技术相当的最小残留率和复发率以及听力学结果。EES 仍必须证明其与纯微观方法的附加优势或等效性。