This approach is to remove the isolated cholestea-toma limited to the middle ear often seen at the anterosuperior portion of mesotympanum. An incision is made on the posterior canal wall as in the stapes operation. A dissector is used to raise the posterior tympanomeatal flap to enter the middle ear (Fig. 14-2A). Exposure of the stapes, the oval and round windows, and the promontory is obtained by elevating the annulus. To expose the anterosuperior portion of mesotympanum, an incision is made on the manubrium of the malleus (Fig. 14-2B). The eardrum is then dissected and elevated off the malleus. The tympanic membrane can be completely separated from the ossicles and the middle ear widely exposed. The cholesteatoma mass can now be adequately visualized and removed (Fig. 14-2C). The congenital cholesteatoma often arises at the medial aspect of the neck of the malleus. A right-angle pick is used to dislodge the mass from its connection to the malleus. The mass is then moved inferiorly and posteriorly into the space between the manubrium of the malleus and the promontory. Once the cholesteatoma is moved through the narrow space, it can be easily removed from the middle ear. During the removal process, care must be taken not to disrupt the matrix of the cholestea-toma.
Grundfast et al34 reported a new approach to the removal of the anterosuperior middle ear for removal of congenital cholesteatoma. They used a superiorly based tympanomeatal flap to get better exposure of the anterosuperior portion of the middle ear. They reported eight cases in which the choles-teatoma was removed without disrupting the matrix.
This approach can also be extended into an atticot-omy or mastoidectomy in cases in which a tympa-notomy alone does not allow adequate access. Stabilization and healing of the tympanic membrane is rapid when the middle ear has been exposed via this approach.
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