Author's: Guincho, Joana ¹; Baptista, Luís ¹; Sousa, Carlota ¹; Cabral, Rui ¹; Correia, Filipe ¹; Escada, Pedro ¹

Affiliations: 1 – Otorhinolaryngology Department of Hospital Egas Moniz – Unidade Local de Saúde Lisboa Ocidental (ULSLO);  

Corresponding author: Joana Guincho; joana.guincho@live.com.pt; ORCID: https://orcid.org/0009-0006-4630-831X   

Hospital Egas Moniz, Unidade Local de Saúde Lisboa Ocidental 

Rua da Junqueira 126, 1349-019, Lisboa, Portugal 

ABSTRACT

Subtotal petrosectomy (STP) has evolved with the expanding indications for its use, including modifications based on the underlying pathology, such as reducing the amount of bone and mucosa removed and eliminating the need for fat obliteration. We present a clinical case of a 71-year-old female with cholesteatomatous chronic otitis media in the right ear, who had previously undergone three surgeries in the same ear and presented with an open mastoidectomy cavity, recurrent exacerbations, and profound ipsilateral hearing loss. The patient underwent STP, with obliteration of the tympanic membrane and cul-de-sac closure of the external auditory canal. Fat obliteration was not performed. STP is an effective and permanent solution for treating chronic and recurrent middle ear diseases, offering significant benefits to patients with useful contralateral hearing. It improves the quality of life. Despite the challenge of monitoring the ear during outpatient follow-up, STP is considered a safe procedure with a low recurrence rate of disease in the long term. 

Keyword's: cholesteatomatous chronic otitis media, otorrhea, subtotal petrosectomy, mastoidectomy cavity, deafness 

INTRODUCTION

The primary goal in the treatment of chronic otitis media (COM) is to achieve a stable, dry surgical cavity. In most cases, this is accomplished by completely eradicating the underlying pathology and creating a well-structured, self-sustaining cavity [1,2]. 

However, in some cases, this goal is not achieved due to recurrence or persistence of cholesteatoma. Additionally, surgical cavities that have not been obliterated may develop granulation tissue, trapped mucosa and poor epithelialization, leading to chronic, persistent or recurrent suppurative cavities. This can occur despite multiple surgical procedures. If these cases are accompanied by severe or profound sensorineural hearing loss, the patients become ideal candidates for subtotal petrosectomy (STP) [3].  

STP classically involves the complete exenteration of the tympanomastoid cells, followed by obliteration of the Eustachian tube (ET), closure of the external auditory canal (EAC), and cavity obliteration with abdominal fat [1,2,3]. With the increasing indications for this procedure, the technique has undergone modifications based on the underlying pathology, including variability in the extent of bone cell removal and, in many cases, the decision not to obliterate the cavity with fat [1,2,3]. 

The most critical step in this procedure is the proper closure of the EAC, as incomplete closure may lead to the iatrogenic entrapment of epithelium. This step is particularly challenging in patients who have previously undergone canal wall down mastoidectomy with meatoplasty [1,2,3]. After surgery, the primary concern in STP patients remains the inability to monitor the ear during outpatient follow-up [1,2,4].  

The aim is to describe a clinical case of complicated and recurrent cholesteatomatous chronic otitis media (CCOM) treated with STP, highlighting the key procedures of this surgical treatment. 

CASE PRESENTATION

A 71-year-old female patient with a history of cholesteatomatous chronic otitis media (COM) in the right ear, previously undergoing three surgical interventions on the same ear. She had an open mastoidectomy cavity with frequent episodes of exacerbation that are difficult to manage in an outpatient setting, along with profound ipsilateral deafness. The contralateral ear has normal hearing. 

Otoscopic examination revealed an insufficient meatoplasty and a high facial ridge, which contributed to the presence of uncontrollable recesses within the cavity and recurrent otorrhea. 

Considering this case, where the patient has no useful hearing and the cavity was constantly infected, STP was proposed as the treatment. 

A STP was performed on the right ear, which included the following steps:  

1. Retroauricular approach; 
2. Sectioning of the external auditory canal (EAC) (figure 1);  
3. Careful cul-de-sac closure of the EAC in two layers (skin and cartilage) (figures 2, 3, 4, 5); 
4. Removal of all skin and mucosa from the external and middle ear (figure 6); 
5. Removal of the tympanomastoid cells (figure 6); 
6. Cavity saucerization with a diamond drill; 
7. Obliteration of the Eustachian tube with temporalis muscle and Surgicel® (figure 7);  
8. Closure in layers (figure 8).  

The obliteration of the cavity with fat in cases of chronic otitis media is debatable and was not performed. 

The surgical steps are illustrated in the figures. 

