138 Original Investigation

DOI: 10.4274/jarem.galenos.2020.2948
J Acad Res Med 2020;10(2):138-42

A Comparison of the Clinical Features and Intraoperative

Findings in Cholesteatoma Patients with and without Sinus
Tympani Invasion
Deniz Baklacı1, İsmail Güler2, İhsan Kuzucu3, Rauf Oğuzhan Kum4, Müge Özcan4
1BülentEcevit University Faculty of Medicine, Department of Otolaryngology, Zonguldak, Turkey
2Ankara Medipol University Faculty of Medicine, Department of Otolaryngology, Ankara, Turkey
3Medisun Private Hospital, Clinic of Otolaryngology, Ankara, Turkey
4Ankara City Hospital, Clinic of Otolaryngology, Ankara, Turkey

Cite this article as: Baklacı D, Güler İ, Kuzucu İ, Kum RO, Özcan M. A Comparison of the Clinical Features and Intraoperative Findings in Cholesteatoma
Patients with and without Sinus Tympani Invasion. J Acad Res Med 2020;10(2):138-42

ABSTRACT
Objective: The sinus tympani (ST) comprise one of the most hidden areas in the human body. It is one of the most common locations of residual
cholesteatomas and is in close proximity with the facial nerve and stapes. These characteristics render ST as a key factor in chronic otitis media
surgeries. This study aimed to investigate the clinical features and intraoperative findings of cholesteatoma patients with and without ST invasion
(STI).
Methods: One hundred and fifty-one cholesteatoma patients who had undergone the canal wall-down procedure at our center were retrospectively
reviewed. They were categorized into two groups: cholesteatoma patients with and without STI. Comparisons were made between the two groups
in terms of the disease duration, surgical technique, rate of facial canal dehiscence (FCD), and number of locations of FCD and erosion of the stapes
suprastructure. The mean hearing gain of the patients who underwent hearing reconstruction was compared between both groups.
Results: The rates of disease duration >5 years, radical mastoidectomy surgery, and erosion of the stapes suprastructure were significantly higher in
patients with STI than in those without STI. Mean hearing gain was significantly higher in patients without STI than in those with STI. The numbers of
locations and rate of FCD were also significantly higher in patients with STI than in those without STI.
Conclusion: The presence of STI in cholesteatoma patients is a significant intraoperative finding for the predicting the extent of FCD. STI should serve
as a warning to surgeons because it indicates a potential for less functional outcomes due to erosion of the stapes suprastructure.
Keywords: Sinus tympani, cholesteatoma, facial canal, stapes suprastructure

INTRODUCTION semicircular canal (1). The ST is clinically important during

chronic otitis media surgery because of the risk of cholesteatoma
The sinus tympani (ST) are one of the most obscure areas in the
recurrence due to the incomplete removal of the growth from the
human body. It lies medial to the pyramidal eminence, stapedial
ST and conductive hearing loss due to its close proximity with the
muscle, and facial nerve and lateral to the vestibule and posterior
oval window and stapes suprastructure (2,3).The cholesteatoma

ORCID IDs of the authors: D.B. 0000-0001-8449-4965; İ.G. 0000-0001-6093-6757; İ.K. 0000-0001-5773-4126; R.O.K. 0000-0002-9639-0204; M.Ö.
0000-0003-2384-3564.

Corresponding Author/Sorumlu Yazar: Deniz Baklacı, Received Date 05.05.2019 Accepted Date: 09.01.2020
E-mail: doktorent@gmail.com ©Copyright 2020 by University of Health Sciences Turkey, Gaziosmanpaşa
Training and Research Hospital. Available on-line at www.jarem.org
 Baklacı et al.
Cholesteatoma Patients with/without STI 139
J Acad Res Med 2020;10(2):138-42

