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Microscope had been the mainstay of cholesteatoma surgery since the middle of the twentieth century. Since the early part of the nineties endoscopic surgery for middle ear and attic cholesteatoma had been started by few surgeons with good results. In spite of great resistance from the microscopic surgeons, the use of endoscope has been accepted by many as an adjunct to microscopic surgery for cholesteatoma at the present state. Cholesteatoma is a disease originating in the attic and the posterior quadrant of the pars tensa tympanic membrane. The advancement in equipment and techniques of diagnosis of ear diseases has allowed early diagnosis of the cholesteatoma disease in the last few decades. Thus, the incidence of complications arising out of cholesteatoma diseases is rapidly decreasing. The early cholesteatoma diseases are best treated by starting the tacking of the disease from the area of origin.

This helps in reducing post-operative complications of large mastoidectomy cavities with consequent problems like frequent infections, inability to enter water sports, swimming and diving. Microscopic inside out mastoidectomy starting from atticotomy is an improvement in microscopic cholesteatoma surgery. But the advantages of endoscope are increased visualization of corners, mobility of the endoscope tip in the operating field and 3600 visualization of the operative field. This study has been done to observe the endoscopic surgery in treatment of cholesteatoma in avoiding complications and exposure of large and extensive cholesteatoma using only endoscopes.


The study was Retrospective descriptive study of endoscopic cholesteatoma surgeries done in 243 ears in a duration of eight years from 2009 to 2017. The following are the criteria of case selection

Staging of Cholesteatoma

Our study used staging of the attic cholesteatoma as per Daniele Marchioni and Livio Presutti. [1]

Inclusion Criteria

The sites of cholesteatoma involving all of the given below:--

Site: (a) Lateral attic (with anterior epitympanum) and (b) Medial attic. * Subsites: (a) Mesotympanum, (b) Protympanum, (c) Hypotympanum, (d) Retrotympanum, (e) Antrum and (f) Mastoid. * I Extensiono C1: cholesteatoma with limited attic extension,--C1a: cholesteatoma involving only the lateral attic,--C1b: cholesteatoma involving also the medial attic. o C2: cholesteatoma with extension in one or more subsites,--C2a: posterior extension to the antrum and mastoid,--C2b: inferior extension to the mesotympanic, protympanic and hypotympanic regions- C2c: both posterior and inferior extension. o C3: cholesteatoma involving the retrotympanic space (Sinus tympani/subtympanic sinus; subpyramidal space) and/or with facial nerve involvement. For Mesotympanic and Acquired Cholesteatoma, the cases were selected from the staging system of Telmesani et al modified by Daniele Marchioni and Livio Presutti as given below--

* T = Tympanic cavity (Mesotympanic spaces), o T1 = mesotympanum involvement without hidden recess involvement (Hypotympanum, retrotympanum, protympanum), o T2 =mesotympanic cholesteatoma with one hidden recess involvement (Hypotympanum, retrotympanum, protympanum) and o T3 = 2 or more hidden recess involvements

* A = Attic: o A0 = no attic involvement, o A1 = lateral attic involvement, o A2 = medial attic involvement and o A3 = entire attic involvement

* M= Mastoid: o M0= no mastoid involvement, o M1= antrum cholesteatoma, o M2= cholesteatoma extending beyond the antrum and o M3= cholesteatoma affects the whole mastoid cavity.

Exclusion Criteria

Cases involving the petrous apex, inner ear and intracranial complications are excluded from the study. Cases allergic to lignocaine, suffering from hyperglycaemia, hypertension, pathological problems of kidney, liver and heart; suffering from hepatitis B and C, HIV infection etc. are also excluded from the study. This was Retrospective descriptive study of exclusive endoscopic cholesteatoma removal in 8 years duration from 2009 to 2017.

Principle of Endoscopic Cholesteatoma Surgery

For proper surgery of the middle ear cholesteatoma, the classification of the compartments of the middle ear is done as--

1. Epitympanum--a. Anterior, b. Posterior, c. Prussak's Space.

2. Mesotympanum.

3. Protympanum.

4. Retrotympanum.

Ventilation of Various Compartments of the Middle Ear Cleft Are Affected in This Manner:

1. Epitympanum

a. Anterior compartment from isthmus or through Tensor Tympani Fold if incomplete,

b. Posterior compartment from Isthmus,

c. Prussak's Space from Eustachian tube (ET) lateral to posterior malleolar ligament.

