Second look after closed and obliterative techniques

Abstract

The indications for a second-look operation after closed and obliterative techniques are:

• postoperative cholesteatoma,

• planned second-stage reconstruction of the ossicular chain,

• inadequate closure of the air-bone gap, and

• postoperative infection of the obliteration material.

With the canal wall down technique used by the author, the frequency of the postoperative cholesteatoma is relatively low compared with experiences of the intact canal wall technique, but this harm cannot be completely avoided. In a long-term follow-up Ojala and Palva have shown how these few cholesteatomas grew in the meso- and epitympanum only, but none primarily in the obliterated mastoid. This can only be understood on the basis of complete radicalism of the surgery in the mastoid, with sufficient concern to every possible projection of the cholesteatoma within any little cell as well as into the Haversian canals in the bone. A golden rule to be kept in mind is therefore: “Never obliterate the mastoid without full reliability of your radicalism!” One ear with previous inadequate surgery in another hospital, reoperated on by the author, showed clearly the serious consequences forgetting this rule can have. A residual cholesteatoma on top of the labyrinthine massive advanced quickly resulting in a large fistula on the lateral semicircular canal. In the middle ear the radicalism of the primary surgery remains more or less questionable due to other demands. In order to improve the risk evaluation concerning the postoperative cholesteatoma, the author routinely takes specimens for histological examination from the hideaways of the middle ear, and from the mucosal borderlines when removing parts of the middle ear mucosa. However, keratinizing squamous cell epithelium is seen in these specimens far more frequently than the postoperative cholesteatoma which is to be expected, and the author does not consider such a finding as an indication for a second look. Due to the use of lyophilized dura on the bare bone surfaces in the middle ear the author waits nine to twelve months before the second look, due to persistent air-bone gap, or the second-stage reconstruction of the ossicular chain is performed. During this time the lyodura disappears as completely at it will do, and the regrowth of the middle ear mucosa can take place undisturbed.

Postoperative infection of the autogenous bone chips and the Palva flap is a seldom occurring complication. Two cases seen by the author were obviously infected by the bacterial strain grown even preoperative. In both cases, an open cavity was made two months after the primary surgery. The reconstructed middle ears did not need to be touched, the ears became dry within a few weeks, and the hearing results were not worse than the average of the normal closed and obliterative technique.