Prospective study of treatment outcome in chronic suppurative otitis media (Attico-antral Disease)

Aim: To analyse the post operative outcome in patients with CSOM – Atticoantral type and compare the outcomes in terms of disease clearance and improvement in hearing. Material and Methods: 50 Patients who were diagnosed as Chronic Suppurative otitis Media of Attico-antral type, detailed history & clinical examination and investigations were performed. Per-operative findings (status of ossicles, middle ear, antrum, mastoid), Post operative follow up (1, 3 and 6 months)disease clearance and hearing status was done. Results: Out of total 50 patients, Canal Wall Down Procedures (Modified radical mastoidectomy with Tympanoplasty) had a good success rate in disease clearance when compared with Canal Wall Up Procedures (Cortical Mastoidectomy/ Atticotomy With Tympanoplasty). Irrespective of canal wall up (or) canal wall down procedures, Type II Tympanoplasty show better results of hearing improvement when compared to other surgical procedures. Conclusion: In our study, postoperative surgical outcome were statistically analyzed using Chi square test, in which Canal wall down procedures showed good result in terms of disease clearance and Type II tympanoplasty showed good result in terms of hearing improvement.


Introduction
Chronic Suppurative Otitis Media (CSOM) defined as inflammation of the middle ear cleft [1]. The chronic discharging ear is still one of the common problems that the Otorhinolaryngologist in India and other developing countries are encountering. Although, thanks to the advent of newer antibiotics, the incidence of acute suppurative otitis media and its complications have reduced, chronic suppurative otitis media and their complications are still prevalent.
The continuation of the infection and the bone eroding properties of granulation tissue and cholesteatoma seen in CSOM are known to be the major pathological process causing these complications. As there is no simple means to eradicate this chronic pathology, appropriate and timely intervention by an otologist goes Manuscript received: 10 th January 2019 Reviewed: 20 th January 2019 Author Corrected: 28 th January 2019 Accepted for Publication: 2 nd February 2019 a long way in the prevention of these human maladies. In cases of chronic suppurative otitis media with atticoantral pathology, treatment modality is only surgery. Surgical options available are the canal wall down mastoidectomy and intact canal wall mastoidectomy.
Austin DF et al reported that rate of recurrence of cholesteatoma was 4% for the Canal wall down technique and 39% in intact canal wall technique [2]. Dodson EE et al reported patients who undergone intact canal wall technique for treatment of cholesteatoma shows better hearing results post operatively compared to canal wall down technique [3].
The choice of technique is controversial and it is dependent on several factors, including extent of disease. Sheeley et al proposed two-stagesurgery as the first stage was disease eradication and membrane repair with silastic elastomer and the second stage of tympanic exploration and ossicular reconstruction, 6-12 months later [4]. Prior to the mid-1950s, the treatment for unsafe ear was accomplished by removal of the posterior external auditory canal wall, resulting in a radical or modified radical mastoidectomy cavity. The past 50 years have witnessed a trend away from mandatory canal wall removal.
Many otologic surgeons now prefer intact canal wall mastoidectomy with tympanoplasty except when canal wall removal is required because of extensive disease, inadequate access for cholesteatoma excision, operation on an "only hearing ear," or uncertainty of adequate followup. Portmann et al, cut the posterior canal wall bone of the external canal after skeletonization of the mastoid and repositioned the bone after complete resection of the disease [5].
Tarabichi M et al stated that the endoscopic technique allows for transcanal, minimally invasive, eradication of limited cholesteatoma. Preservation of the ossicles coupled with complete removal of disease is more likely with the endoscope. Continuous post-operative office based endoscopic surveillance is critical to the success of this approach [6].
The popularity of intact canal wall mastoidectomy stems from the benefits of maintaining a canal wall, which include freedom from the need for frequent mastoid bowl cleanings, freedom from water intolerance and calorically induced vertigo, and less difficulty in fitting and use of hearing aids. Kim JH et al (2009) reported in attic cholesteatoma, if the mass is removed by attico-antrotomy and the attic is obliterated or reconstructed with cartilage, the rates of recurrence can be decreased.
Attic reconstruction with cartilage could improve the hearing post-operatively, while attic obliteration could not. Thus attico-antrotomy is a relatively effective procedures that can be used in the management of cholesteatoma extending from the attic [7].
Kapur TR et al detected 26.5% failures (recurrence), 47.5% of which were due to attic retraction pocket, and 10% of which are due to residual cholesteatoma. The cholesteatoma recurrence rate in their patients with less than 10 years of follow up was 8.8%, significantly lower than the rate in patients with more than 10 years of follow up [8].
The present study has been carried out to provide an idea to the treating surgeon in choosing the appropriate surgical procedure for chronic suppurative otitis media -attico antral disease in terms of disease clearance and hearing improvement.

