0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Intratympanic Membrane Cholesteatoma After Tympanoplasty With the Underlay Technique FREE

Mohammad Nejadkazem, MD; Javad Totonchi, MD; Masood Naderpour, MD; Minoo Lenarz, MD
[+] Author Affiliations

Author Affiliations: Departments of Otolaryngology, Tabriz University of Medical Sciences, Tabriz, Iran (Drs Nejadkazem, Totonchi, and Naderpour), and Medical University of Hannover, Hannover, Germany (Dr Lenarz).


Arch Otolaryngol Head Neck Surg. 2008;134(5):501-502. doi:10.1001/archotol.134.5.501.
Text Size: A A A
Published online

Objective  To evaluate the incidence of intratympanic membrane cholesteatoma (ITMC) in patients after tympanoplasty with the underlay technique.

Design  Retrospective study.

Setting  Ear, nose, and throat department, Tabriz University of Medical Sciences, Tabriz, Iran.

Patients  A total of 1121 patients with central tympanic membrane perforation were evaluated after tympanoplasty.

Interventions  Tympanoplasty was performed with the underlay technique using temporal facial graft.

Main Outcome Measure  The patients were followed up to assess the postoperative incidence of ITMC.

Results  During the follow-up period of 5 years, ITMC was observed in 9 patients (0.8%). Of these 9 patients, 8 were asymptomatic and had intact tympanic membranes. The asymptomatic cases were detected 1 to 2 years after surgery during routine follow-up examinations. Only 1 of 9 patients had otorrhea, which was due to a posterior perforation away from the location of the ITMC. The most common site of the ITMC was near the umbo.

Conclusions  Even after tympanoplasty with underlay technique, ITMC may develop between the layers of the tympanic membrane. The most common location of these cholesteatomas is near the umbo, which may be the result of insufficient removal of the residual squamous epithelium from the handle of the malleus. The cholesteatomas are usually asymptomatic and can be detected during routine follow-up examinations 1 to 2 years after surgery. Although ITMCs are usually noninvasive in nature, a review of the literature revealed that in rare cases they can also show a rapid and invasive growth pattern. Early detection and removal of these asymptomatic cholesteatomas during routine postoperative follow-up examinations can prevent their progression as well as consequent residual problems and complications.

Cholesteatomas that are located between the layers of tympanic membrane are called intratympanic membrane cholesteatomas (ITMCs), which are categorized as congenital or acquired. The acquired type of ITMC is further subdivided into inflammatory and iatrogenic types.19 The iatrogenic type of ITMC can potentially occur after tympanoplasty, especially after tympanoplasty with an overlay technique or a combined overlay-underlay technique. Unfortunately, there are no clear reports in the literature about the incidence of these cholesteatomas after tympanoplasty with the underlay technique. In this study, we evaluated the incidence of ITMC in a series of 1121 patients with central tympanic membrane perforation who underwent tympanoplasty with the underlay technique and were followed up for 5 years after surgery.

We retrospectively evaluated 1121 patients with central tympanic membrane perforation who underwent type I tympanoplasty with an underlay technique using temporal facial graft (with or without mastoidectomy). Patients with cholesteatoma and marginal perforation were not included. All 1121 patients received at least 5 years of follow-up. The follow-up examinations were performed 7, 21, and 60 days after surgery. Further follow-up examinations were performed every 3 months during the first 2 years, every 6 months during the third year, and then once a year during the fourth and fifth years.

Nine cases (0.8%) of ITMC were identified in 1121 patients (Table). Eight of the 9 patients involved were asymptomatic and had an intact tympanic membrane. The ITMC was detected during routine postoperative follow-up examinations in all 9 patients. Only 1 of the 9 patients presented with otorrhea, which was due to a posterior perforation that was not related to the ITMC. In this case, the ITMC was located anteriorly and away from the perforation. In all 9 patients, the ITMCs were diagnosed between 13 and 22 months after surgery, and the most common location was near the umbo (6 cases). The average diameter of the ITMC at the time of diagnosis was approximately 2 mm.

