HSC Section 8_April 2017

Reprinted by permission of Laryngoscope. 2016; 126(4):980-987.

The Laryngoscope V C 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Systematic Review

The Disease Recurrence Rate After the Canal Wall Up or Canal Wall Down Technique in Adults

Kelly G. P. Kerckhoffs*, BSc; Maarten B.J. Kommer*, BSc; Thom H. L. van Strien*, BSc; Simeon J. A. Visscher*, BSc; Hanneke Bruijnzeel, MD; Adriana L. Smit, MD; Wilko Grolman, MD, PhD

Objectives/Hypothesis: To review which type of cholesteatoma surgery, canal wall up (CWU) or canal wall down (CWD), provides the lowest risk for residual and/or recurrent disease in adults with primary acquired cholesteatoma. Data Sources: PubMed, Embase, CINAHL, the Cochrane Library, Scopus and Web of Science. Study Design: We selected articles comparing CWU with CWD, reporting on disease recidivism (combined residual and recurrent disease) or independent residual or disease recurrence rates. We included studies with a moderate to high relevance. Results: Our search yielded 2,060 articles. We selected seven studies that carried a moderate risk of bias. Six studies described higher disease recidivism after the CWU procedure [16.7–61.0%] compared to the CWD technique [0–13.2%]. Four studies showed statistical significant difference ( P < .05). One study showed opposite results: recidivism was found in 7.8% CWU and in 22.1% CWD cases ( P < .001). Studies showed CWU recidivism more likely to be residual disease, whereas CWD recidivism tended to be recurrent disease. Conclusion: The majority of included studies showed CWU to result in more disease recidivism compared to the CWD technique in adult patients with a primary acquired cholesteatoma. If recidivism risk is the most important factor to consider a certain surgical technique, we recommend application of the CWD procedure. However, many additional factors in patient care will define the best treatment decision, such as residual hearing and access to health care. Our recommendations are based on Level II evidence, which underlines the need for future high-level evidence studies. Key Words: Cholesteatoma, recurrence, residual disease, canal wall up, canal wall down, hearing outcome, hearing loss. Laryngoscope , 126:980–987, 2016

INTRODUCTION Cholesteatoma is a cystic lesion formed from kerati- nizing stratified squamous epithelium. 1 The disease entity can be divided into congenital and acquired dis- ease. Acquired cholesteatomas can be divided into pri- mary and secondary cholesteatoma: disease enters the middle ear in primary cholesteatoma either through the weakest location of the tympanic membrane (Shrapnell’s membrane) or medially to the posterior–superior quad- rant of the tympanic membrane (TM) 2,3 ; in secondary cholesteatoma, however, squamous epithelium migrates to the middle ear by an iatrogenic or traumatic TM per- Additional supporting information may be found in the online ver- sion of this article. From the Department of Otorhinolaryngology, University Medical Center ( K . G . P . K ., M . B . J . K ., T . H . L . VS ., S . J . A . V ., H . B ., A . L . S ., W . G .); the Brain Cen- ter Rudolf Magnus ( H . B ., W . G .), Utrecht, The Netherlands Received February 25, 2015, Editor’s Note: This Manuscript was accepted for publication July 27, 2015. W.G. receives unrestricted grants from Cochlear, MED-EL, and Advanced Bionics. The authors have no other funding, financial relation- ships, or conflicts of interest to disclose. *The first four authors contributed equally. Send correspondence to H. Bruijnzeel, M.D., Department of Oto- rhinolaryngology, Utrecht Medical Center, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands. E-mail: ent-research@umcutrecht.nl

foration. Both primary and secondary cholesteatoma therapy consist of surgical removal. Two main surgical techniques are the canal wall down (CWD) and the canal wall up (CWU) procedure. With the CWD procedure, the posterior auditory canal wall is removed, whereas it remains intact during the CWU procedure. The disad- vantage of CWD is that an open cavity remains, necessi- tating hospital follow-up for earwax removal and cleaning, possible cavity infection and/or recurrence checkups and lifestyle adjustments. 4,5 Although CWU avoids these consequences, the intact canal wall might deter intraoperative visualization for complete cholestea- toma removal. This could result in a higher risk of resid- ual disease. 3,4 Furthermore, since the original anatomy is left intact, the recurrent disease risk might be higher. Current literature often fails to make a distinction between residual and recurrent disease. 6,7 Residual cho- lesteatoma is defined as nonradically removed epider- moid cells . Alternatively, a new retraction pocket containing keratin could arise and develop into a second- ary episode of cholesteatoma: recurrence. 8 Cholestea- toma behind the epitympanum could be suggestive for recurrent disease. 9 However, cholesteatoma found behind the mesotympanum mainly contains residual

DOI: 10.1002/lary.25591

Laryngoscope 126: April 2016

Kerckhoffs et al.: A Review on Cholesteatoma Recidivism After CWU and CWD

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