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![Schematic of divisions of the middle ear space using STAM system: S1, supratubal recess; S2, the sinus tympani; T, tympanic cavity; A, attic; M, mastoid (Adapted from Yung et al. [4] 2017).](publication/332847611/figure/fig1/AS:754526227275776@1556904479091/Schematic-of-divisions-of-the-middle-ear-space-using-STAM-system-S1-supratubal-recess.png)
Schematic of divisions of the middle ear space using STAM system: S1, supratubal recess; S2, the sinus tympani; T, tympanic cavity; A, attic; M, mastoid (Adapted from Yung et al. [4] 2017).
Source publication
Objectives:
The aim of the present study was to investigate the prognostic factors for short-term hearing outcomes of ossiculoplasty for primary pars flaccida cholesteatoma according to the European Academy of Otology and Neurotology/Japanese Otological Society (EAONO/JOS) and 2015 JOS staging systems.
Materials and methods:
A total of 34 patien...
Context in source publication
Context 1
... patients were classified according to the EAONO/JOS staging system. The extension of cholesteatoma in each ear was surgically confirmed and scored according to middle ear involvement using the STAM system: S1 (supratubal recess), S2 (sinus tympani), T (tympanic cavity), A (attic), and M (mastoid) (Figure 1) [4] . The staging system for pars flaccida cholesteatoma was as follows: I (cholesteatoma localized in the attic), II (cholesteatoma involving two or more sites), III (cholesteatoma with extracranial complications), and IV (cholesteatoma with intracranial complications) ( Table 1) [4] . ...
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Objectives:
To assess the clinical characteristics of extent patterns in pars tensa cholesteatoma.
Materials and methods:
This was a retrospective chart review. Forty-four patients with pars tensa cholesteatoma who underwent primary surgery at a tertiary academic medical center were included. The main outcomes measured were sex, age, clinical ba...
Purpose
Otology and neuro-otology surgeries pose significant challenges due to the intricate and variable anatomy of the temporal bone (TB), requiring extensive training. In the last years 3D-printed temporal bone models for otological dissection are becoming increasingly popular. In this study, we presented a new 3D-printed temporal bone model nam...
Background:
The role of imaging in cholesteatoma continues to evolve with excellent bony details provided by high-resolution computed tomography and high soft tissue identification for cholesteatoma by diffusion-weighted magnetic resonance imaging. The fusion of highresolution computed tomography and diffusion-weighted magnetic resonance imaging c...
Objective: To determine the stage of middle ear cholesteatoma of patients who underwent
middle ear surgery at the Southern Philippines Medical Center from January to December 2019,
based on European Academy of Otology and Neurotology / Japan Otological Society (EAONO/
JOS) system.
Methods:
Design: Case Series
Setting: Tertiary Government Hosp...
Citations
... An international validation study of nine centers and 1482 cases demonstrated statistically significant differences in 5 years residual and recurrence rates between stages I and II, respectively 3-13% and 4-10% [6]. Another retrospective single-center study with 34 patients with PFC found a relation between better postoperative audiological outcome and three factors: lower stage (stages I, II and III), better condition of the stapes and a better development of the mastoid cells [7]. A single-center cohort of 125 patients with retraction pocket cholesteatomas (RPC) showed no direct correlation between stage and recidivism. ...
... James et al. demonstrated a higher residual rate between stages I and II [6], contrary to Angeli et al. [8] and Ardiç et al. [9]. This last publication and the one from Fukuda et al. [7] correlated a higher disease stage with poorer audiological results. However, none of the two studies specified a difference between stage I and II. ...
... In our population, a statistically significant influence of the number of affected sites on the performed TPL according to the Wullstein's classification was registered, which reflects indirectly the state of the ossicles. Fukuda et al. [7] reported a better state of the stapes for lower disease stages, without directly comparing the different stages. The former JOS classification of 2015 [3], the already mentioned ChOLE [11] and STAMCO [12] also featured the ossicles state. ...
Purpose
The European and Japanese system for cholesteatoma classification proposed an anatomical differentiation in five sites. In stage I disease, one site would be affected and in stage II, two to five. We tested the significance of this differentiation by analyzing the influence of the number of affected sites on residual disease, hearing ability and surgical complexity.
Methods
Cases of acquired cholesteatoma treated at a single tertiary referral center between 2010-01-01 and 2019-07-31 were retrospectively analyzed. Residual disease was determined according to the system. The air–bone gap mean of 0.5, 1, 2, 3 kHz (ABG) and its change with surgery served as hearing outcome. The surgical complexity was estimated regarding the Wullstein’s tympanoplasty classification and the procedure approach (transcanal, canal up/down).
Results
513 ears (431 patients) were followed-up during 21.6 ± 21.5 months. 107 (20.9%) ears had one site affected, 130 (25.3%) two, 157 (30.6%) three, 72 (14.0%) four and 47 (9.2%) five. An increasing number of affected sites resulted in higher residual rates (9.4–21.3%, p = 0.008) and surgical complexity, as well poorer ABG (preoperative 14.1 to 25.3 dB, postoperative 11.3–16.8 dB, p < 0.001). These differences existed between the means of cases of stage I and II, but also when only considering ears with stage II classification.