Table Graphic Jump LocationTable. Patients' Demographics and Findingsa

Once the ITMC was detected, the patients were informed about the diagnosis, and removal under local anesthesia was planned. Eight patients with intact tympanic membranes and small cholesteatomas underwent surgery on an outpatient basis. A sickle knife was used to remove the cholesteatoma pearls from the tympanic membrane, with preservation of the intact medial layer. The diagnosis of ITMC was confirmed histopathologically in all cases. Recurrence was not observed during the 8- to 42-month follow-up period after surgery. In the only case with an anterior ITMC accompanied by a dorsal perforation and otorrhea, the patient was admitted to the hospital, and explorative tympanotomy and type I tympanoplasty were performed to rule out further cholesteatomas in the middle ear and to close the tympanic membrane perforation, which was not related to the ITMC.

The acquired form of ITMC may be caused by an inflammatory injury or surgery.1,911 Inflammatory injuries to the tympanic membrane may lead to the proliferation of the basal layer of squamous epithelium into protruding cones. In such cases, although microscopically the tympanic membrane is injured, macroscopically it appears intact. The cones then form cholesteatomas within the layers of tympanic membrane.2 Tympanoplasty is another important pathogenetic factor in acquired ITMC. The ITMC usually occurs after tympanoplasty with an overlay technique or a combined overlay-underlay technique.10,11

Our study revealed that an underlay tympanoplasty can also lead to the development of an ITMC, which occurs mostly near the umbo, where insufficient separation of the squamous epithelium rests from the handle of the malleus can be the responsible factor. The ITMC is often limited to the tympanic membrane and progresses very slowly and silently.1 Most of our patients did not have any symptoms, and their cholesteatomas were diagnosed during the second year after surgery; therefore, regular follow-up examinations after tympanoplasty are extremely important, even in asymptomatic patients, for a period of up to 2 years after surgery. In rare cases, ITMC may also show an invasive growth and invade the middle ear structures.2

Appropriate management of ITMC consists of early diagnosis and evacuation of the keratin while it is still small and before the endothelial layer of the tympanic membrane erodes. The operation can be performed on an outpatient basis with the patient under local anesthesia. If the ITMC is associated with other pathologic conditions, such as otorrhea or perforation, exploratory tympanotomy and revision tympanoplasty are required to rule out its progression to the middle ear and to repair tympanic membrane perforation.

Correspondence: Mohammad Nejadkazem, MD, Department of Otolaryngology, Medical University of Tabriz, Suite 5, No. 5 S Sadii St, Valiasr, Tabriz Az 5157936513, Iran (nejadkazem@yahoo.com).

Submitted for Publication: February 28, 2006; final revision received June 27, 2007; accepted September 4, 2007.

Author Contributions: Dr Nejadkazem had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Nejadkazem and Lenarz. Acquisition of data: Nejadkazem, Totonchi, and Naderpour. Analysis and interpretation of data: Nejadkazem and Totonchi. Drafting of the manuscript: Nejadkazem and Lenarz. Critical revision of the manuscript for important intellectual content: Totonchi and Naderpour. Statistical analysis: Nejadkazem and Totonchi. Obtained funding: Nejadkazem, Totonchi, and Naderpour. Administrative, technical, and material support: Nejadkazem and Lenarz. Study supervision: Nejadkazem.

Financial Disclosure: None reported.

