HSC Section 8_April 2017

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.

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

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

), 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

recorded data regarding ear discharge and ossicular

chain disruption; 2) Brown

collected information about

the extent and location of disease; and 3) Nyrop and

Bonding

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,

sig-

nificantly more recidivism occurred in pars tensa choles-

teatoma compared to pars flaccida cholesteatoma. 2)

Similarly, Stankovic

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

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.

Currently, new surgical techniques

are being developed to be applied in cholesteatoma sur-

gery, for example, intraoperative otoendoscopy to

improve visualization intraoperatively.

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,

studies published

after this year still not all provided high validity in their

reported results. Except for one study,

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.

S., and S.J.A.V.

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