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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-
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
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.nlDOI: 10.1002/lary.25591
Laryngoscope 126: April 2016
Kerckhoffs et al.: A Review on Cholesteatoma Recidivism After CWU and CWD
Reprinted by permission of Laryngoscope. 2016; 126(4):980-987.
105