Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada.
Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
JAMA Otolaryngol Head Neck Surg. 2020 May 1;146(5):408-413. doi: 10.1001/jamaoto.2020.0001.
Transcanal totally endoscopic ear surgery (TEES) improves tympanic cavity visibility during cholesteatoma resection but does not readily permit 2-handed surgery, which is possible with a postauricular approach and use of an operating microscope. Improved visibility and 2-handed access may reduce rates of incomplete surgical clearance and residual cholesteatoma.
To compare rates of residual cholesteatoma after TEES vs those after open surgery with a postauricular approach for initial disease limited to the middle ear and/or attic.
DESIGN, SETTING, AND PARTICIPANTS: This propensity score-matched cohort study considered a consecutive sample of 209 pediatric cases of cholesteatomas resected at a tertiary referral center between January 1, 2005, and December 31, 2017, by either TEES or postauricular approach. The 177 cases (84.7%) in 172 patients that were eligible for inclusion in the study had undergone at least 1 of the following assessments: second-look tympanoplasty, diffusion-weighted magnetic resonance imaging, or in-clinic follow-up examination at least 2 years after the operation. Ears were matched on the basis of the propensity score, a function of age, sex, comorbid diagnoses, etiology, disease extent, ossicular chain condition, presence or absence of tympanic membrane perforation, and otorrhea status at the time of surgery.
Transcanal totally endoscopic ear surgery was defined as a transcanal approach with surgeon-reported use of an endoscope for resection of cholesteatoma. Use of an operating microscope was permitted in the TEES group for graft placement during tympanoplasty. The postauricular approach was characterized by a postauricular incision and use of an operative microscope with or without adjunct use of an endoscope.
Residual cholesteatoma.
Of 177 cases included in the study, the unmatched cohort consisted of 65 ears that had undergone TEES (mean [SD] age, 9.9 [3.6] years; 33 [50.8%] female) and 112 ears of patients who had undergone surgery with a postauricular approach (mean [SD] age, 9.9 [3.5] years; 72 [64.3%] male). Propensity score matching was accomplished for a total of 128 cases, with 64 in each group. After matching, standardized differences between TEES and postauricular approaches were less than 0.20 for all measured baseline characteristics, indicating balanced groups. The TEES group had a residual disease incidence of 4 of 64 (6.3%) compared with 7 of 64 (10.9%) in the propensity score-matched postauricular approach group (absolute risk difference, -4.7%; 95% CI, -14.8% to 5.4%).
This study's findings suggest that there was no apparent advantage of the 2-handed postauricular microscopic approach with respect to surgical clearance of cholesteatoma limited to the middle ear and/or attic. Transcanal totally endoscopic ear surgery may be an effective alternative to a postauricular approach for removal of limited cholesteatoma in children.
经耳道全内镜耳部手术（TEES）可改善胆脂瘤切除过程中的鼓室可视性，但不易进行双手手术，而耳后入路结合显微镜使用则可以进行双手手术。可视性和双手操作的改善可能会降低不完全手术清除率和残留胆脂瘤的发生率。
比较 TEES 与耳后入路开放式手术治疗中耳和/或鼓室局限性胆脂瘤的残留胆脂瘤发生率。
设计、环境和参与者：这是一项倾向评分匹配的队列研究，纳入了 2005 年 1 月 1 日至 2017 年 12 月 31 日期间在一家三级转诊中心接受治疗的 209 例儿童胆脂瘤患者，手术方式为 TEES 或耳后入路。172 例患者中有 177 例（84.7%）符合纳入研究的条件，这些患者接受了以下至少一项评估：二期鼓室成形术、弥散加权磁共振成像或术后至少 2 年在门诊进行随访检查。通过年龄、性别、合并症诊断、病因、疾病范围、听小骨链状况、鼓膜穿孔与否以及手术时耳漏情况的倾向评分来匹配耳朵。
TEES 定义为经耳道入路，术者报告使用内镜切除胆脂瘤。TEES 组允许在显微镜下进行鼓膜成形术时使用手术显微镜。耳后入路的特点是耳后切口和显微镜使用（或不联合使用内镜）。
残留胆脂瘤。
在研究的 177 例病例中，未匹配的队列包括 65 例接受 TEES（平均[标准差]年龄，9.9[3.6]岁；33[50.8%]为女性）和 112 例接受耳后入路手术的患者的耳朵（平均[标准差]年龄，9.9[3.5]岁；72[64.3%]为男性）。对总共 128 例病例进行了倾向评分匹配，每组 64 例。匹配后，TEES 组和耳后入路组所有基线特征的标准化差异均小于 0.20，表明两组均衡。TEES 组的残留疾病发生率为 4/64（6.3%），而匹配后的耳后入路组为 7/64（10.9%）（绝对风险差异，-4.7%；95%CI，-14.8%至 5.4%）。
本研究结果表明，在中耳和/或鼓室局限性胆脂瘤的手术清除方面，双手操作的耳后显微镜入路并没有明显优势。对于儿童局限性胆脂瘤的切除，经耳道全内镜耳部手术可能是耳后入路的有效替代方法。
