Extensive intratemporal cholesteatoma: surgical strategy.

Objective: To evaluate the decisional elements in the surgical strategy for extensive intratemporal cholesteatomas.

Study design: A retrospective review of cases followed up between 1985 and 1996.

Setting: Tertiary referral center.

Patients: Nineteen patients with temporal bone cholesteatoma extending beyond the middle ear limits and surgically treated were included. Preoperative imaging distinguished apical (8), infralabyrinthine (3), supralabyrinthine (3), retrolabyrinthine (1), and translabyrinthine (4) cholesteatomas.

Intervention: Apical and supralabyrinthine lesions were treated through a middle fossa approach. Infralabyrinthine and translabyrinthine locations were exposed through a subtotal petrosectomy or a transotic route, depending on the preoperative audiovestibular status and labyrinthine destruction on computed tomography. The retrolabyrinthine lesion was approached through a retrolabyrinthine route.

Main outcome measures: Patients were assessed for postoperative audiologic and facial functions and for recurrence of tumor.

Results: The facial nerve was neither rerouted nor interrupted during surgery. Among the 12 patients with preoperative facial palsy (FP), 5 cases of improvement (42%), 6 cases of stable function (50%), and 1 case of mild deterioration (8%) were observed postoperatively. In patients without preoperative FP, facial function remained unchanged postoperatively. The labyrinth could be preserved in three patients (16%), with postoperative stable hearing function in two (11%), and a 40-dB mean auditory deterioration in one (5%). Complete macroscopic resection was obtained in all patients. Two cases (11%) of postoperative recurrence were observed.

Conclusion: The surgical strategy, principally based on cholesteatoma location and preoperative auditory function, yielded a high rate of local disease control and facial function preservation.