located at the ST may come in contact with the stapes for a longer window]. Combinations of PT, GG, and MG were also calculated.
period with a higher pressure and may lead to erosion of the Dehiscence occurring in the mastoid segment of the nerve was
stapes suprastructure and less favorable functional outcomes. noted as mastoid.
The close proximity of the ST with the facial nerve makes the To evaluate the extent of cholesteatoma, the posterior canal wall
nerve more vulnerable during cholesteatoma surgery, especially was lowered to the level of the facial ridge. In patients where
if dehiscence is present in the bone covering the nerve (4-14). The the cholesteatoma extended into the ST, the cholesteatoma was
facial canal dehiscence (FCD) may be caused by developmental removed from the ST with a blunt pick and cottonoid.
bony defects or bony erosion caused by the enzymatic or pressure
Ossicular Reconstruction in CWDP
effect of cholesteatoma located at the ST. An unobserved FCD
in the vicinity of the ST may be a risk factor for iatrogenic facial Ossicular chain reconstruction was performed in the presence
paralysis during the removal of cholesteatoma from the ST. of an intact and/or mobile stapes and good cochlear function.
The integrity of the stapes suprastructure was assessed by the
In this study, we aimed to compare the clinical features and
presence or absence of stapes footplates. Footplate mobility was
intraoperative findings in cholesteatoma patients with and without
evaluated by eliciting the round window reflex. Temporalis fascia
ST invasion (STI).
graft was placed under the remnant of the anterior tympanic
METHODS membrane and over the enlarged inferior canal wall. A small piece
of cartilage (conchal) was placed between the fascia graft and
The study protocol was approved by the local ethical committee
stapes head. If the stapes suprastructure was absent and footplate
(approval number: E-18-1859, date: 11 April, 2018). Overall, 151
mobile, we used titanium ossicular replacement prosthesis with a
cholesteatoma patients (85 males, 66 females; 15-80 years of age;
cartilage cap and place it between the footplate and temporalis
average age 42.9 years) who had undergone the canal wall-down
fascia graft.
procedure (CWDP) [51 radical mastoidectomy (RM), 100 modified
radical mastoidectomy (MRM)] at our tertiary referral center All the procedures performed were in accordance with the
between January 2010 and December 2017 were retrospectively ethical standards of our institution and with the 1964 Helsinki
reviewed. All the patients underwent otoscopic examination and declaration and its later amendments or comparable ethical
audiometric investigation. Preoperative imaging of the temporal standards. Written informed consent was obtained from all
bone was obtained for all the patients and included high- individual participants prior to surgery.
resolution computed tomography (HRCT) or magnetic resonance All the patients underwent preoperative and postoperative
imaging. The diagnosis of cholesteatoma was confirmed by (at 6 months) pure-tone audiometry measurements at 0.5, 1, 2,
histopathological examination. The disease duration, type and 4 kHz and at 3 kHz frequencies using an Interacoustic AC-
of surgeries, hearing gain, and operation records, including 40 (Middelfart, Denmark) clinical audiometer. The average of
information about the facial canal, STI, and stapes integrity, were the values at 2 and 4 kHz was used to calculate the value for 3
documented for all the patients. The patients were categorized kHz. Preoperative and postoperative air and bone conduction
into two groups: cholesteatoma with STI and cholesteatoma thresholds were measured at these four frequencies. The air-bone
without STI. gap (ABG) was calculated as the average difference between the
Our main indicators for CWDP were extensive cholesteatoma air and bone conductions at four frequencies (0.5, 1, 2, and 3 kHz).
advancing into the mastoid and beyond, eustachian tube (antero- Statistical Analysis
medial to the ossicles) or ST, extensive damage of the external
The SPSS statistical software (SPSS 21.0 for Windows, Inc.,
auditory canal by disease, failure of previous canal wall-up
Chicago, IL, USA) was used for data analysis. Quantitative data
surgery with recurrent cholesteatoma from epitympanic retraction
were presented as mean ± standard deviation or median and
pockets, patients with poor preoperative auditory thresholds,
interquartile range and categorical variables were presented as
complicated cases, and the patients whose postoperative follow-
percentages. The data was tested for normal distribution using
up constitutes a problem. Patients who had undergone a revision
the Kolmogorov-Smirnov test. Student’s t-test or Mann-Whitney U
tympanomastoidectomy and those with aural or intracranial
tests, as appropriate, were used to compare continuous variables.
complications were excluded from the study.
Chi-square test was used to identify statistically significant
Intraoperative Findings differences between categorical variables. A 2-tailed p<0.05 was
FCD observations were made with an operating microscope and considered significant.
confirmed by palpation with a blunt pick. We used the Moody
and Lambert (13) classification for describing the FCD location.
Results
FCD located at the tympanic segment (TS) of the nerve was A total of 151 patients (mean age: 36.2±13.2 years) with 151
divided into three groups: [pure tympanic (PT); directly superior operated ears (80 left, 71 right) who met the aforementioned
to the oval window], [geniculate ganglion (GG); proximal to the criteria were evaluated. The overall STI rate was 41.7% (63
cochleariform process], and [mastoid genu (MG); distal to the oval patients).
 Baklacı et al.
140 Cholesteatoma Patients with/without STI
J Acad Res Med 2020;10(2):138-42

