Attic cholesteatoma with extension into the tympanum.

The otoscopic view is of a right ear that has a large attic defect. The handle of the malleus is vertical in the center of the photograph. The incus and the head and neck of the malleus are missing. The pars tensa is almost completely normal. A mass of cream-colored tissue is visible anterior to the lateral process of the malleus and medial to the pars tensa. A globular, pearl-like mass is seen pressing against the posterior portion of the pars tensa and extending inferiorly into the tympanum to the level of the round window. This is an attic cholesteatoma in a patient with Pulec-Deguine classification type IV chronic otitis media.

The required treatment is a Pulec type IV tympanoplasty and mastoidectomy. The edges of the perforation must be excised. A generous tympanomeatal flap might be necessary to provide adequate exposure to dissect the cholesteatoma from the tympanum. In most cases, the cholesteatoma and its basement membrane will separate easily from the pars tensa, allowing the pars tensa to be preserved. Complete removal of the remaining cholesteatoma in the epitympanum, antrum, and mastoid is accomplished with a postauricular approach. The posterior bony external auditory canal is left unharmed and intact. The mastoid cavity and epitympanum must be obliterated with bone paste, and the perforation is repaired with an underlay graft of fascia. Second-stage ossicular reconstruction is required after a healing period of at least 6 months.

From the Pulec Ear Clinic, Los Angeles (Dr. Pulec), and Gap, France (Dr. Deguine).