Evolving Considerations in the Surgical Management of Cholesteatoma in the Only Hearing Ear

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Abstract
Objective To describe a contemporary, pragmatic approach to managing cholesteatoma in the only hearing ear. Study Design Retrospective case series. Setting Single tertiary referral center. Patients All patients that underwent cholesteatoma surgery, having profound hearing loss in the contralateral ear. Intervention(s) Cholesteatoma surgery. Main Outcome Measure(s) Surgical strategy, preoperative and postoperative audiometric outcomes, short- and long-term complications, recidivism. Results Twenty-eight patients met criteria, representing 0.25% of all chronic ear surgeries performed between 1970 and 2012. Patients undergoing surgery in the latter half of the study underwent intact canal wall procedures and ossicular chain reconstruction more frequently despite having similar severities of disease. All patients with inner ear fistula underwent an open-cavity operation. In the early postoperative period, 86% of ears had stable or improved hearing levels, and all patients maintained preoperative bone conduction thresholds. At a mean follow-up of 48 months, 79% of patients maintained stable or improved pure tone thresholds, whereas 2 subjects experienced delayed sensorineural hearing loss and 2 experienced isolated declining speech discrimination. Notably, 3 of the latter 4 patients were diagnosed with labyrinthine fistula and had undergone radical mastoidectomy. None of the patients who received an intact canal wall tympanomastoidectomy experienced worsening bone conduction thresholds, whereas 1 subject demonstrated a delayed decline in speech discrimination and another recurred. Conclusion It is commonly held that the radical or classic modified radical mastoidectomy is the procedure of choice when managing cholesteatoma in the only hearing ear while intact canal wall techniques are contraindicated. Over the last 20 years, we have adopted a less-rigid, functional approach favoring intact canal wall procedures in the absence of inner ear fistula rather than unequivocally committing to an open cavity. This strategy has been influenced by advancements in preoperative evaluation, increasing familiarity and refinement of closed-cavity techniques, postoperative imaging surveillance options, and the potential for cochlear implant “salvage” in the rare case of profound hearing loss. Based on the current series, this approach appears safe when performed by an experienced surgeon, and reliable long-term patient follow-up is maintained.

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