Definition & Overview

Atticotomy is a surgical procedure to treat cholesteatoma, the abnormal growth of squamous epithelium in the middle ear or the mastoid process. It is also known as skin cyst.

Cholesteatoma can be a congenital or acquired condition. If it’s the latter, it is typically the result of perforation, infection, or trauma. The epithelial tissue is filled with keratin that can spread to other parts of the ear and even to the base of the skull. When this happens, it could lead to the destruction of the surrounding bones and cartilages. The abnormal growth also produces enzymes that can erode the bone separating the ear from the brain, leading to the possible infection of the latter. This condition affects people of all age groups, ranging from infants to the elderly. If left untreated, it can lead to total hearing loss as well as irreparable damage to surrounding structures.

Who Should Undergo and Expected Results

Atticotomy is advised for patients diagnosed with:

  • Attic cholesteatoma – A condition characterised by the presence of epidermoid cyst in the “attic” or the bone above and behind the upper part of the eardrum.

  • Acquired cholesteatoma - Patients with this condition typically experience numerous symptoms including ear discharge and exhibit varying degrees of hearing loss. Other symptoms include tinnitus, pain, headaches, and even bleeding from the ear. Some report facial nerve weakness. Typically, patients are given medications to stop ear discharge prior to the surgery.

  • Otitis media - Patients diagnosed with otitis media with evidence of cholesteatoma are also offered atticotomy to avoid extensive damage to the middle ear.

  • Limited mastoiditis - This refers to the inflammation within the mastoid bone. Though rare in occurrence, this condition can be caused by an infection that spread from other parts of the ear, such as the middle ear.
    Atticotomy is a relatively safe procedure with high satisfaction rating. Long-term benefits include the effective prevention of total hearing loss and preservation of nearby ear parts that might have otherwise been affected by cholesteatoma.

How is the Procedure Performed?

Following the administration of anaesthesia, a small incision is made in the ear to allow access to the ear canal. The tympanomeatal flap is then elevated to locate the cholesteatoma. There are several atticotomy techniques that can be used to perform the surgery. The first type involves locating the eardrum to allow access to the middle ear. The surgeon will drill the overlying bone structure to obtain a clear visual of the retraction pocket. Depending on the need, some cases may require the removal of the posterior ear canal wall and the ossicles. The cholesteatoma is then excised using a curved pick. If part of the tympanic membrane was removed, a cartilage graft is placed on the remnant of the membrane. An ossicular chain reconstruction is also performed following the removal of the ossicles. The eardrum is then laid back down, and the incision is closed with an absorbable suture.

The second type of atticotomy extends the procedure to include the removal of more attic bone. This way, the body of the incus is revealed to remove any keratinized abnormal growth that spread into this part of the ear.

If the cholesteatoma has spread to the malleus, the surgeon will extend the operation and remove the abnormal growth in this part of the ear. This is considered the third type of atticotomy. Both types two and three require extensive reconstruction of the affected ear parts to avoid the development of retraction pockets and recurrent growth.

In some cases, the surgeon may need to insert a grommet tube into the eardrum to help relieve pressure.

The patient may experience pain and dizziness in the first few hours following surgery. Strenuous activities should be avoided for a week or two. Patients are also expected to visit their physicians several times after the surgery to evaluate the efficacy of the treatment.

Possible Risks and Complications

Patients who undergo this surgery may suffer from the following:

  • Adverse reaction to anesthesia used
  • Hearing loss - Some patients complain of persistent hearing loss. In some cases, this resolves on its own after a few weeks without treatment. However, in some cases, it leads to a permanent condition.
  • Recurrence - There is also the possibility of recurrent formation of retraction pocket due to negative pressure in the middle ear. This can also lead to the reformation of cholesteatoma that will require additional surgical intervention.
  • Infection - There is also the risk of infection, especially if there is no proper drainage. In such cases, the patient will require regular checkups for routine draining of fluid.
  • Facial paralysis - Though rare, this can develop if a facial nerve was injured or damaged during the procedure.
  • Vertigo – This is another possible complication that is usually accompanied by the ringing of the ears or tinnitus.

References:

  • Potsic WP, Korman SB, Samadi DS, Wetmore RF. Congenital cholesteatoma: 20 years' experience at The Children's Hospital of Philadelphia. Otolaryngol Head Neck Surg. 2002 Apr. 126(4):409-14.

  • Drahy A, De Barros A, Lerosey Y, Choussy O, Dehesdin D, Marie JP. Acquired cholesteatoma in children: Strategies and medium-term results. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Apr 2.

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