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BackTable / ENT / Article
Cholesteatoma Surgery: Expert Strategies for Optimal Outcomes
Melissa Malena • Sep 6, 2023 • 47 hits
Expert ENT Dr. Gauri Mankekar provides key insights and considerations associated with surgical removal of cholesteatomas. The operative risks include facial and tympanic nerve damage, hearing loss, dizziness and infection. To avoid nerve damage and hearing loss, Dr. Mankekar implements precise dissection of the ossicles. In order to combat post operative infection, patients are given courses of preoperative antibiotics. Before operating, it is critical for clinicians and patients to discuss expectations and the likelihood of cholesteatoma recurrence.
This article features excerpts from the BackTable ENT podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Fine dissection around the chorda tympani nerve is crucial for facial and chorda tympani nerve preservation. If a cholesteatoma completely covers the nerve, retention can become challenging.
• Gentle dissection around the ossicles, particularly avoiding drilling with the incus in position and not rocking the foot plate, can prevent hearing loss.
• Annual clinical checks are vital due to the potential for late recurrences in cholesteatoma patients. MRI surveillance at the first year and then possibly at the three-year mark is beneficial.
Table of Contents
(1) Mitigating Cholesteatoma Surgery Risks
(2) Postoperative Care & Long-term Surveillance After Cholesteatoma Surgery
(3) Managing Cholesteatoma Recurrence: Clinical & Auditory Monitoring
Mitigating Cholesteatoma Surgery Risks
Dr. Mankekar sheds light on the primary concerns associated with cholesteatoma surgeries, emphasizing the potential risks to the facial nerve, chorda tympani nerve, and the tegmen. Beyond the familiar complications of hearing loss, dizziness, and postoperative infections, she meticulously highlights the importance of gentle surgical techniques, such as caressing the ossicles, to minimize these risks. Dr. Mankekar advocates for perioperative antibiotics to counteract wound infections, meticulous dissection to prevent nerve injuries, and avoiding aggressive maneuvers that might jeopardize hearing structures. The analogy of "caressing the ossicles" underscores the need for a delicate approach to preserve the intricate structures within the ear.
[Dr. Gopi Shah]
Then in terms of potential complications, what are things that you counsel their families on, and things that you do in the OR to prevent them?
[Dr. Gauri Mankekar]
I think the most important complication that I counsel families about is facial nerve injury and the chorda tympani nerve injury. Taste, sensation, and then injury to the tegmen, meningitis, dizziness, of course, hearing loss, and wound infections postoperatively. These are the main things that we discuss preoperatively, and the way we prevent it, of course, is perioperative antibiotics for the wound infection, facial nerve monitoring intraoperatively, very fine dissection around the chorda tympani nerve avoiding stretching the nerve.
Sometimes if there's cholesteatoma completely covering the nerve, it's difficult to keep the nerve, or the chorda tympani. That's a challenge, and then avoiding hearing loss. As far as possible, very gentle dissection around the ossicles, avoiding drilling with the incus in place, and then not rocking the foot plate. Every step is important, and I think as one of my residents said, caressing the ossicles.
[Dr. Gopi Shah]
That's good. Haven't heard that one yet.
[Dr. Gauri Mankekar]:
Yes.
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Postoperative Care & Long-term Surveillance After Cholesteatoma Surgery
Navigating postoperative care in otologic surgery demands precision, vigilance, and patient-specific considerations, as illustrated by Dr. Mankekar. She emphasizes a protocol that includes straining and weight precautions for two weeks and underscores the criticality of water precautions for three months—particularly during summer to prevent infections. With scheduled reviews at two weeks, three months, and then biannually, the pathway she outlines caters to individualized care, especially for canal-wall-down cavities. An integral part of her post-op management involves using antibiotic ear drops to dissolve gel foam packing, avoiding potential damage to the graft. When it comes to surveillance for cholesteatoma recurrence, Dr. Mankekar recommends a Diffusion-Weighted MRI (DWIMRI) around the one-year mark and lays out scenarios that might necessitate earlier interventions.
[Dr. Gopi Shah]
Post-op. Do you have them on drops? Do you have them weighed? What's your dryer precautions? Do you do orals, and how long do you have dryer precautions or straining precautions and things like that?
[Dr. Gauri Mankekar]
Straining precautions for about two weeks, and weight precautions also for about two weeks. Then water precautions for three months, especially in summer because everybody wants to swim, and so we want to avoid any kind of infections. I see them at two weeks post-op, and then again three months post-op, and then follow every six months. If it's a canal wall down cavity, I might see them every four months, and then at approximately the one year post-op, I will get a DWIMRI to confirm if there is any recurrence.
Then antibiotic ear drops, I will have them used for about a month post-operatively, mainly to have the packing or gel foam in the ear dissolved. I don't like to remove the gel foam because I might accidentally suction the graph, so I continue the ear drops for about a month.
