How Necessary is a Second-Look Tympanoplasty-Mastoidectomy Strategy for Preventing Cholesteatoma Recurrence?

We asked a Marathon Medical, Inc. client and Duke University School of Medicine Head and Neck Surgery professor Calhoun Cunningham, MD. He and several Duke colleagues co-authored “Cost analysis and outcomes of a second-look tympanoplasty-mastoidectomy strategy for cholesteatoma,” which appeared in The Laryngoscope a few years ago. Co-authors were Dr. Matthew Crowson, Dr. Vaibhav Ramprasad, Dr. Nikita Chapurin, and Dr. David Kaylie.

Here’s what Dr. Cunningham taught us:

What Is a Cholesteatoma?

A cholesteatoma is an abnormal, non-cancerous growth that forms behind the eardrum in the middle ear. It’s similar to a cyst. Cholesteatomas are somewhat rare, but they can cause big problems like hearing loss, tinnitus, and dizziness. Sometimes medication can resolve a cholesteatoma, but they often require surgical treatment. Even if surgery is successful, sometimes cholesteatomas grow back after they have been removed. Dr. Cunningham worked on a retrospective study to understand whether certain standards of care reduce the risk of a “cholesteatoma recidivism,” that is, a cholesteatoma coming back.

Canal Wall Down (CWD) vs. Canal Wall Up (CWU)

To remove a cholesteatoma, a surgeon typically performs tympanoplasty with mastoidectomy. Tympanoplasty repairs the damage to the tympanic membrane (eardrum) that the cholesteatoma has caused. During mastoidectomy, the surgeon removes infected or damaged cells from the air-filled spaces in the mastoid bone. If left intact, this diseased tissue would raise the risk of more ear infections that could continue to spread into the skull base.

There are two main types of tympanoplasty with mastoidectomy surgery:

1. 1. Canal Wall Down (CWD) allows for superior exposure of the middle ear and results in lower disease recurrent rates. But CWD is more invasive and doesn’t preserve hearing as well as the second type of surgery.
   2. Canal Wall Up (CWU) procedures are less invasive because they preserve the ear’s natural external canal wall and tympanic membrane position. They result in preserved or improved hearing outcomes and avoid a mastoid cavity.

The downside of CWU procedures? They have a slightly higher risk of residual or recurrent cholesteatoma.

Why Surgeons Do Second-Look Procedures

Researchers defined cholesteatoma found in the middle ear space and secondary to incomplete disease resection as “residual cholesteatoma.” In other words, the surgeon has left some cholesteatoma behind during the first surgery and expects it to be there on the second look. A surgeon performs the second look to confirm that the residual cholesteatoma isn’t getting worse. 

Researchers defined cholesteatoma in a new retraction pocket as “recurrent cholesteatoma.” This kind of cholesteatoma isn’t at the original site when the surgeon performing a second-look procedure views the area through a surgical microscope.  

Overall, CWU patients in the retrospective study had good outcomes: only about 2.5 percent of them had recurrent cholesteatoma.

A “second look” strategy means the patient must undergo anesthesia, the risks of any surgery, and post-surgical healing two times instead of one time. Dr. Cunningham and his colleagues studied medical records of cholesteatoma patients to determine how necessary second-look surgeries really are for patients who undergo CWU tympanoplasty with mastoidectomy.

Advantages of Single-Stage Strategies

The primary goal of cholesteatoma surgery is to create what otologists call a “safe ear,” an ear that is free of disease and damage and therefore at low risk for future infections. A secondary goal to preserve or improve hearing. That said, there was no significant difference in audiologic outcomes between single-stage and second-look strategies (P > 0.05). (To measure audiologic outcomes before and after surgeries, clinicians deployed Air Bone Gap and Word Recognition Score.)

The total charges were 76% higher for a second-look strategy compared to a single-look strategy, with arguably no benefit in reducing the recurrence rate. Single-stage patients had significantly fewer post-op visits (6.32 vs. 10.4; P = 0.007). And they had significantly lower overall charges for care ($23,529 vs. $41,411; P < 0.0001). When the inherent risk of complication in any surgical procedure is considered, avoiding unnecessary procedures becomes even more pronounced.

A second-look strategy should not be not universally performed. Instead, surgeons should individually tailor their decisions based on what they observe during each case, concluded Drs. Cunningham and his co-authors.  

When To Skip a Second-Look Surgery

If a surgeon is confident that no residual cholesteatoma remains after the first procedure, then an automatic second-look strategy is unnecessary and costly. The study showed that:

• Of the 34 CWU patients who did not have a planned second look, four (7.5%) had an unanticipated second look after clinical findings suggested recurrent disease. All four were found to have recurrent cholesteatoma. 
• None had residual cholesteatoma, showing that the surgeons were very good at identifying when they removed all of the cholesteatoma.

When To Incur the Additional Risk and Cost of a Second Look

If, after an initial procedure, the surgeon believes there is residual cholesteatoma despite best efforts, then a second-look procedure is likely worth the additional risk and cost. The study showed that:

• • Of the 46 CWU patients with a planned second-look procedure, 22 (47.8%) had cholesteatoma identified during the second-look.
  • 2 of those 22 patients (4.35% of planned second-look patients) had recurrent cholesteatoma. 
  • 20 of those 22 patients (43.5% of planned second-look patients) had residual cholesteatoma.

These findings show that the second look is justified when the surgeon believes there was some residual cholesteatoma after the primary procedure.

Another reasonable indication for a second look: Evidence of excessive middle ear inflammation that may compromise primary ossicular chain reconstruction. Too much inflammation can cause problems as the surgeon rebuilds the hearing bones. In these cases, it may make sense to rebuild the hearing bones during a second procedure to ensure a good outcome. 

If excessive inflammation is absent, the surgeon may complete any ossicular chain reconstruction during the first surgical procedure.