Osteoplastic atticoantrotomy with autologous bone chips and a bony attic strut in cholesteatoma surgery

The objectives of this study were to determine whether autologous bone chips are suitable materials for canal wall reconstruction after cholesteatoma removal and to evaluate the effectiveness of a separate attic bone graft for the prevention or recurrent cholesteatomas using prospective study of two consecutive patient series (29/31 unselected patients with an average follow-up of 36.3 ± 11.1/21.5 ± 6.3 months) and retrograde resection of the posterior-superior canal wall followed by reconstruction of the canal defect using one or more temporal squama bone chips. In the second series, lateral attic wall reconstruction and pars flaccida reinforcement was established by a notched bony attic strut attached onto the neck and short process of the malleus for structural support. In the first series, the rate of recurrent cholesteatomas (17.3%), in particular of attic retraction pockets (31%), was significantly high. The average postoperative air–bone gap was 6.4 ± 6.3 dB in type-I tympanoplasty (TP), 8.7 ± 3.4 dB in type-III TP with intact stapes suprastructure, and 16.4 ± 9.3 dB in type-III TP with TORP, respectively. In the second series, recurrent cholesteatoma and retraction pocket rate could be decreased to 9.7 and 6.5%, respectively. The postoperative air–bone gap was 7.5 ± 5.1 dB HL in type-I tympanoplasty (TP), 11.6 ± 4.9 dB HL in type-III (PORP) TP, and 17.9 ± 12.2 dB HL in type-III (TORP) TP. Connecting the attic strut to the malleus neck did not affect the malleus mobility and hearing outcome. Osteoplastic atticoantrotomy with autologous bone chip reconstruction enables a tailor-made anatomical and physiological reconstitution of the auditory ear canal, thus enhancing the acoustic properties. Precise reconstruction of the lateral attic wall and reinforcement of the superior part of the tympanic membrane seems to be important for the prevention of retraction pockets and subsequent recurrent cholesteatoma development.