2. Mesotympanum from ET

3. Protympanum from ET

4. Retrotympanum from ET.

The failure of ventilation of the various compartments is the cause of retraction pocket formation and subsequent development of cholesteatoma. Therefore, it is imperative to look for adequacy of ventilation pathways at the end of cholesteatoma surgery of middle ear and attic.

The Principles of Cholesteatoma Surgery Are, To Aim For:

1. Eradication of cholesteatoma

2. Adequacy of ventilation pathways of various middle ear, attic and mastoid compartments

3. Reconstruction of hearing mechanism

4. Avoiding cavity problems.

Under endoscopic vision, structures of the middle ear became clear and exposure became easy for difficult areas: (1). Sinus Tympani: variation of shape and depth: types A, B and C; (2). Variations in structures of (a). Ponticulus, (b). Subiculum, (c). Finiculus, (d). Pyramidal eminence, (e). Subpyramidal space, (f). Sinus Subtympanicus, (g). Supratubal Recess.

Special endoscopic ear surgery instruments and specially made curved instruments with suction attachments and angled drill handpiece with self-irrigation (by Smith & Nephew co. [R]) are useful for ease of exposure and dissection. 3 mm 11-15 cm 0[degrees], 30[degrees], 45[degrees] endoscopes are especially useful for the negotiation in the isthmus, sinus tympani, subpyramidal space, sinus subtympanicus, mastoid tip, retrofacial cells etc.

Operation Procedure

All surgeries were done in local anaesthesia. Premedication was given with injection ondansetron (Adults: 4-8 mg. and children: 4 mg. slow intravenous), promethazine (Adults: 25 mg and children 6.25-12.5 mg. slow intravenous), glycopyrrolate (4 mc gm/Kg slow intravenous) and tramadol (Adults: 50-100 mg and children: 25-50 mg intramuscular) about 30-60 minutes before surgery. Local anaesthesia was given in the form of 2% lignocaine with adrenaline (1:30, 000) for local infiltration and 4% lignocaine with adrenaline (1:10, 000) for surface anaesthesia and blood haemostasis.

After the patient was kept in the supine position with a soft pillow under the head, the face was turned away from the surgeo n. After proper antiseptic dressing, a plastic adhesive draping with a hole for the pinna was used to cover the operating area along with large cotton cut-out sheets covering the remaining part of the whole body. Under endoscopic guidance 0.4 ml of 2% lignocaine adrenaline infiltration was done at 12, 3, 6 and 9 O'clock positions in the osteo-cartilaginous junction of the external canal. Further infiltrations were given in the incisura terminalis, around upper end of pinna and all around the mastoid along post-auricular sulcus about 0.5 ml for every 1 cm distance.

Usual incision was from 7 to 3 O'clock position clockwise on the right ear and 4 to 9 O'clock position anticlockwise on the left ear at the osteo-cartilaginous junction or hairline (About 1.5 to 2 cm lateral to annulus) of the external canal. The incision was deepened to the bone and elevated medially and inferiorly up to the fibrous annulus of the tympanic membrane and the tympanic membrane was reflected inferiorly up to the umbo. This exposes the attic, protympanum, retrotympanum and some part of mesotympanum revealing the ossicular chain. Retraction pockets and C1a cholesteatoma were easily removed here. This exposure were also enough for C1a (Lateral epitympanum and Prussak's space lesions), C2b (Mesotympanum, Protympanum, sinus tympani and Hypotympanum cholesteatomas), C2c (Posterior and inferior extensions) lesions and C3 cholesteatoma involving retrotympanic space (Sinus tympani/subtympanic sinus; subpyramidal space) and or with facial nerve involvement.

Removal of head of Malleus and body of Incus or Incus completely with dislocation of Incudo-stapedial joint and removal of scutum was done for C1b cholesteatoma (medial attic).

