Mediterr J Otol 2005:1(2):64-69.

Histomorphometrical analysis of the structural changes in the incus and the results of cartilage ossiculoplasty in attic cholesteatoma surgery

Stankovic M.

Dept. Otolaryngology, Medical Faculty Nis, Serbia. milan.orl@bankerinter.met

OBJECTIVES: The aim of this study was to conduct a histomorphometrical analysis of the structural changes in the incus in attic cholesteatoma and to compare the results obtained with canal wall down (CWD) and intact canal wall tympanoplasty (ICWT) techniques for attic cholesteatoma.

PATIENTS AND METHODS: This study was conducted in two different stages. A total of 147 intraoperatively removed human incudes during middle ear surgery for chronic otitis media were evaluated according to the presence and localization of cholesteatoma (attic, sinus, tensa, and no cholesteatoma) and then were analysed under the operation microscope according to the following features: undamaged, external osteitis, lenticular defect, crus longum defect, combined defect with or without osteitis. The ossicles were prepared for histologic procedures and 10 sections from each ossicle were histomorphometrically analyzed using a projection microscope with regard to erosions on the ossicular surface, vitality, diameter of vascular spaces, osteomyelitis, and applicability. In the second stage, the results of attic cholesteatoma surgery were reviewed in 160 cases, of whom 68 patients had been treated within the period 1983 to1990 with the CWD technique and no attic reconstruction, and 92 patients had been treated with the ICWT technique and attic reconstruction with autologous tragal cartilage within the period 1991 to 2000. Anatomical and functional results were evaluated after at least three years postoperatively. The operation was regarded as successful when air conduction and air-bone gap were 10 dB or more and less than 20 dB, respectively.

RESULS: Most of the analysed parameters were significantly more intense in the group with cholesteatoma compared to that without cholesteatoma. Incudes with external osteitis were usually applicable when cholesteatoma was absent. The presence of cholesteatoma reduced potential applicability of the incudes by 25%. The localization of cholesteatoma was a significant factor for osteolysis. The lowest applicability was found for attic cholesteatoma. On the other hand,  postoperative audiological results were comparable in both groups, with slightly better results in the ICWT group. Postoperative air-bone gap was significantly better in patients treated with ICWT. There were no significant differences between audiometric findings at three months, at one year, and at the end of the follow-up period. Retraction and recurrent disease were significantly more common and of faster development with the CWD technique.

CONCLUSION: Intraoperative macroscopic findings of the incus in chronic otitis media closely correlate with its histologic structure. The results of this study confirm the superiority of ICWT with attic reconstruction for surgical treatment of attic cholesteatoma.