Canal Cholesteatomas: Treatment Guidelines Based on Otologic Practices at a Tertiary Care Center

Introduction: External auditory canal cholesteatoma (EACC) is an uncommon entity that has been sparsely described in the literature. We present the largest EACC retrospective review to date with the aim of proposing treatment guidelines based on the practices of otologists/neurotologists in a tertiary care center.

Methods: A retrospective review was performed on patients who were diagnosed and treated with EACC from January 1, 2010 to January 1, 2021 at a tertiary care center. Inclusion criteria included diagnosis of EACC with at least one follow-up visit after diagnosis. Patient demographics, risk factors, etiology if acquired, EACC characteristics such as location and staging, and treatment modality were analyzed. Primary outcome was recurrence of disease.

Results: Ninety-eight patients were reviewed, and 57 met inclusion criteria. Most patients were treated with surgery (82%, N=47) as opposed to medical management (i.e. serial debridements). Surgical intervention was more likely to be performed patients with smoking history (N=22, 88%) and with arterial disease (N=10, 90%), and those with evidence of bony erosion (N=26, 90%). All patients (N=5) with erosion extending beyond the cortex were managed surgically. Mastoidectomy was more likely to be performed in higher staged cholesteatomas (OR=12.57, p=0.0348), but was also associated with increased recurrence rates (OR=2.86, p=01460). Other factors associated with increased risk of recurrence included smoking (OR=2.1, p=0.2750), and those acquired from surgery (OR=4.5, p=0.2360) and stenosis (OR=4.7, p=0.3205).

Conclusions: Patient risk factors, etiology and staging should be used in the shared management decision-making. Patients with a smoking history, and EACC acquired from previous surgery will need more aggressive surgery or closer serial evaluations. EACC with bony erosion can rarely be managed conservatively however if there is extension beyond the cortex, these should be managed with surgery. More frequent follow-ups after mastoidectomy is recommended.