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consequences of an open cavity and cost-effectiveness. Three included articles assessed postoperative hearing outcomes, measured by air bone gap in two studies 4,18 and air conduction in the remaining study. 19 Although no general conclusion on hearing outcomes can be drawn from results of these studies, none of the three studies reported significant differences between techni- ques. 4,18,19 A quality-of-life study 26 compared interfer- ence with social activities between 50 CWU and 50 CWD patients: 16% of the CWU patients and 24% of the CWD patients reported interference with daily activities (not significant). It is essential to clarify that the operation technique is not the only factor influencing the risk of cholestea- toma recidivism. In addition, this risk is affected by the extent of the disease 27–30 (especially mastoid exten- sion 31 ), ossicular chain disruption, 29,30,32–34 cholestea- toma location 27,34,35 and preoperative ear discharge. 27,35 However, it should be emphasized that all studies inves- tigating the aforementioned risk factors included only children 29–33,35 or studied a population consisting of both children and adults. 27,28 Therefore, the question remains whether these results can be extrapolated to an adult cholesteatoma population. Six of the included stud- ies 4,6,7,15,19,20 collected data on the presence of the afore- mentioned risk factors. However, three studies 6,7,20 did not mention the possible influence of these factors on the cholesteatoma recidivism risk: 1) Palmgren 20 recorded data regarding ear discharge and ossicular chain disruption; 2) Brown 6 collected information about the extent and location of disease; and 3) Nyrop and Bonding 7 recorded the extent and location of cholestea- toma, as well as ossicular chain disruption. The remain- ing three studies 4,15,19 did mention risk factor influence on disease recidivism. 1) In the study of Declerck, 4 sig- nificantly more recidivism occurred in pars tensa choles- teatoma compared to pars flaccida cholesteatoma. 2) Similarly, Stankovic 15 found more cases of disease recidi- vism in patients with pars tensa cholesteatoma com- pared to patients with attic or sinus tympani cholesteatoma. 3) Ajalloueyan 19 stated that ear dis- charge, especially in combination with TM retraction, is a major predisposing factor for recurrence. Therefore, pars tensa cholesteatoma showed to be an important additional recidivism risk factor in two studies 4,15 and ear discharge in one study, especially in combination with TM retraction. 19 Currently, new surgical techniques are being developed to be applied in cholesteatoma sur- gery, for example, intraoperative otoendoscopy to improve visualization intraoperatively. 36 However, these new developments are not yet applied worldwide; the additional benefits of these newer procedures must be elucidated in the future. Strengths and Weaknesses The strength of this study is the extensive litera- ture search, even identifying a nonindexed study. Also, we provide specific patient information on disease recidi- vism after cholesteatoma surgery by 1) exclusively pre- senting data concerning adolescents and adults and 2)

making a distinction between residual and recurrent dis- ease rates. We constructed our own CAT; however, we believe we performed a thorough relevance and validity assessment that reassures transparent assessment of retrieved studies. A remark needs to be made regarding the limited level of identified evidence. Articles scored low on overall validity (Table I). Loss to follow-up and handling of missing data were often not described and confounding by indication makes it hard to draw accu- rate conclusions about recidivism risks. This is not nec- essarily a limitation of our study but rather a limitation of the current available evidence. Although standardized research methods of evidence-based medicine are increasingly being used since 2000, 37 studies published after this year still not all provided high validity in their reported results. Except for one study, 15 all included articles were retrospective case series (Table I). There- fore, we recommend that a randomized controlled trial (RCT) should be performed in which cholesteatoma dis- ease residue and recurrence risks are compared between both surgical procedures at 5-year follow-up. Only cho- lesteatoma patients who are eligible for undergoing both surgical removal techniques (CWU and CWD) should be included. CONCLUSION In conclusion, the majority of included studies showed more cholesteatoma recidivism after the CWU technique than after the CWD technique in adult patients at 5-year follow-up. Studies showed that CWU recidivism was more likely to be residual disease, whereas CWD recidivism tended to be recurrent disease. Besides the elected surgical technique, the risk for cho- lesteatoma recidivism could be influenced by the extent of the disease, the cholesteatoma location (pars tensa) and presentation of preoperative ear discharge. There- fore, if one or more of these factors are present, a high cholesteatoma recidivism risk could exist, and we recom- mend that a CWD procedure should be performed. In addition, factors such as residual hearing need to be taken into account when opting for the surgical tech- nique. Our recommendation is based on level II evi- dence, which underlines the need for an RCT to clarify disease recidivism after cholesteatoma removal by either the CWU or CWD technique. Acknowledgment The following authors contributed equally to this work: K.G.P.K., M.B.J.K., T.H.L. V S., and S.J.A.V. BIBLIOGRAPHY 1. Semaan MT, Megerian CA. The pathophysiology of cholesteatoma. Otolar- yngol Clin North Am 2006;39:1143–1159. 2. Ramakrishnan Y, Kotecha A, Bowdler DA. A review of retraction pockets: past, present and future management. J Laryngol Otol 2007;121:521– 525. 3. Heyning P Van de, Mulder JS. Aandoeningen van het trommelvlies en het middenoor. In: Huizing EH, Snow GB, Vries Nd, Graamans K, Heyning P Van de, eds. Keel-neus-oorheelkunde en hoofd-halschirurgie. 1st ed. Houten, The Netherlands: Bohn Stafleu van Loghum; 2009:61–78. 4. Declerck T. Resultaten na cholesteatoomchirurgie: Een retrospectieve ana- lyse . 2010. Available at: http://lib.ugent.be/fulltxt/RUG01/001/458/841/ RUG01-001458841_2011_0001_AC.pdf. Accessed September 3, 2014.

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