Endoscopic assistance in CWU mastoidectomy has significantly reduced the number of second-look procedures. When a second look is necessary, it can most often be done as a transcanal procedure because residual cholesteatoma most commonly occurs in the epitympanum, facial recess, or sinus tympani rather than in the mastoid cavity.14
McKennan15 described performing an endoscopic approach to the mastoid through a small postauricular stab incision and doing a separate middle ear exploration when indicated. McKennan uses a transcanal approach with angled endoscopes to visualize the epitympanum and mastoid antrum. initially, microsurgical elevation of a tympanomeatal flap is done followed by lysis of middle ear adhesions and hemostasis. A 70-degree, 2.3-mm-diameter endoscope is introduced into the middle ear and rotated 360 degrees to carefully inspect the epitym-panum, supratubal recess, hypotympanum, sinus tympani, and facial recess. Lysis of some adhesions using long angled picks is usually needed to view beyond the scutum into the attic, aditus, and mastoid antrum. Satisfactory views well into the mastoid and superiorly up to the tegmen are usually obtained, and the postauricular incision is avoided in most cases (Figs. 21-9 and 21-10).
FIGURE 21 -9 A 2.3-mm, 70-degree Hopkins rod endoscopic view of second-look case after primary cholesteatoma removal from cochleariform process and area medial to malleus head.
When residual cholesteatoma is identified, it is possible to remove small lesions by endoscopic dissection.15 Bulky residual disease usually requires microsurgical removal. Patients are counseled pre-operatively about the possibility of reopening the postauricular incision if it is necessary for removal of cholesteatoma.
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