Experience Summary

In this 360-degree video, observe reconstruction following a complex mastoidectomy procedure for paediatric cholesteatoma surgery.

Clinical Context

Surgical intervention for cholesteatoma in children, particularly complex mastoid exploration, represents a critical and often necessary procedure aimed at preventing progressive ear disease and preserving vital functions such as hearing and facial nerve integrity. Cholesteatoma is characterised by an abnormal growth of keratinising squamous epithelium within the middle ear and mastoid air cells. In paediatric patients, cholesteatomas are often more aggressive than in adults, with a higher risk of bone erosion, ossicular destruction, and intracranial complications if not appropriately managed.

Children commonly present with persistent or recurrent ear discharge (otorrhoea), hearing loss, and sometimes a visible retraction pocket or perforation of the tympanic membrane. In advanced cases, signs of complications such as facial weakness, dizziness, or even signs of intracranial extension may be present. Imaging with high-resolution computed tomography (CT) of the temporal bones is essential in surgical planning, as it provides detailed information on the extent of disease, involvement of surrounding structures, and anatomical variations.

Complex mastoid exploration is indicated when there is extensive disease within the mastoid cavity, middle ear, or when complications such as ossicular erosion, facial nerve dehiscence, or labyrinthine fistulae are suspected. The procedure involves careful removal of cholesteatoma and diseased tissue from the mastoid air cells and middle ear spaces while preserving critical structures such as the facial nerve, inner ear, and dura. Depending on the extent of disease, the surgery may involve a canal wall up or canal wall down mastoidectomy, reconstruction of the ossicular chain, and repair of the tympanic membrane.

Surgery in children poses unique challenges due to the smaller anatomical structures, more aggressive disease patterns, and the need for long-term follow-up into adolescence and adulthood to monitor for recurrence, which is more common in the paediatric population. Intraoperative facial nerve monitoring, meticulous surgical technique, and a thorough understanding of temporal bone anatomy are essential to minimising complications.

The overall goals of surgery are to achieve a safe, dry, and disease-free ear, preserve or restore hearing, and prevent life-threatening complications such as meningitis or brain abscess. Given the complexity of cholesteatoma surgery in children, a multidisciplinary approach involving otolaryngologists, audiologists, radiologists, and anaesthetists is essential to ensure optimal patient outcomes.

Learning Outcomes

1. Observe the reconstruction step as part of mastoid surgery in a child.
2. Understand the 3D anatomical skills required to complete this procedure.
3. Observe key steps involved in the procedure and the equipment needed to safely perform this.

External Resources

• Endoscopic versus microscopic surgery for treatment of middle ear cholesteatoma: A systematic review and meta-analysis
• Mastoidectomy - StatPearls article