[Surgical treatment of chronic otitis media. I: Indications, preoperative care and surgical principles].

The two classic types of chronic otitis media--chronic suppurative disease and cholesteatoma--not only differ in their clinical course and prognosis, but they also require different therapeutic strategies. Benign chronic suppurative disease with its chronic irritating otorrhea can often be managed conservatively. Surgery is recommended if improvement of hearing is the goal, but also to heal the chronic inflammatory disease. Diagnosis of a cholesteatoma, however, is a clear indication for surgical treatment; conservative and wait-and-see strategies are the exception. Even in cases of precholesteatoma, there is an increasing tendency for surgery to be performed to halt the progress of the retraction pocket. Preparations for ear surgery comprise an extensive investigation with tympanic microscopy, audio- and vestibulometry and radiography. The information given to the patient must be comprehensive, and should include details of operative strategies and the risks involved, thus allowing the surgeons to adapt their operative techniques to intraoperative findings. Several surgical techniques are recommended for the removal of cholesteatomas. There is no "best" method, however, as shown by fluctuations in the different more or less dogmatically propagated techniques performed in the last few decades. Nowadays, the operative procedure, i.e. whether open or closed technique, retroauricular or endaural approach, is individualized, which means the appropriate technique is chosen according to the requirements of a given case. Each technique has its own specific advantages (and disadvantages) and can be employed taking into account the individual factors of the chronic ear disease to be treated in order to reduce the intolerably high recurrence rates. The acoustic results of tympanoplasty, the pathophysics of which are briefly described, are also unsatisfactory. Closure of a drum perforation alone is connected with a high success rate regardless of the material used. Hearing results of ossicular chain reconstruction depend only partially on the prosthesis material in spite of the strong propagation of modern materials. Rather, mechanical factors and unresolved problems such as continuing tubal dysfunction and chronic inflammation are crucial as regards the successful restoration of normal hearing. Postoperative complications such as inner ear trauma, facial nerve injury etc. are rare; early diagnosis and treatment of complications improve the prognosis. The careful, sometimes extensive postoperative management is necessary and must continue lifelong in cases of cholesteatoma because of the high recurrence rate.