The disease duration was ˂5 years in 31 patients (20.5%) and ˃5 and sensitivity of imaging systems are low for the detection of
years in the remaining 120 patients (79.5%). STI was observed in perioperative FCD (17). Therefore, ear surgeons should be familiar
57 of 120 patients (47.5%) with a disease duration ˃5 years and in 6 with the pathologies having a high likelihood of observing FCD,
of 31 patients (19.4%) with a disease duration ˂5 years. The rate of especially in cholesteatoma patients. Sometimes, surgeons may
the disease duration ˃5 years was significantly higher in patients reasonably approach the facial nerve path more carefully and
with STI than in those without STI (p=0.005, Table 1). even risk the incomplete removal of the cholesteatoma when
FCD is intraoperatively observed. FCD had been previously
Overall, 36 of 63 patients (57.1%) with STI and 15 of 88 patients
demonstrated to negatively affect surgical outcomes, including
(17%) without STI had undergone RM and this difference was
suboptimal hearing results and a potential requirement for
statistically significant (p<0.001, Table 2).
revision surgery (18).
The mean preoperative ABG was 33.3±5.2 dB in patients with
In our study, 63 of 151 patients (41.7%) had cholesteatoma
STI and 29.2±6.1 dB in those without STI. There was a statistically
invading into the ST. The disease duration was ˃5 years in 57 of 63
significant difference between the groups in terms of preoperative
patients (90.4%) with STI and in 63 of 88 patients (70.1%) without
ABG (p<0.001). The mean postoperative ABG was 30.8±5.9 dB in
STI. A longer disease duration prior to the surgery may provide
patients with STI and 22.6±5.1 dB in patients without STI. There
insight into the extent of the disease in the ST. Overall, 36 of 63
was a statistically significant difference between the groups in
(57%) with STI and 15 of 88 (17%) without STI had undergone RM.
terms of postoperative ABG (p<0.001). The mean hearing gain was
These results indicated that the extent of cholesteatoma into the
2.4±1.1 dB in patients with STI and 6.5±5.8 dB in those without STI
ST affects a surgeon’s choice for RM (p<0.001). The assessment of
and this difference was statistically significant (p<0.001).
The overall FCD rate was 33.8% and FCD was observed in 34 of Table 2. Distribution of the type of surgery according to STI
63 patients (54%) with STI and 17 of 88 patients (19.3%) without Type of surgery
STI (+) STI (-) Total
p
STI. Among the 51 patients with FCD, dehiscence was located (n=63) (n=88) (n=151)

at the TS in 47 patients (92%). The locations of dehiscence were Radical 36 15 51

