There has been a long standing controversy over whether to treat primary cholesteatoma with open or closed technique. The general consensus is that limited disease can be treated with closed technique whereas the canal wall down approach helps reduce recidivism in larger cholesteatomas. A third method of taking the canal wall down and reconstructing it subsequently has found application in this field. Worldwide literature was used in this study to obtain a combined analysis of outcomes, namely, recidivism, postoperative discharge and hearing results in the three methods.

There was no level 1 evidence available. Level 2 evidence showed recidivism rates of 25.7% in closed, 16.9% in open and 20% in subsequent canal wall reconstruction techniques.

The discharge rate was much lower in closed and subsequent reconstruction techniques. Improvement in postoperative hearing levels was the same in all three methods. Caution is expressed in deriving data from level 3 studies which show a much lesser difference in recidivism between open and closed techniques and can skew opinion in favour of closed technique because of a much lower postoperative ear discharge rate in the latter. From this study, it appears that open surgery with subsequent reconstruction is most suitable, although the study has limitations because methods vary tremendously. However, this study provides another logical dimension to these long debated methods.

Pooled analysis of the evidence for open cavity, combined approach and reconstruction of the mastoid cavity in primary cholesteatoma surgery.
Harris AT, Mettias B, Lesser THJ.
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Madhup K Chaurasia

Mid and South Essex NHS Foundation Trust, UK.

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