A radial incision starting at 1 O'clock on right ear and 11 O'clock on left ear drawn laterally towards incisura terminalis a nd soft tissues retracted after adequate mastoid bone exposure: Endaural extension was used for C2a (Posterior extension to the antrum and mastoid) lesions. But if the mastoid is sclerotic, this endaural exposure was not needed.

A set of variable sized sturdy and sharp bone curettes of little curvature in the end was effectively employed to expose small antrum, aditus and attic. Only in very pneumatised mastoid with wide extension up to the mastoid tip, extension of incision by endaural approach and drilling under endoscopy was needed. Dry drilling was enough to expose the whole of extensive mastoid.

Statistical Analysis

Collected data was entered into MS-Excel and data cleansing was performed. Data was then transferred into IBM SPSS ver-22.0 software and analysed. Descriptive statistics like Mean, Median, Standard deviation and percentage were used. Analytical Statistics like Chi square by using Yates' correction formula and ANOVA F-test was applied. P-value of <0.05 was taken as statistically significant.


This was Retrospective descriptive study of exclusive endoscopic cholesteatoma removal, all done by the author in JNIMS, Imphal in 8 years duration from 2009 to 2017 in 243 ears. Attic cholesteatoma cases encountered were from stages C1a to C3 only. Cases of involvement of labyrinth, petrous temporal bone and intracranial compartments were not encountered. Cases were operated exclusively with Endoscopic Trans-canal only in 78.6%% (191) cases and with Extension by endaural inside-out technique in 21.4% (52) cases. All were done under local anaesthesia with sedation. Age group of cases were from 8-65 years (median age was 30 years). There were 74.9% (182) males and 25.1% (61) females. All cases under 20 years 41.6% (101 cases) were operated in two stages at six months interval. Age and sex distribution were significant at the 5% C.I. Table 2 shows the distribution of cases were 9.9% (24 cases) of C1a, 20.2% (49 cases) of C1b, 60% (146) of C2a, 7% (17 cases) of C2b, 1.6% (4 cases) of C2c and 1.2% (3 cases) of C3: 3. -value of <0.05 was taken as statistically significant.

Table 3 shows that mean PTA air conduction in the C1a stage was 25.27 [+ or -] 5.76 while the mean PTA air condition in the C2C stages was 64.57 [+ or -] 20.69. PTA air conduction in the different stages was significant. Table 4 also shows that mean PTA bone condition in the C1a stage was 25.27 [+ or -] 5.76 while the mean PTA air condition in the C2C stages was 11.17 [+ or -] 8.48. PTA bone conduction in the different stages was significant.

Legend for ossicular configuration designated in the table 5 can be expanded as: HMBI- = Absent head of the malleus and body of incus by erosion. I- = Incus absent. LI- = Lenticular process of incus absent. M+I+S = Malleus, incus and stapes all intact. M+S = Only Malleus and stapes present. M+SF = Malleus and stapes footplate present, but, stapes superstructure eroded. PM+S = Partial malleus and whole stapes present. S = Only whole of stapes present. SF = Only stapes footplate present.

Complications most prevalent were pain around the ear complained by some patients. Next in incidence were cavity problems of discharge and debris collection needing cleaning minimum once in 6 months in about 12 cases. Reason of most cases with complication occurring in early part of the study may be due to learning curve or leaving of mucosa or bony overhang. Most got cured in later minor revision surgeries. Temporary facial nerve weaknesses seen in 3 cases, fully recovered later. In later cases, employment of soft canal wall reconstruction by tragal or conchal cartilage and obliteration of the large mastoid cavities by temporalis muscle, cartilage or bone lead to reduction of cavity problems. The follow up duration ranged from 12 months to 7 years and 9 months. There was no recurrence of the cholesteatoma during the whole duration of follow up.