mastoidectomy (57.1%) (17%) (33.7%)
as follows: GG, 2 patients (4.2%); PT, 13 patients (27.6%); MG, 4 <0.001*
patients (8.6%); PT+GG, 9 patients (19.2%); PT+MG, 10 patients Modified radical 27 73 100
mastoidectomy (42.9%) (83%) (66.3%)
(21.2%); and GG+PT+MG, 9 patients (19.2%). Overall, 4 patients
n: Number of patients, STI: sinus tympani invasion, *p<0.05
(8%) had both tympanic and mastoid segment dehiscence. There
were at least 2 locations of FCD in 31 of 34 patients (96.9%) with
STI and 1 of 17 patients (6.2%) without STI (Figure 1). There was a Table 3. Incidence of facial canal dehiscence and stapes
statistically significant difference between the groups in terms of suprastructure erosion according to the groups
the number of FCD location (p<0.001, Table 3). STI (+) STI (-) Total
p
(n=63) (n=88) (n=151)
Erosion of the stapes suprastructure was observed in 46 of 63
34 17 51
patients (73%) with STI and in 37 of 88 patients (42%) without Facial canal dehiscence <0.001*
(54%) (19.3%) (33.8%)
STI. There was a statistically significant difference between both 3 16 19
groups in terms of erosion of the stapes suprastructure (p<0.001, One location
(3.1%) (93.8%) (37%)
Table 3). <0.001*
31 1 32
More than one location
(96.9%) (6.2%) (63%)
Discussion Stape suprastructure 46 37 83
<0.001*
The ST has always been considered as important during erosion (73%) (42%) (55%)
cholesteatoma surgery due to its inability to be directly visualized n: Number of patients, STI: sinus tympani invasion, *p<0.05
under microscopes and because it is the most common location
of residual cholesteatomas (2,3,15,16). The ST also has a critical
anatomical proximity with the facial canal, and this proximity
obstructs its surgical manipulation, especially when there is
an anatomical defect or variation in the canal. The specificity

Table 1. Disease duration in cholesteatoma patients with

and without STI
STI (+) STI (-) Total
Disease duration p
(n=63) (n=88) (n=151)
Less than 5 years 6 (9%) 25 (28%) 31 (20%) Figure 1. Status of the facial canal and sites of facial canal
0.005* dehiscence with respect to STI
More than 5 years 57(91%) 63 (72%) 120 (80%) STI: Sinus tympani invasion, PT: pure tympanic, GG: geniculate ganglion,
N: Number of patients, STI: sinus tympani invasion, *p<0.05 MG: mastoid genu, TS: tympanic segment, M: mastoid
 Baklacı et al.
Cholesteatoma Patients with/without STI 141
J Acad Res Med 2020;10(2):138-42

