Atticotomy: A Neglected Otosurgical Technique

Transmeatal atticotomy was a popular surgical procedure during the turn of the century. Due to its limited success it was replaced by the modified radical mastoidectomy. An investigation of the indications, technique and results of transmeatal atticotomy done at the University of Iowa Hospitals was undertaken. A review of 82 patients with a 12 month or more follow-up and 61 patients with a 24 month or more follow-up was done. An attempt was made to discuss what factors in the history, physical examination, x-ray and audiological exam, operative findings and operative techniques influenced the patient's eventual outcome. The criteria for a successful result were considered to be: 1) no drainage from eight weeks postoperatively; 2) no tympanic membrane perforation; 3) no retraction pocket out of sight or touch with a Day hook; 4) no residual or recurrent cholesteatoma. The transmeatal atticotomy is primarily used in the extirpation of cholesteatoma confined to the epitympanum. It is occasionally used in the mobilization of ossicles with congenital fixation in the attic. At our institution the indications for atticotomy in patients with cholesteatoma are 1) drainage responsive to medical therapy (aural saline irrigations and antibiotic steroid ear drops); 2) absence of bone erosion on otologic or radiologic examination; 3) minimal hearing loss, e.g., an SRT of 40 dB or better; 4) absence of complication. Of the cases investigated 73.2% had a clean, dry ear without a retraction pocket, perforation or cholesteatoma at two years postoperative follow-up. Of the failures there were 12 cholesteatomas and two marginal perforations that occurred. There was therefore a 17.1% incidence of failure of atticotomy resulting in a dangerous ear. Of these, five required modified radical mastoidectomy for irradication of disease. Examination of the history presented by these patients revealed that those who had a history of drainage had a less chance of a favorable result than those who did not. Those whose drainage responded to conservative management did better than those who did not. If longer than four months of medical therapy was required before the drainage stopped then the surgical outcome was not as good. The presence or absence of scutum erosion had no significant effect on the results. The degree of hearing loss had little effect on the results. Those who still had suppuration at the time of surgery did less well than those who did not. The patients who had a small amount of scutum excised at surgery did less well than those who had greater attic exposure. Those patients who had recurrent cholesteatoma tended to have less scutum excised, and had their ossicles left intact more often. Transmeatal atticotomy should be limited to those patients with disease confined to the epitympanum. This may be indicated by a history of drainage that responds well to conservative medical therapy and in a patient demonstrating no evidence of bone erosion in the antrum. The operation should include wide exposure of cholesteatomatous disease with removal of the head of the malleus and the incus whenever there is doubt of the extent of the lesion.