Endoscopic management of en-plaque cholesteatoma associated with tympanic membrane perforations

Background: En-plaque cholesteatoma (EPC) describes cholesteatoma occurring on the medial surface of the tympanic membrane (TM). This occurs with both marginal and central perforations due to squamous migration onto the medial surface of the TM. Experience with endoscopic removal of EPC associated with perforation is presented. Methods: A Retrospective chart audit was undertaken of patients treated with endoscopic ear surgery for cholesteatoma associated with a TM perforation treated at tertiary referral centers for endoscopic ear surgery in Sydney, New South Wales, Australia between 2012-2018. Inclusion criteria was TM perforation with EPC undergoing primary surgery via endoscopic approach. Revision cholesteatoma cases were excluded. The primary outcomes of interest were the rates of residual cholesteatoma. Secondary outcomes assessed were change in pure tone average pre vs. postoperatively, and closure of perforation. Results: During the study period 486 myringoplasties were performed. Thirty-seven patients with EPC were included (25 male, 12 female) for a total of 37 ears (14 left, 23 right), yielding a prevalence of 7.6%. Average age was 46 (range, 12-78). Average length of follow up was 22 (range, 6-66) months. Two cases (5.4%) of residual cholesteatoma were identified on second-look surgery. Re-perforation occurred in 4 (10.8%) cases. There was no statistically significant difference between pre- vs. postoperative pure tone average (32.2 vs. 30.7 dB, P=0.38). The majority of cases were performed entirely via endoscopy, with an endoscopic atticotomy in 11 patients (29.7%) and canaloplasty in 3 (8.1%). There were no significant intraoperative or postoperative complications. Conclusions: Endoscopic management of EPC is a safe and effective approach with low rates of residual disease and minimal surgical morbidity.