[Dr. Gopi Shah]
When do you get an audio? Do you get an audio in three months or?
[Dr. Gauri Mankekar]
At the three-month point yes, I do get an audio at the three-month point.
[Dr. Gopi Shah]
If you have to do a second stage, when are you planning for that?
[Dr. Gauri Mankekar]
Somewhere after the MRI. Let's say we did a one year MRI, I would consider doing it sooner if the child started especially, and this is so more in children, if they started to have foul smelling drainage earlier, then I would try to go in earlier. Maybe around the eight months to one year.
[Dr. Gopi Shah]
Then let's say it looks good, do you get longer term surveillance? Do you get MRIs again at like year, three year, five? How far out, and how frequent do you have to keep getting imaging for cholesteatoma in your experience? Or what do you do in your practice? I don't know if there's guidelines for this or not yet.
Managing Cholesteatoma Recurrence: Clinical & Auditory Monitoring
Dr. Gauri Mankekar further explains why long-term clinical surveillance is a necessary component of cholesteatoma management. While MRIs play a crucial role in the early postoperative years, she strongly advocates for annual clinical checks as recurrences can arise even eight years post-surgery. Red flags include foul-smelling drainage and granulation tissue, while audiograms more commonly indicate other complications than cholesteatoma recurrence itself. Furthermore, the discussion highlights the complex considerations around the timing of amplification, particularly in children and adults with financial constraints, reinforcing the need for individualized care based on clinical findings and imaging studies.
[Dr. Gauri Mankekar]
Yes, so, I do the MRI for the first one year, and then clinically follow them, and if I suspect there's drainage, if there is any suspicion, then I would repeat the MRI. Otherwise, I try to get it at the three-year point, and then if it's still clear, then just follow them clinically.
[Dr. Gopi Shah]
These are going to be lifetime patients that come at least once a year type of thing?
[Dr. Gauri Mankekar]
Yes.
[Dr. Gopi Shah]
Audio ear check?
[Dr. Gauri Mankekar]
Yes.
[Dr. Gopi Shah]
Your long-term surveillance?
[Dr. Gauri Mankekar]
Yes. Audio as well as clinical.
[Dr. Gopi Shah]
As we start to round this out, Gauri, thank you so much. Any other final pearls or tricks, whether it's diagnosis or surgical management of cholesteatoma?
[Dr. Gauri Mankekar]
I think we have to individualize the surgical approach based on our clinical findings and imaging studies. The scope is here to stay, so it's really a very useful tool. The instruments are improving, so we can use them around the corners. I think it's there for the long term. Then, in cholesteatoma, long-term surveillance is absolutely essential. Sometimes, we can see a recurrence as late as five to even eight years down the line, even longer, and so, we do need to see these patients in the long term.
[Dr. Gopi Shah]
Actually, that's one last question I was going to ask you. In terms of red flags on your surveillance, what are things that are going to tip you off that it's back?
[Dr. Gauri Mankekar]
Foul smelling drainage, granulation tissue, any squamous debris, especially in the mastoid tip or hard-to-see areas clinically.
[Dr. Gopi Shah]
Does the audio ever tip you off? Are there ever changes on the audiogram that might tip you off, or is that not as common, it's mostly your exam?
[Dr. Gauri Mankekar]
The audiogram doesn't tip me off to the cholesteatoma. The audiogram tips me off more towards worsening hearing loss, so it's more related to the ossicles or to the inner-ear issues, but let's say it's a canal wall up. Then, I would think the audiogram would tell me that there's some destruction or fluid. Sometimes there's just middle-ear effusion in these cases, so, yes.
[Dr. Gopi Shah]
Because sometimes even with cartilage, it's hard to examine if the audiogram is rebuilt with cartilage.
[Dr. Gauri Mankekar]
Yes, it's difficult to see.
[Dr. Gopi Shah]
Yes, it can be hard to tell. Then, in terms of hearing aids, just for unilateral cholesteatoma, when do you consider-- I know, insurance in the states, it's going to be different, especially for unilateral, they can be very difficult depending on the resources. Let's say, you are able to get a hearing aid, or the family is interested, when do you consider the amplification?
[Dr. Gauri Mankekar]
If we are waiting for a second stage surgery for ossicular reconstruction, then I would typically get it done after the three-month audiogram, so especially in children, I would refer them for amplification. In adults, it is a little bit difficult because as you mentioned, the insurance may not cover it, and they may not be able to afford it. In those cases, I may have to wait a little longer to do the ossicular reconstruction, or even to offer them, say , a bone-anchored hearing aid.
Podcast Contributors
Dr. Gauri Mankekar
Dr. Gauri Mankekar is an otolaryngolgist and head and neck surgeon with Ochsner LSU Health in Shreveport, Louisiana.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, July 18). Ep. 120 – Evaluation and Management of Cholesteatoma [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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