Traditional cholesteatoma surgery employed microscopic surgery till the late 1990's when endoscope came into the picture. Canal wall up (CWU) and canal wall down (CWD) surgeries were usually employed to achieve cholesteatoma eradication. Endoscopy has been accepted as an adjunct to cholesteatoma surgery. Visualization of entire middle ear space was difficult under microscopy and field of vision was limited by the narrowest segment. Hidden areas like sinus tympani, facial recess, anterior epitympanum, attic, hypotympanum and protympanum was the common areas of leaving residual cholesteatoma. Employment of endoscope had improved the field of vision by giving a panoramic view, passing through the narrowest segments and showing the hidden areas. [2] Employment of endoscope as an adjunct to cholesteatoma surgery had reduced the incidences of residual cholesteatoma in CWU surgery (Up to 47%) and CWD (Above 10%) to less than 6%. [3,4,5,6,7] The occurrence of residual cholesteatoma were due to insufficient primary resection because of (1) very thin epidermal matrix or middle ear inflammation and (2) limited exposure of hidden areas, limited by the narrowest segment in surgery under microscope. This had prompted combined approach tympanoplasty through mastoid and posterior tympanotomy. Persistence of physio-pathologic phenomena that determined cholesteatoma development should be avoided to avoid recurrence of the disease by avoiding tympanic membrane retractions. [1] Ventilation of different compartments of the middle ear cleft and adequate reconstruction of scutum should be achieved at the end of cholesteatoma surgery. Exclusive endoscopic cholesteatoma surgeries have not been practised unless in limited attic and middle ear cholesteatomas. [8,9,10] In our study, trans canal curetting of bone was employed in small mastoid antrum with effective exposure and drilling of bone after endaural extension in some cases with very pneumatised mastoids. In this study series, it was possible to eradicate all cases of cholesteatomas presented to the surgeon in a span of eight years, by pure endoscopic approach without any need for microscope usage. Longest follow up time was 8 years and shortest was 12 months. There were no cases of recurrence of cholesteatoma.

Our study was aimed at establishing the point that only endoscope can effectively treat cholesteatoma disease of the ears. The routine examination of the ear by endoscopy has increased chances of early diagnosis and treatment leading to avoidance of very complicated and advanced spread of the disease in the petrous apex and labyrinth. In our study, we didn't come across this advanced spread of the disease, and, this may be the reason why we could employ endoscopic approach effectively.


Routine examination of the ear by endoscopy has enabled early diagnosis of cholesteatoma disease of the ear. Excellent visualization of the hidden areas of the middle ear has greatly removed recurrence of cholesteatoma from the middle ear cavity. Transcanal endoscopic approach reduces the size of post-operative open cavity of mastoid leading to avoidance of cavity problems. Soft tissue reconstruction after mastoidectomy could be done endoscopically and reduced cavity problems. Endaural extension of the incision allowed endoscopic surgery to reach the far corners of a well pneumatised mastoid and thus cholesteatoma surgery can be performed exclusively with endoscopy alone.

DOI: 10.14260/jemds/2019/36


[1] Presutti L, Marchioni D. Endoscopic ear surgery principles, indications and techniques. Georg Thieme Verlag 2015, (ISBN 9783131630414).

[2] Presutti L, Gioacchini FM, Alicandri-Ciufelli M, et al. Results of endoscopic middle ear surgery for cholesteatoma treatment: a systematic review. Acta Otorhinolaryngol Ital 2014;34(3):153-7.

[3] Yung MM. The use of rigid endoscopes in cholesteatoma surgery. J Laryngol Otol 1994;108(4):307-9.

[4] Thomassin JM, Korchia D, Doris JM. Endoscopic-guided otosurgery in the prevention of residual cholesteatoma. Laryngoscope 1993;103(8):939-43.

[5] Badr-el-Dine M. Value of ear endoscopy in cholesteatoma surgery. Otology & Neurotology 2002;23(5):631-5.

[6] Sajjadi H. Endoscopic middle ear and mastoid surgery for cholesteatoma. Iranian Journal of Otorhinolaryngology 2013;25(71):63-70.

[7] Aoki K. Advantages of endoscopically assisted surgery for attic cholesteatoma. Diagnostic and Therapeutic Endoscopy 2001;7(3-4):99-107.

[8] Kanzara T, Virk JS, Chawda S, et al. Wholly endoscopic permeatal removal of a petrous apex cholesteatoma. Case Reports in Otolaryngology 2014;(2014):184230. http//

[9] Tarabichi M. Endoscopic transcanal middle ear surgery. Indian Journal of Otolaryngology Head and Neck Surgery 2010;62(1):6-24.

