Modified radical mastoidectomy.

The otoscopic view is that of the left ear of a 15-year-old boy, taken 2 months after he had undergone revision surgery. At the age of 13 years, he had undergone surgery for an attic cholesteatoma via a closed technique. A tragal cartilage graft had been used to reconstruct the attic wall, but the patient developed a retraction pocket. This recurrence led to a second intervention--this time via an open technique (modified radical mastoidectomy).

The photo shows the malleus (minus the head, which had been amputated), the chorda tympani supporting the pars tensa, and the transposed incus on the head of the stapes. The atticoantral cavity appears to be epithelialized and healthy--or at least under control. It is surprising to see bubbles at this level. This evidence of serous otitis is further confirmed by the dullness and dark hue of the drum, which extends upward under the epithelialized tissue of the atticoantral cavity.

The patient's hearing fluctuated; it was excellent when the ear was well aerated, and it was worse when there was a seromucinous build-up, which necessitates paracentesis or placement of a tympanostomy tube.

This case illustrates the fact that acquired cholesteatoma is associated with an underlying physiopathology in the middle ear. Cholesteatoma must be removed because it might lead to complications. In choosing a surgical technique, the surgeon must consider the nature of the underlying disease process, which is not always easy to assess.

Jack L. Pulec, MD ([dagger]) Christian Deguine, MD

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

([dagger]) The late Dr. Pulec was editor-in-chief of Ear, Nose & Throat Journal from 1992 until 2003.