ossicular chain defects could explain the tendency of performing duration was significantly longer in patients with STI than in
RM in patients with STI. We assessed the integrity of the stapes those without STI.
suprastructure according to the proximity of the oval window Hence, we may conclude that the gross dehiscence of the facial
and stapes with ST. Our results demonstrated that the stapes canal may be due to prolonged contact with cholesteatoma or
suprastructure was eroded in 46 patients (73%) with STI and in enlargement of a microdehiscence resulting from the disease.
37 patients (42%) without STI. The close proximity of the ST with Conversely, it can be stated that cholesteatoma located at the ST
the stapes may cause the cholesteatoma to come in contact with may cause erosion in the adjacent bony structures as it expands.
the stapes for a longer period and with a higher pressure. The The pressure effect may increase when the cholesteatoma in
absence of the stapes suprastructure may complicate ossicular
the ST enlarges. Due to the pressure and enzymatic effects of
reconstruction.
cholesteatoma in this narrow space, the microdehiscence on the
Postoperative hearing outcomes were found to be better facial canal can be transformed into a macrodehiscence.
in cholesteatoma patients with the presence of the stapes
Previous studies have demonstrated that the most common
suprastructure (19). Hence, STI resulting from cholesteatoma
location of dehiscence is the TS of the facial canal. Reportedly,
should alert surgeons regrading potentially less functional
FCD was also mainly observed in the tympanic region (92%). When
outcomes, and the preoperative evaluation of STI by HRCT
we divided the number of locations of the tympanic dehiscences
may provide insights concerning the integrity of the stapes
into three groups, the most common sites of dehiscence were the
suprastructure.
PT, MG, and GG, respectively. However, only mastoid dehiscence
FCD may be caused by developmental defects due to failure was not observed. The bony canal surrounding the facial nerve
during the ossification process of the bony canal or bony erosion in the TS is quite thin; therefore, pathologies in the middle ear,
caused by cholesteatoma and inflammation (20). The mechanism i.e., cholesteatoma, infections, and inflammation, may directly
of bony erosion resulting from cholesteatoma has indicated damage the facial canal in these locations. In patients with STI,
that bony erosion is due to the enzymatic or compression effect dehiscence was found at more than one location in 31 patients
of cholesteatoma (21). The rate of dehiscence was reportedly (96.9%). The number of dehiscence locations was correlated with
higher (ranging between 55% and 72%) in other anatomical STI. In patients with STI, dehiscence was observed at PT+GG in
studies (22-24). Yetiser et al. (10) have reported an FCD rate of 9, PT+MG in 9, PT+GG+MG in 9, and T+M in 4 patients. Hence,
11% in non-cholesteatoma patients. Bayazit et al. (20) have we may conclude that cholesteatomas invading the ST were
reported an FCD rate of 8.9% in non-cholesteatoma patients more aggressive and extensive in terms of FCD, and a significant
and 18.4% in cholesteatoma patients, whereas Ozbek et al. (14) correlation was noted between STI and the extent of dehiscence.
have reported this rate at 37.2% in cholesteatoma patients. In It should be kept in mind that the presence of dehiscence at one
the series of Magliulo et al. (17), which comprised 336 patients segment of the facial canal in patients with STI may indicate the
who had undergone mastoidectomy for cholesteatoma, this rate presence of additional dehiscence at other regions of the canal.
was reported as 27.1%. Selesnick and Lynn-Macrae (4) reported
this rate at 33% during primary surgery and 35% during revision Study Limitations
surgery. Moreover, Genc et al. (25) have reported this rate at 32.7% There are two limitations to be addressed in this study. Firstly,
in cholesteatoma patients. some personal biases may have crept in during the evaluation
However, no healthy controls were analyzed in our study. The of the surgical findings. Secondly, in retrospective studies, some
rate of FCD was 33.8%, which is similar to the results of Genc of the records obtained from medical charts may be incomplete
et al. (25) (32.7%) and Selesnick and Lynn-Macrae (4) (33%). or lost in the course of time, leading to missing data. Further
The likely cause for this high percentage was that most of the prospective studies can provide more reliable and accurate data.
patients included in our study had delayed or extensive disease.
Our clinical approach for extensive cholesteatoma is CWDP. By
CONCLUSION
this approach, we could accurately remove pathological growth FCD may be a challenging issue during cholesteatoma surgery,
from the middle ear and evaluate the FCD. The FCD rate was even for experienced surgeons. Dehiscence is more common in
found to be significantly higher (54%) in patients with STI than patients when cholesteatoma invades the ST. Our study indicates
in patients without STI, possibly due to a longer duration of that FCD is present in more than half of cholesteatoma patients
contact of the cholesteatoma with the bony canal covering the with STI. Hence, for patients in whom STI is intraoperatively
facial nerve in the middle ear. Magliulo et al. (17) found that the observed, their facial nerve is likely at risk. The presence of
risk for FCD was approximately 3.5 times more likely in patients STI in cholesteatoma patients is a significant finding for the
with disease duration ˃5 years. These findings indicate that the prediction and extent of FCD. Ear surgeons must cautiously
longer pressure and enzymatic effects of the cholesteatoma evaluate the intraoperative findings that may suggest FCD,
mass on the bony canal results in a higher incidence of FCD or such as the presence of STI, especially in patients with extensive
microdehiscence is enzymatically enlarged by cholesteatoma cholesteatoma. Hence, the prevention of facial injury should
with time. This theory is supported by the fact that the disease be a priority while operating upon cholesteatoma patients with
 Baklacı et al.
142 Cholesteatoma Patients with/without STI
J Acad Res Med 2020;10(2):138-42

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