Prevention of recurrent cholesteatoma: use of hydroxyapatite plates and composite grafts.

Recurrent cholesteatoma after closed techniques occurs in four patterns: (1) through an attic defect, (2) via erosions in the canal wall, (3) as a pars tensa invagination, and (4) as a borderline invagination between an attic defect repair and a normal pars tensa. Semicircular porous hydroxyapatite ceramic plates 7, 10, and 14 mm in diameter, and 1 mm thick are used as underlays to repair attic defects, supplemented by bone dust pate and fine tragal cartilage-perichondrium composite grafts. Pate and either the tragal composites or fine tragal cartilage shavings are used to minimize the risk of wall erosion pockets. Borderline invaginations and pars tensa recollapse are prevented with the fine tragal composites. The extent of pars tensa reinforcement is determined by the extent of disease. Care to anticipate and prevent each of the four patterns has produced a comprehensive reduction of recurrent cholesteatoma to acceptable levels (under 10%). Residual disease, found in 19 percent of second stage cases, has required open conversion in only 3 percent of cases. The above techniques therefore provide optimal results and are recommended as routine closed cavity techniques.