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Introduction
Combined approach tympanoplasty has traditionally been associated with a higher risk of leaving residual cholesteatoma, compared with canal wall down procedures. In our experience, combined approach tympanoplasty offers several advantages, and provides an excellent view of the facial recess and incus region while maintaining an intact posterior ear canal. This avoids the inherent problems related to mastoid cavity formation and provides a physiological tympanic membrane position; it may also allow more numerous ossicular reconstruction techniques. The key disadvantage of the canal wall up approach is a potentially increased risk of residual and recurrent disease.
In recent years, endoscopy has allowed better visualisation of the middle-ear space and may increase the ability to completely remove cholesteatoma during canal wall up surgery.1,2 The aims of this study were (1) to explore whether the experience at the Radcliffe Infirmary (Oxford, UK) supported the use of combined approach tympanoplasty for cholesteatoma, by determining the rate of disease at subsequent surgery, and (2) to assess whether this rate differed from findings reported elsewhere in the literature, possibly due to the effect of using an oto-endoscope.
Methods
Between January 1998 and December 2004 inclusive, 66 patients underwent 68 primary combined approach tympanoplasty procedures, with data available for all 'second look' procedures. Data were entered prospectively for operations performed by a single surgeon. The rate of residual and recurrent disease was determined at second look surgery. Data were recorded for the site and extent of cholesteatoma at subsequent surgery and for the ossiculoplasty techniques used at second and third combined approach tympanoplasty procedures. The rate of modified radical mastoidectomy was determined. All patients underwent endoscopic evaluation of the mastoid cavity and middle ear during their second combined approach tympanoplasty, by post-auricular access (see Figures 1 to 3).
Fig. 1
The mastoid cavity was evaluated with a 45° oto-endoscope, using a post-auricular stab incision.
Fig. 2
Closer view of the post-auricular stab incision shown in Figure 1.
Fig. 3
Endoscopic view of a right posterior tympanotomy slot, viewed from the mastoid cavity. This demonstrates the head of the malleus and the under-surface of the tympanic membrane, and provides good visualisation of the middle ear.
A Storz (Tuttlingen, Germany), 2.7 mm, 45° oto-endoscope was used at all procedures. Endoscopy was...