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Add as Friendmanagement of cholesteatoma ppt by dr manas

by: manas.rout2008

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1 : Management of C.S.O.M with Cholesteatoma Dr Manas 1
2 : Aim of the management of CSOM with Cholesteatoma To relieve the pts symptoms Eradication of the disease To prepare a epithelialized self cleaning ear Minimize the risk of complication of the disease Improvement of hearing Dr Manas 2
3 : Management Diagnosis Treatment Dr Manas 3
4 : Diagnosis of Cholesteatoma Otoscopic examination Microscopic examination CT scan MRI scan Post operative biopsy Audiometry Dr Manas 4
5 : Otoscopic examination Dr Manas 5
6 : Otoscopic examination Dr Manas 6
7 : Congenital cholesteatoma Dr Manas 7
8 : Computed Tomography CT is not essential for preoperative evaluation Should be obtained for: Revision cases due to altered landmarks from previous surgery Suspected congenital abnormalities Cases of cholesteatoma in which sensorineural hearing loss, vestibular symptoms, or other complication evidence exists Dr Manas 8
9 : Computed Tomography Erosion of scutum Destruction of ossicular chain Erosion of the labyrinth (fistula) Low tegmen / tegmen defect Facial nerve dehiscence Petrous Apex Involvement Dr Manas 9
10 : Computed Tomography Dr Manas 10
11 : Computed Tomography Dr Manas 11
12 : Magnetic Resonance Imaging Determine between recurrence or persistent cholesteatoma vs. scar tissue / granulation tissue Dural involvement or invasion Subdural or epidural abscess Facial nerve involvement Tegmen defect / brain herniation Sigmoid sinus thrombosis Dr Manas 12
13 : Magnetic Resonance Dr Manas 13
14 : Pure tone Audiometry Dr Manas 14
15 : Treatment of Cholesteatoma ear Dr Manas 15
16 : Treatment of Cholesteatoma ear Surgery is the main stay of treatment in CSOM with Cholesteatoma Few cases we can go for conservative medical treatment Dr Manas 16
17 : Indications of conservative medical treatment Elderly pt, unfit for surgery, with minimal risk of complications. Small cholesteatoma, easily accessible to suction clearance under operating microscope Dr Manas 17
18 : Conservative medical treatments Regular aural toilet with removal of squamus epithelial debris Periodic check up with repeated suction clearance Topical treatment at regular interval Cauterization of granulation tissue with silver nitrate or TCA Hearing aid for hearing disability Dr Manas 18
19 : Dr Manas 19 Surgical Treatment
20 : Principle of surgical treatment Completely remove the disease and minimize the risk of recurrence Ear should be returned to near normal Ear should be self cleaning and should not require regular aural toilet Hearing should be restored secondary to disease clearance. Dr Manas 20
21 : So aim of surgery is to prepare a safe and functioning ear Dr Manas 21
22 : Surgical techniques There are number of surgical techniques, but broadly it has been classified in to Canal wall down mastoidectomy Canal wall up mastoidectomy Dr Manas 22
23 : Canal wall down mastoidectomy Radical mastoidectomy Modified Radical mastoidectomy Small cavity mastoidectomy (Attico-antrostomy) Dr Manas 23
24 : Facial bridge Facial ridge Anterior buttress – Part of bone where posterior canal wall meets the tegmen Posterior buttress -- Part of bone where posterior canal wall meets the floor of the external auditory canal Dr Manas 24
25 : Dr Manas 25
26 : Extrastructures removed in Radical mastoidectomy then MRM Mallius, Incus Remnant of tympanic membrane Bony sulcus Eustachian tube is to be blocked Dr Manas 26
27 : Small cavity mastoidectomy or Attico-antrostomy (anterior to posterior approach/ inside out technique) –> popular because it gives a small cavity –> but only use full in case of limited cholesteatoma disease. Dr Manas 27
