Inside-out Technique Cholesteatoma Surgery: A Retrospective Long-term Analysis of 604 Operated Ears Between 1992 and 2006

Objective: To retrospectively present the experience with 586 patients or 604 ears operated for cholesteatoma. Patients: All patients, adults and children, with histologically confirmed cholesteatoma and a mean age of 36 years (3 to 86 yr). Intervention: With the inside-out technique, cholesteatoma is eradicated from the epitympanum toward the mastoid: small cholesteatoma is removed by a transcanal approach, and medium-sized cholesteatoma is removed by a retroauricular atticotomy and cartilaginous reconstruction of the canal wall. An extended cholesteatoma is eradicated by a classical canal wall down radical cavity. A simultaneous reconstruction of the middle ear by tympano-ossiculoplasty is performed. Main Outcome Measures: Postoperative anatomic results with regard to recurrence, intactness of the tympanic membrane, and condition of the ear site. Auditory performance including air-bone gap, auditory threshold and improvement of hearing. Results: A complete removal of cholesteatoma in 93% of adults and 87% of children (mean postoperative follow-up, 10 yr; range, 2-15 yr) was achieved, with 95% dry ears and a mean air-bone gap of less than 30 dB in 78% postoperatively. Nine percent of all patients were lost to follow-up. Conclusion: The inside-out technique allows the safe removal of cholesteatoma according to the extent of disease combining the advantages of the canal wall down technique with respect to radicality of cholesteatoma removal and of the canal wall up technique with respect to functional results, with the added advantage of single-stage reconstruction.