[10] Tarabichi M, Nogueira JF, Marchioni D, et al. Transcanal endoscopic management of cholesteatoma. Otolaryngology Clinics North America 2013;46(2):107-30.

DhakeswarSingh Potsangbam (1)

(1) Associate Professor, Department of Otorhinolaryngology, J. N. Institute of Medical Sciences, Porompat, Imphai, Manipur, India.

'Financial or Other Competing Interest': None.

Submission 30-10-2018, Peer Review 07-01-2019, Acceptance 14-01-2019, Published 21-01-2019.

Corresponding Author:

Dhakeswar Singh Potsangbam, Singjamei Chingamakha, Heirangoithong Bazar, Imphal-795001, Manipur, India.


Caption: Figure 1. Different Compartments of Middle Ear

Caption: Figure 2. Ventilation Pathways in Middle Ear Cavity

Caption: Figure 3. Endoscopic Anatomy of Middle Ear

Caption: Figure 4. Endoscopic Anatomy of Middle Ear (2)

Caption: Figure 5. Position of Operating Team in the Operation Theatre

Caption: Figure 6. Exposure of Cholesteatoma in Limited Middle Ear Disease

Caption: Figure 7. Exposure of Cholesteatoma in Extensive Disease by Open Endoscopic Technique
Table 1. Age and Sex Distribution

Age-wise                          Sex                    Total

                                Male (%)    Female (%)

< 20                           79 (78.2)    22 (21.8)     101
20-40                          44 (63.8))   25 (36.2)     69
40-60                          44 (75.9)    14 (24.1)     58
[greater than or equal to]60    15 (100)     0 (0.0)      15
Total                          182 (74.9)   61 (25.1)     243

[chi square] = 10.194 with 3d.f; P-Value = 0.017 < 0.05.

Table 2. Distribution of Diagnosis and Stages

Stage of Cholesteatoma      No. of Cases   Percentage

C1a                              24          09.9%
C1b                              49          20.2%
C2a                             146          60.1%
C2b                              17          07.0%
C2c                              4           01.6%
C3                               3           01.2%
Total                           243           100

Table 3. Mean Distribution of PTA Air Conduction (AC) in Different
Stages (Before Surgery).

Stages   No. of          PTA air          Min    Max
          Cases        conduction
                    (Mean [+ or -] SD)

C1a        24      25.27 [+ or -] 5.76    15.0   36.6
C1b        49      43.42 [+ or -] 5.18    23.3   50.0
C2a        146     50.48 [+ or -] 8.37    25.0   90.0
C2b        17      47.54 [+ or -] 7.29    40.0   65.0
C2c         4      64.57 [+ or -] 20.69   40.0   90.0
C3          3      52.21 [+ or -] 10.57   40.0   58.0
Total      243     46.61 [+ or -] 11.05    15     90

Stages   F-Value   P-Value

C2b      48.840     0.000

Table 4. Mean Distribution of PTA Bone Conduction (BC) in Different
Stages (Before Surgery).

Stages   No. of         PTA bone          Min     Max
          Cases        Conduction
                    (Mean [+ or -] SD)

C1a        24       6.87 [+ or -] 3.85    1.66   13.33
C1b        49       6.29 [+ or -] 3.47    1.66   15.0
C2a        146     11.17 [+ or -] 8.48    1.66   50.0
C2b        17       9.40 [+ or -] 7.04    1.66   28.33
C2c         4      25.63 [+ or -] 21.46   3.33   50.0
C3          3       7.22 [+ or -] 4.81    1.66   10.0
Total      243      9.83 [+ or -] 8.05    1.66    50

Stages   F-Value   P-Value

C2a       7.38      0.000

Table 5. Distribution of Ossicular Configuration in Various Stages of

Ossicular Configuration     No. of Cases   Percentages

HMBI-                            11           4.5%
I-                               1            0.4%
LI-                              1            0.4%
M+I+S                            27           11.1%
M+S                              11           4.5%
M+SF                             2            0.8%
PM+S                             2            0.8%
S                               129           53.1%
SF                               59           24.3%
Total                           243            100
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Title Annotation:Original Research Article
Author:Potsangbam, Dhakeswar Singh
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Jan 21, 2019

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