Jaisinghani  VJPaparella  MMSchachern  PA Silent intratympanic membrane cholesteatoma. Laryngoscope 1998;108 (8, pt 1) 1185- 1189
PubMed Link to Article
Weber  PCAdkins  WY  Jr Congenital cholesteatomas in the tympanic membrane. Laryngoscope 1997;107 (9) 1181- 1184
PubMed Link to Article
Sobol  SMReichert  TJFaw  KDStroud  MHSpector  GJOgura  JH Intramembranous and mesotympanic cholesteatomas associated with an intact tympanic membrane in children. Ann Otol Rhinol Laryngol 1980;89 (4, pt 1) 312- 317
PubMed
Schwartz  RHGrundfast  KMFeldman  BLinde  REHermansen  KL Cholesteatoma medial to an intact tympanic membrane in 34 young children. Pediatrics 1984;74 (2) 236- 240
PubMed
Smith  RMoran  WB Tympanic membrane keratoma (cholesteatoma) in children with no prior otologic surgery. Laryngoscope 1977;87 (2) 237- 245
PubMed Link to Article
Rappaport  JMBrowning  SDavis  NL Intratympanic cholesteatoma. J Otolaryngol 1999;28 (6) 357- 361
PubMed
Pasanisi  EBacciu  AVincenti  VBaccicu  S Congenital cholesteatoma of the tympanic membrane. Int J Pediatr Otorhinolaryngol 2001;61 (2) 167- 171
PubMed Link to Article
Kim  SAHaupert  MS Congenital cholesteatoma of the tympanic membrane. Otolaryngol Head Neck Surg 2002;127 (4) 359- 360
PubMed Link to Article
Tos  M A new pathogenesis of mesotympanic (congenital) cholesteatoma. Laryngoscope 2000;110 (11) 1890- 1897
PubMed Link to Article
Kartush  JMMichaelides  EMBecvarovski  ZLaRouere  MJ Over-under tympanoplasty. Laryngoscope 2002;112 (5) 802- 807
PubMed Link to Article
Plester  DPusalkar  A The anterior tympanomeatal angle: the aetiology, surgery and avoidance of blunting and annular cholesteatoma. Clin Otolaryngol Allied Sci 1981;6 (5) 323- 328
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable. Patients' Demographics and Findingsa

References

Jaisinghani  VJPaparella  MMSchachern  PA Silent intratympanic membrane cholesteatoma. Laryngoscope 1998;108 (8, pt 1) 1185- 1189
PubMed Link to Article
Weber  PCAdkins  WY  Jr Congenital cholesteatomas in the tympanic membrane. Laryngoscope 1997;107 (9) 1181- 1184
PubMed Link to Article
Sobol  SMReichert  TJFaw  KDStroud  MHSpector  GJOgura  JH Intramembranous and mesotympanic cholesteatomas associated with an intact tympanic membrane in children. Ann Otol Rhinol Laryngol 1980;89 (4, pt 1) 312- 317
PubMed
Schwartz  RHGrundfast  KMFeldman  BLinde  REHermansen  KL Cholesteatoma medial to an intact tympanic membrane in 34 young children. Pediatrics 1984;74 (2) 236- 240
PubMed
Smith  RMoran  WB Tympanic membrane keratoma (cholesteatoma) in children with no prior otologic surgery. Laryngoscope 1977;87 (2) 237- 245
PubMed Link to Article
Rappaport  JMBrowning  SDavis  NL Intratympanic cholesteatoma. J Otolaryngol 1999;28 (6) 357- 361
PubMed
Pasanisi  EBacciu  AVincenti  VBaccicu  S Congenital cholesteatoma of the tympanic membrane. Int J Pediatr Otorhinolaryngol 2001;61 (2) 167- 171
PubMed Link to Article
Kim  SAHaupert  MS Congenital cholesteatoma of the tympanic membrane. Otolaryngol Head Neck Surg 2002;127 (4) 359- 360
PubMed Link to Article
Tos  M A new pathogenesis of mesotympanic (congenital) cholesteatoma. Laryngoscope 2000;110 (11) 1890- 1897
PubMed Link to Article
Kartush  JMMichaelides  EMBecvarovski  ZLaRouere  MJ Over-under tympanoplasty. Laryngoscope 2002;112 (5) 802- 807
PubMed Link to Article
Plester  DPusalkar  A The anterior tympanomeatal angle: the aetiology, surgery and avoidance of blunting and annular cholesteatoma. Clin Otolaryngol Allied Sci 1981;6 (5) 323- 328
PubMed Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

917 Views
5 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs