Back to the Future: The Evolution of Cholesteatoma Diagnosis and Management

Abstract

Confucius once said, “Study the past if you would define the future.” As an introduction to the 10th International Conference on Cholesteatoma and Ear Surgery, the American Neurotology Society has assembled panelists (Mr. David Moffat (Addenbrooks Hospital), Dr. Jack Lane (Mayo Clinic), Dr. Clough Shelton (U. of Utah), Dr. Moises Arriaga (LSU) and Dr. Dennis Poe (Harvard) to discuss the evolution of cholesteatoma diagnosis and management. Dr. John McElveen (Carolina Ear Research Institute) will moderate the panel. Mr. Moffat will trace the history of the diagnosis of cholesteatoma from ancient times to the present. Based on the research in 1967 by McKenzie and Brothwell, the existence of chronic suppurative otitis media in prehistoric times has been clearly documented. It was the French anatomist Joseph-Guichard Du Verney who in 1683 first described a temporal bone tumour which was probably a cholesteatoma. However, the term, “cholesteatoma”, was first used by Johannes Peter Muller in 1838. Although a misnomer, it has continued to be used to describe “keratomas” involving the temporal bone and skull base. Abramson et al in 1977 provided a more detailed definition of cholesteatomas at the First International Conference on Cholesteatoma. The classification of cholesteatoma into congenital and acquired and the latter's subdivision into primary and secondary acquired was the natural sequel of refinements in diagnostic capability which accompanied the use of the microscope both in histopathology and in the clinical examination of the ear (Nylen, 1921). Since the dawn of medical imaging, radiographic examination of the temporal bone has been used in the evaluation and management of cholesteatoma. X-ray modalities have evolved from plain radiographs (1900-1940s) to polytomography (1950-60s) to single slice Computed Tomography (CT) acquired separately in the axial and coronal planes (1970-1980s) to multislice CT with multiplanarreconstruction (1990-2010s). MR with diffusion-weighted imaging (DWI) (1990-2000s) has been employed most effectively in the detection of recurrent cholesteatoma, particularly in the setting of canal wall up procedures. In some centers, DWI MR has obviated the need for many second look procedures. Dr. Lane will explore the evolution of these radiographic techniques and discuss recent advances in temporal bone imaging, including Photon Counting CT and high field MR (3 T and 7 T). These imaging modalities are anticipated to achieve greater degrees of resolution and sensitivity in the detection of acquired and congenital cholesteatomas involving the temporal bone. Just as imaging techniques have continued to evolve, so have the surgical techniques used to manage cholesteatomas. However, surgical management of cholesteatomas involving the temporal bone continues to be a source of some controversy. Some advocate a one stage procedure with revision of the failures. Others promote modern techniques for post-operative surveillance by employing imaging or endoscopic inspection. Dr. Shelton will discuss the surgical options currently used and review the rationale, controversy and history of the two stage strategy as advocated by the late JimSheehy. Skull base cholesteatomas can be particularly destructive and potentially life threatening. Dr. Arriaga will discuss the traditional and modified versions of skull base neurotologic approaches such as Middle Cranial Fossa, Middle Fossa Transpetrous (extended middle fossa), Retrolabyrinthine, Retrosigmoid and Translabyrinthine approaches. In addition, he will explore the use of four-hand skull base surgery techniques, fallopian bridge strategies and simultaneous application of the endoscope to microscopic visualization to deal with challenging skull base cholesteatomas. Dr. Poe will bring us “Back to the Future” with an update on the current understanding and treatment of Eustachian tube dysfunction as it relates to chronic otitis media. His focus will be on tubal dilatory dysfunction which typically involves the cartilaginous portion of the Eustachian tube. He will explore the use of Eustachian tuboplasty to treat tubal dysfunction and discuss its potential role in standard tympanoplastic and tympanomastoid procedures.