Clinical Indications for Canal Wall-down Mastoidectomy in a Pediatric Population

Objective. To establish clinically derived indications for performing canal wall-up or canal wall-down surgery when treating children with cholesteatoma. Study Design. Case series with chart review. Setting. Tertiary care academic pediatric otolaryngology practice. Subjects and Methods. Retrospective review of 420 children who underwent 700 procedures for cholesteatoma between 1996 and 2010. Results. The canal wall was preserved in 89.5% of cases. Common reasons for removing the canal wall were to provide access to the disease, extensive erosion of key structures, and the desire to avoid further surgery. The mean pure-tone average (PTA) for the canal wall-up group was 30 dB, whereas the canal wall-down group had a mean PTA of 45 dB. A matched-pairs analysis demonstrated that the better performance of the canal wall-up group was independent of preoperative hearing levels. Furthermore, although the presence of the stapes did influence hearing results, the canal wall-up procedure yielded better results even when the condition of the stapes was taken into account. The number needed to treat with canal wall-up to prevent 1 case of hearing loss (ie, mean threshold.30 dB) would be around 6. The need for revision surgery was higher in the canal wall-up group (51%) compared with the canal wall-down group (21%). Conclusion. In the setting of adequate follow-up and open access to surgical resources, most children with cholesteatoma can be managed with an intact canal wall technique. The authors believe that the better audiometric outcomes and easier postoperative care outweigh the need for revision surgery in this group.