Dr. Rubén Polo's Surgery
In the world of otology, cholesteatoma represents a surgical challenge that requires precision, exhaustive anatomical knowledge and an adaptable strategy. In the online surgery app SurgSchool, we have the privilege of presenting this intervention made by the Dr. Ruben Polo: A tympanoplasty with mastoidectomy to treat an attic-antral cholesteatoma in a young patient. Join us as we break down the key moments of this complex surgery.
The Case: A Silent, Infiltrating Cholesteatoma
Dr. Polo introduces us to a young patient with a diagnosis of cholesteatoma Right attic-antral cholesteatoma. This type of cholesteatoma, a collection of keratinized skin within the middle ear and/or mastoid, has the ability to erode bone and cause significant complications. In this case, imaging studies revealed nonspecific occupation of the mastoid, indicating the need for a mastoidectomy. Interestingly, the diagnosis was a chance finding following trauma that caused tamponade, underscoring the sometimes insidious nature of this condition.
Surgical Planning: Closed Technique with Flexibility
Dr. Polo's initial strategy was a tympanoplasty with mastoidectomy using a closed technique, taking advantage of the patient's acceptable mastoid size. However, as Dr. Polo emphasizes, cholesteatoma surgery often requires adaptability. Therefore, he prepared for possible endoscopic support and even conversion to an open technique if the surgical field or extent of the disease required it.
Preparations included:
- Un standard retroauricular approach.
- La obtaining fascia from the temporalis muscle for grafting and prefascia, anticipating a possible need for additional tissue for epithelialization in the event of converting to an open technique.
- The design of a Koerner-type flap, crucial for access and subsequent reconstruction.
The Intervention Step by Step: Precision and Meticulousness
1. Access and Creation of Flaps:
Dr. Polo began with lidocaine infiltration with adrenaline and proceeded to carve the Koerner flap, differentiating the incision from a standard myringoplasty to ensure adequate skin remnant for medial support of the graft. He then made the retroauricular incision and carved a inverted Palva muscle flap, useful both for closure in closed technique and for possible obliteration in open technique.
2. Mastoidectomy:
With bone exposure achieved, the mastoid was reamed. Dr. Polo emphasized the importance of:
- Achieve flat edges for better tissue coupling.
- Identify key anatomical landmarks: temporal line, middle fossa (dura), sigmoid sinus and the root of the zygoma for proper access to the attic above.
- Manage the medullary bone, typical of underdeveloped mastoids, and the cells with cholesterol-filled fluid, indicative of inflammation.
3. Excision of Cholesteatoma:
Once the mastoid antrum was reached, the cholesteatoma was visualized. The ossicular chain presented a long osteitic and eroded branch of the incus, and the hammer was also affected. The following procedure was followed:
- Disarticulate and remove the anvil.
- Expanding anthrotomy and atticotomy, reaming the "cog" to access the anterior epitympanic cell, a frequent area of residual cholesteatoma.
- Identify and skeletonize the lateral and superior semicircular canal, as well as the Facial nerve, working with diamond burs to minimize risk.
- make a posterior tympanotomy for better control of the tympanic cavity and facial recess.
- Remove the hammer head to ensure complete removal of the cholesteatoma in the attic. The chorda tympani, infiltrated by the cholesteatoma, could not be preserved.
- Meticulous cleaning of the perilabyrinthine and supralabyrinthine cells, even using gauze to remove any matrix debris.
4. Endoscopic Inspection:
Before reconstruction, Dr. Polo used a 0 degree endoscope to thoroughly inspect the entire cavity, especially the attic and recesses, confirming the absence of residual cholesteatoma.
5. Reconstruction:
The reconstructive phase was multifaceted:
- Medial temporalis fascia graft over the tympanic remnant.
- Attic obliteration and posterior tympanotomy with fragments of autologous cartilage obtained from the cymbal of the auricular concha.
- Placement of a titanium partial denture (3 mm PORP) on the stirrup, which was found to be mobile.
- Interposition of a sheet of thinned cartilage between the prosthesis and the neotympanum to prevent extrusion.
- Reconstruction of the attic frame defect with a fragment of curved conchal cartilage.
- Obliteration of the mastoid cavity with Bonalive® (S54P4 bioactive glass granules), a bacteriostatic synthetic material that promotes new bone formation. The goal is to reduce the cavity volume and, consequently, the rate of recurrent cholesteatoma.
Key Points and Teachings from Dr. Polo:
- Adaptability: Cholesteatoma surgery doesn't always follow a fixed script. It's crucial to be prepared to modify the technique based on intraoperative findings.
- Anatomy: A thorough understanding of the three-dimensional anatomy of the temporal bone is essential for the safety and success of the surgery. The patient's anatomy (mastoid size, position of the middle fossa and sinus) is the primary factor in deciding between an open or closed technique.
- Chain Management: The decision to sacrifice ossicular remnants is based on infiltration by the cholesteatoma and the need for complete excision.
- Obliteration: Obliteration of the mastoid cavity and attic aims to reduce dead space, reduce the need for ventilation, and thus lower the incidence of recurrent cholesteatomas. Dr. Polo mentioned alternatives to Bonalive, such as the use of muscle flaps (Palva), cartilage, or bone pâté.
- Endoscopy as an Aid: Although Dr. Polo prefers the microscope for primary dissection due to its convenience and binocular vision, the endoscope is an invaluable tool for inspecting hidden areas.
- Follow-up: Magnetic resonance imaging (with non-echo-planar diffusion sequences) is followed up at one and a half, three and five years to detect possible recurrences.
