Learning Objectives: 1) to demonstrate the influence of impaired surgical field clarity due to intraoperative bleeding on development of residual cholesteatoma. 2) To emphasize the importance of implementing methods to minimize surgical site bleeding, such as hypotensive general anesthesia.
Introduction: Sites within the middle ear and mastoid with limited visualization are more frequently implicated in residual cholesteatoma. We hypothesize that other factors leading to compromised surgical field visualisation may similarly affect rates of residual cholesteatoma. The objective of this study was to evaluate whether impairment of surgical site visualisation from intra-operative bleeding contributes to the risk of residual cholesteatoma.
Methods: Data were collected prospectively on a consecutive series of children having intact canal wall surgery for cholesteatoma at an academic pediatric hospital. Clarity of surgical field was assessed intra-operatively on a six-point rating scale and categorized as minimally compromised (grades 0-I) or significantly compromised (grades II-V). Presence of residual cholesteatoma was assessed at follow up clinical encounters, second stage procedures, and with MRI.
Results: Surgery was completed on 224 ears, during which 82 (37%) had minimal visual field compromise from bleeding. Residual cholesteatoma was identified in 38 (17%) of ears, with only 8 (9.8%) in cases with minimal bleeding at first surgery, and 30 (21%) in cases with significant bleeding. Predictors of residual disease on univariate regression analysis included severity of bleeding (p = 0.029), extent of cholesteatoma (p < 0.001), years of surgeon's experience (p = 0.0045). Age and type of cholesteatoma were not found to be significant. Multivariate regression analysis demonstrated that the most robust predictor was extent of cholesteatoma (p < 0.001).
Conclusions: Impairment of surgical field visualization from intraoperative bleeding is one factor that contributes to the presence of residual cholesteatoma. These findings support the use of techniques, such as hypotensive general anesthesia, that minimize surgical site bleeding and improve surgical field visualization.