Aims and Objectives
To analyse the pre-operative findings and postoperative outcome in patients with CSOM Atticoantral type and compare the outcomes in terms of disease clearance and improvement in hearing. Per-operative findings (status of ossicles, middle ear, antrum, mastoid), Post operative follow up (1, 3 and 6 months)-disease clearance and hearing status was done. Statistically analyzed using Chi square test.P value <0.05 was taken as significant.

Methodology
Anesthesia-Patients were operated under General Anaesthesia. Local infiltrationwith 2% lidocaine with epinephrine (1 in 50,000) was used to achieve haemostasis during surgical procedures [9]. According to Wullstein's classification, Type I, Type II or Type III tympanoplasty was done for intact canal wall mastoidectomy and Type II, Type III or Type IV tympanoplasty was done for canal wall down mastoidectomy.

Surgical Procedures-1) Patients with Postero-Superior
Post-Operative Management-Patients were started on suitable antibiotics. Antibiotics were given for one week along with Analgesics, Antihistamine.
Mastoid bandage was changed on the 2 nd post operative day & dressings applied. The sutures are removed on the 7 th post operative day. Patients are reviewed 2 weeks after discharge & consecutive review on 1 st , 3 rd and 6 th month post operatively.   It has been found that 68% of patients in our series belong to lower socioeconomic class (family income <= 1500 rupees / month), 24% belong to lower middle class (income between 1500 -6000rupees). As people from lower classes live in crowded rooms with poor and unhygienic living conditions, giving rise to chronic ear problems and it is further compounded by pond bathing.
Preoperative Imaging Studies-In our study, Out of 50 patients, all the patients (100%) X-ray shows sclerosed mastoid air cells. Out of which 15 (30%) patients shows presence of Cholesteatoma and 7 (14%) shows presence of cavity. In our study, as a part of investigation to all patients we had taken HRCT-Temporal bone. We found erosion and destruction of the lateral attic wall i. escutum in 5 patients (10%), widening of the aditus and antrum as the destruction extends into antrum 11 patients (22%), displacement of ossicles 16 patients (32%), destruction of ossicles 27 patients (54 %), fistula formation with lateral semicircular canal in 1 patient (2%), destruction of mastoid (Automastoidectomy) in 7 patients (14%), erosion and sagging of the external canal roof in 3 patients (6%).
Intraoperative-All cases, surgery was done through post aural route, canal wall down mastoidectomy with tympanoplasty was done in 22 cases (44%) in whom there was extensive cholesteatoma. 28 (56%) patients presented with limited disease and cortical mastoidectomy with tympanoplasty was done for those patients. Grafting was done with temporalis fasciafree graft in all cases (100%).
All the seven patients with automastoidectomy and 1 patient with lateral semicircular canal fistula undergone modified radical mastoidecomy with tympanoplasty. A. Sengutha et al found that 25 cases (62.5%) in whom there was extensive cholesteatoma, aural polyps, facial paralysis and intracranial complications. About 5(12.5%) patients presented with limited disease and cortical mastoidectomy and tympanoplasty was done for those patients. Grafting was done with temporalis fasciafree graft in 17 cases (42.5%) [10].
Advantage of canal wall down mastoidectomy is that it offers excellent control of cholesteatoma. The disadvantage is that it creates a cavity that is more prone to infections and the patient is required to take  [17]. Glassock (1977) reported that the choleateatoma recurrence rate of closecavity procedure was 14% [15].
Austin DF (1989) reported that rate of recurrence of cholesteatoma was 4% for the Canal wall down technique and 39% in intact canal wall technique [2]. Kapur TR et al (1997) detected 26.5% failures (recurrence), 47.5% of which were due to attic retraction pocket, and 10% of which are due to residual cholesteatoma. The cholesteatoma recurrence rate in their patients with less than 10 years of follow up was 8.8%, significantly lower than the rate in patients with more than 10 years of follow up [8].

Conclusion
Our study was undertaken to analyze the treatment outcome in terms of disease clearance and hearing statusand to find out the best surgical proceduresfor the treatment of chronic suppurative otitis media-attico antral type. In our study, we concluded that Canal wall down procedures shows good result (P value is less than 0.01) thus proving to be statistically significant than canal wall up procedures in terms of disease clearance and Type II tympanoplasty shows good result (P value is less than 0.01) thus proving to be statistically significant than other types of tympanoplasty in terms of hearing improvement.

Why this study adds to existing knowledge?
In conclusion, currently, single stage CWD tympanoplasty is still a clinically effective and cost-effective approach in treating acquired cholesteatoma for better disease clearance and hearing outcome.
Funding: Nil, Conflict of interest: Nil Permission from IRB: Yes