Cholesteatoma in the normal hearing ear

Objectives/Hypothesis: Surgical treatment of cholesteatoma in ears with normal or near-normal hearing represents a challenge, in that complete removal of disease may require sacrifice of the ossicular chain. Our aim was to identify the predictive factors and surgical strategies that favor hearing preservation in these patients. Study Design: Retrospective case review. Methods. Fifty-four procedures were performed in 50 patients with cholesteatoma and a preoperative speech reception threshold or pure-tone average (PTA) of less than 25 dB. Complete audiometric data were available in 51 cases. All patients had complete surgical removal of cholesteatoma. Whenever feasible, ossicular reconstruction was performed at the time of the initial surgical procedure. Results: The median PTA changed by -3 dB, and hearing was preserved to within 10 dB of preoperative level in 72% of patients. An intact ossicular chain was found in 72% of the cases and could often be preserved at surgery. However, similar hearing outcomes resulted after intact versus reconstructed ossicular chains and in open versus closed mastoidectomies. The recidivism rate was 26%, and recidivistic cases had worse hearing outcomes. Congenital cholesteatomas and Prussak space cholesteatomas had better outcomes with respect to hearing preservation and recidivism. Conclusions. Cholesteatoma in the normal hearing ear should be treated with the same surgical priorities as all other cholesteatomas. Preventing recidivism has a significant effect on hearing preservation, whereas preserving an intact ossicular chain and maintaining an intact canal wall do not.