Piezoelectric endoscopic management of attic cholesteatoma and retraction pocket
Authors: Elgarf Tareq , Abdel Naseer Usama , Talaat Nassim , ElNaggar Yahya , Atef Mahmoud 
Published: February 2025

Abstract

Background
Retractions of tympanic membrane can be stable or unstable. The unstable retraction pocket means the formation of a cholesteatoma (attic cholesteatoma). Surgery is the main line of treatment for cholesteatoma which named tympano-mastoidectomy [1]. The popularity of endoscopic ear surgery (EES) is increased in recent years and becoming a routine practice in ENT centers [2]. The benefits of usage of the endoscopes in treatment of retraction pocket and attic cholesteatoma are better visualization of the retraction extension with little bone removal and good access for ME ventilation correction [3]. Piezosurgery is a new system developed to be used in bone cutting with ultrasonic microvibrations [4]. The selectivity of piezosurgery in cutting only mineralized tissues as bone is the major benefit of this new technology [5].

Methods
Patients included in this study were, with no age limitations, diagnosed with attic cholesteatoma or retraction pocket grades III or IV. Exclude patients with previous ear surgery, patients with advanced cholesteatoma (as extended to mastoid), and patients unfit for surgery. All included patients underwent preoperative endoscopic ear examination, computerized tomography (CT) temporal bone, pure-tone audiometry (PTA), and routine labs. Data collected including age, sex, affected side, hearing state, CT finding, operative details and time, post-operative hospital stay, pain, and possible complications. The follow-up was done 6–12 months with endoscopic examination in the clinic, CT scan, and PTA.

Results
Thirty patients with attic cholesteatoma or retraction pocket included in this study. The mean age was 28.5 years old. Eight patients were females, and 22 were males. All patients had unilateral affected ear (8 right and 22 left). All patients complained of intermittent ear discharge (otorrhea) and pain (otalgia), while half of them (15 patients) had hearing loss and 60% (18 patients) had other symptoms as headache, facial pain, ear pressure, tinnitus, and dizziness. PTA showed conductive hearing loss for all patients.
Trans-canal endoscopic technique was done (under GA) helped by piezoelectric device for the bony work. Cholesteatoma sac was removed, careful assessment of ME cavity, and ossicles. Reconstruction of the defect with tragal cartilage graft was done. The mean operative time was 115 +/− 41 min. Post-operative follow-up showed only five patients with mild bacterial or fungal infection and three patients suffering from residual perforation and temporary taste change. No facial nerve injury or tingling was detected. After 6 months, eight patients had worsened conductive hearing compared with the preoperative hearing. No patients got SNHL. The main aim of the operation is to clear the ME cholesteatoma rather than get better hearing.
Endoscopic examination 6 months later showed intact drum with no retractions or discharge except three patients with residual perforation (dry and safe). CT scan temporal bone 6-month post-operative showed clear ME cleft in 21 patients (70%) and 9 patients (30%) with some CT changes (as granulation tissues and the graft shadow) with no evidence of recurrent cholesteatoma or reformation of retraction pocket.

Conclusion
Combined endoscopic ear surgery with piezosurgery giving a hoping and promising results in the management of retraction pockets and attic cholesteatoma.