28 : Small cavity mastoidectomy Dr Manas 28
29 : Causes of active discharge and reccurence after canal wall down mastoidectomy -- High facial ridge Inadequate removal of posterior buttress Perforation of tympanic membrane Small meatoplasty Dr Manas 29
30 : Meatoplasty Dr Manas 30
31 : Advantages / Disadvantages of CWD Procedure Advantages: Residual disease is easily detected Recurrent disease is rare Facial recess is exteriorized Disadvantages: Open cavity created Takes longer to heal Mastoid bowl maintenance Shallow middle ear space makes OCR difficult Dry ear precautions Difficulty to fit hearing aid Dr Manas 31
32 : Tips to reduce the problems of cavity in CWD Partial obliteration of the cavity No over hanging Smooth cavity No facial ridge Wide meatoplasty TM should be repaired to cut off communication between masotympanum, mastoid cavity and eustachian tube. Dr Manas 32
33 : Canal wall up mastoidectomy Cortical mastoidectomy Combined approach tympanoplasty Dr Manas 33
34 : Dr Manas 34
35 : Cortical mastoidectomy Dr Manas 35
36 : Advantages / Disadvantages of CWU Procedure Advantages: Rapid healing time Easier long-term care Hearing aids easier to fit No water precautions Disadvantages: Technically more difficult Staged operation often necessary (second look after 12 – 18 mth) Recurrent disease possible Residual disease harder to detect Dr Manas 36
37 : Hearing results are claimed to be better with canal up procedure than canal wall down procedure, but on long run there is no significant difference. Dr Manas 37
38 : Cerebello-Pontine angle cholesteatoma Dr Manas 38
39 : C.P angle cholesteatoma Third most common c.p angle lesion next to acaustic neuroma and meningioma Congenital cholesteatoma usually found Arises from the congenital epithelial rest in temporal bone or posterior cranial fossa. Typically presents with progressive facial palsy or hemifacial spasm. Dr Manas 39
40 : Surgical approach to C.P angle cholesteatoma Middle cranial fossa aproach Translabyrinthine approach Suboccipital or Retrosigmoid approach Dr Manas 40
41 : Middle cranial fossa aproach Dr Manas 41
42 : Middle cranial fossa aproach Dr Manas 42
43 : Dr Manas 43
44 : Translabyrinthine approach Dr Manas 44
45 : Dr Manas 45
46 : Suboccipital or Retrosigmoid approach Dr Manas 46
47 : Suboccipital or Retrosigmoid approach Dr Manas 47
48 : Suboccipital or Retrosigmoid approach Dr Manas 48
49 : Petrous apex cholesteatoma Dr Manas 49
50 : Petrous apex cholesteatoma Mostly congenital cholesteatoma, rarely acquired. Thought to arise near foramen lacerum It expand and causes bone erosion. May be asymptomatic. Discovered coincidentally on MRI May presents with headache, retro-orbital pain, trigeminal neualgia. Dr Manas 50
51 : Approaches to petrous apex Hearing preservation approaches Hearing sacrificing approaches Dr Manas 51
52 : Hearing preservation approaches to petrous apex Eagleton’s middle cranial fossa approach Frenckner’s subarcuate approach Thornwaldt’s retro labyrinthine approach Dearmin & Farrior’s infra labyrinthine approach Farrior’s hypotympanic sub-cochlear approach Lempert Ramadier peri-tubal approach Kopetsky Almoor’s peri tubal approach Dr Manas 52
53 : Dr Manas 53
54 : Hearing sacrificing approaches to petrous apex Dr Manas 54
55 : Middle cranial fossa approach to petrous apex 6 cm vertical incision above zygomatic process 3X2.5 cm bone flap removed Glasscok triangle ( laterally by line from foramen spinosum to arcuate eminance, medially by GSPN, base by mandibular nerve) Kawase triangle ( laterally by GSPN, medially by petrous ridge, base by arcuate eminence. Dr Manas 55
56 : Dr Manas 56 Thank You
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