The surgery and postoperative period proceeded without complications, and after 2 years, the patient is satisfied, with a reduction in the number of clinic visits and no signs of infection in the STP cavity.

DISCUSSION

STP is primarily indicated for diseases affecting the middle ear and mastoid, particularly when there is extensive disease but limited extension into deeper parts of the temporal bone. This procedure is particularly beneficial in cases where a large cavity is left behind after removing recurrent infections or large cholesteatomas, provided these do not extend deeply into the petrous apex or the internal auditory canal. STP is also used for the removal of large tumors that do not have intradural extensions, and it serves to obliterate the middle ear and mastoid clefts from the external environment. This obliteration is essential to prevent the spread of infection to intracranial structures, especially the dura and inner ear fluids.  

A successful STP procedure aims to eliminate disease and create a stable cavity that prevents recurrence, with the restoration of hearing function being a secondary but still significant goal. Despite the success of many individualized treatments for chronic ear disease, there are cases where even the most experienced otologists struggle to prevent ongoing suppuration, despite multiple revision surgeries and thorough office-based management. A critical challenge in these cases is the inability to monitor the ear during routine outpatient follow-up. However, the availability of magnetic resonance imaging, particularly with fat suppression and diffusion sequences, facilitates surveillance and eliminates the need for additional surgeries, though long-term follow-up remains essential. It is recommended to perform a DWI MRI after 6 months, after 1 year, and once every 2 years thereafter for at least 10 years [1,2,3,7].  

In general, patient satisfaction is very high, with significantly improvement of quality of life. It is important to note that patients stop experiencing discharge, no longer require recurrent specialist visits, can wet their ear, and have a dry and secure ear [3]. 

In this case, we present a patient with CCOM, with no useful ipsilateral hearing and preserved contralateral hearing. Due to frequent episodes of otorrhea and the inability to control the cavity during outpatient visits, the patient underwent STP. This procedure not only allowed the creation of a safe, infection-free cavity but also made cochlear implantation possible in the future, as chronic otitis media is a contraindication for cochlear implantation. 

CONCLUSION

STP emerges as an effective and permanent solution for treating chronic and recurrent middle ear disease, offering the greatest benefit to patients with useful contralateral hearing. It enhances the patient's quality of life, eliminating the need for water precautions and preventing acute exacerbations and other potential intracranial infectious complications. The primary concern remains the inability to monitor the ear during outpatient follow-up. Despite this limitation, STP is considered a safe procedure with a low recurrence rate of disease in the long term, especially in ears that have already undergone multiple surgical interventions.

REFERENCES

[1] Sanna M, Dispenza F, Flanagan S, De Stefano A, Falcioni M. Management of chronic otitis by middle ear obliteration with blind sac closure of the external auditory canal. Otol Neurotol. 2008 Jan;29(1):19-22. doi: 10.1097/MAO.0b013e31815dbb40. PMID: 18199953.

[2] Prasad SC, Roustan V, Piras G, Caruso A, Lauda L, Sanna M. Subtotal petrosectomy: Surgical technique, indications, outcomes, and comprehensive review of literature. Laryngoscope. 2017 Dec;127(12):2833-2842. doi: 10.1002/lary.26533. Epub 2017 Mar 27. PMID: 28349533.

[3] Altuna X, Navarro JJ, Goiburu M, Palicio Management of chronic otitis media by subtotal petrosectomy. Acta Otorrinolaringol Esp. 2016 Sep-Oct;67(5):249-53. English, Spanish. doi: 10.1016/j.otorri.2015.09.011. Epub 2016 Jan 2. PMID: 26753917.

[4] Macielak RJ, Kull AJ, Carlson ML, Patel NS. Disease recidivism after subtotal petrosectomy and ear canal closure. Am J Otolaryngol. 2022 Dec 20;44(2):103743. doi: 10.1016/j.amjoto.2022.103743. Epub ahead of print. PMID: 36580740.

[5] Yan F, Reddy PD, Isaac MJ, Nguyen SA, McRackan TR, Meyer TA. Subtotal Petrosectomy and Cochlear Implantation: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2021;147(1):23–33. doi:10.1001/jamaoto.2020.3380

[6] D'Angelo G, Donati G, Bacciu A, Guida M, Falcioni M. Subtotal petrosectomy and cochlear implantation. Acta Otorhinolaryngol Ital. 2020 Dec;40(6):450-456. doi: 10.14639/0392-100X-N0931. PMID: 33558774; PMCID: PMC7889253.

[7] Schwab B, Kludt E, Maier H, Lenarz T, Teschner M. Subtotal petrosectomy and Codacs™: new possibilities in ears with chronic infection. Eur Arch Otorhinolaryngol. 2016 Jun;273(6):1387-91. doi: 10.1007/s00405-015-3688-4. Epub 2015 Jun 20. PMID: 26092235.