Conclusion
The data showed statistically significant differences when comparing the averages of ears with two to five affected sites, questioning the pertinence of the differentiation between stages I and II.
... In the presented cohort, changes of bone conduction after cholesteatoma surgery were compared, and a significant shift of bone conduction was found in patients with chronic inflammation with cholesteatoma in the mastoid cavity (M); if cholesteatoma is localized in the mastoid cavity, there is a greater probability of bone conduction threshold shift after surgery. This theory is supported by the finding that undamaged mucosa of the mastoid cavity is one of the good prognostic factors for post-surgical hearing [20]. Similarly, changes of bone conduction were seen in patients who have cholesteatoma in the attic (A), and in the supratubal recess (S1), versus those who had no cholesteatoma in those locations. ...
Background:
This study focuses on the hearing threshold for bone conduction (BC) after middle-ear surgery.
Methods:
A total of 92 patients (120 ears) were treated for newly diagnosed chronic otitis media with cholesteatoma (2013-2018). BC was examined at frequencies of 0.5, 1, 2, and 4 kHz prior to and 1 year after surgery. STAM classification for cholesteatoma location, EAONO/JOS for stage, and surgery according to SAMEO-ATO classification were applied. The bone conduction threshold was compared for individual frequencies in patients with occurrence/absence of cholesteatoma in different locations.
Results:
For the occurrence of cholesteatoma in the attic (A), a statistically significant difference was found at 4 kHz (p < 0.001), in the supratubal recess (S1) at 4 kHz (p = 0.003), and for the mastoid (M) at 0.5 kHz (p = 0.024), at 1 kHz (p = 0.032), and at 2 kHz (p = 0.039).
Conclusions:
Cholesteatoma location can influence the post-operative hearing threshold for bone conduction.
... Although they described the number of patients treated with CWU and CWD procedures, the authors did not analyze the role of surgical technique in the recidivism rate. Fukuda et al. [15] reported the short-term hearing results in a small group of patients affected by pars flaccida cholesteatoma and submitted to mastoidectomy and tympanoplasty with cartilage double-block reconstruction on the stapes. The authors classified all the cases with the EAONO/JOS staging system and used a post-operative ABG < 20 dB as success criterion, thereby finding that poorer hearing results were associated with higher EAONO/JOS stages and stapes involvement. ...
Purpose
To evaluate the recently proposed SAMEO-ATO framework for middle ear and mastoid surgery, by correlating it with the functional outcome in a large cohort of patients operated for middle ear and mastoid cholesteatoma in a tertiary referral center.
Methods
We retrospectively included all surgeries for middle ear and mastoid cholesteatoma undergone in our Department between January 2009 and December 2014, by excluding revision surgeries, congenital and petrous bone cholesteatoma. All surgeries were classified according to the SAMEO-ATO framework. The post-operative air bone gap (ABG) was calculated and chosen as benchmark parameter for the correlation analysis.
Results
282 consecutive surgeries for middle ear and mastoid cholesteatoma were released in the study period on a total of 273 patients, with a mean age of 41.2 years. All patients were followed for an average period of 55.3 months. 54% of patients underwent M2c mastoidectomy (Canal Wall Down, CWD), while the remaining underwent Canal Wall Up (CWU) procedures, being M1b2a mastoidectomy the most common one (33%). Mean pre-operative and post-operative ABGs were 29.2 and 23.5 dB, with a significant improvement (p < 0.0001). 'Mastoidectomy' and 'Ossicular reconstruction' parameters of SAMEO-ATO showed significant association with postoperative ABG, with smaller residual gaps for the classes Mx and On, and worse hearing results for M3a and Ox.
Conclusion
Our results show the utility of SAMEO-ATO framework, and in particular of 'M' (Mastoidectomy) and 'O' (Ossicular reconstruction) parameters, in predicting the hearing outcome.
... Авторы REVIEW выявили, что прогрессирование стадии заболевания ассоциировано с ухудшением слуха пациента. В ряде исследований подтверждены прогностические значения стадии по EAONO/JOS в отношении улучшения слуха после операции [8,21,22]. В работе, проведенной A. Fukuda и соавт. (2019 г.) с включением 34 пациентов с ХСУ, показано, что восстановление слуха с достижением PTA-ABG≤10 и ≤20 дБ после оперативного лечения наблюдается в 23,5 и 55,9% случаев соответственно, при этом более низкая стадия заболевания по системе стадирования EAONO/JOS статистически значимо ассоциирована с благоприятным исходом в отношении восстановления слуха [21]. ...
... В работе, проведенной A. Fukuda и соавт. (2019 г.) с включением 34 пациентов с ХСУ, показано, что восстановление слуха с достижением PTA-ABG≤10 и ≤20 дБ после оперативного лечения наблюдается в 23,5 и 55,9% случаев соответственно, при этом более низкая стадия заболевания по системе стадирования EAONO/JOS статистически значимо ассоциирована с благоприятным исходом в отношении восстановления слуха [21]. В то же время в ретроспективном исследовании, проведенном H. van der Toom и соавт. ...
Middle ear cholesteatoma (MEC) is a common problem of modern otology. The European Academy of Otology and Neurootology in cooperation with the Japanese Otological Society (EAONO/JOS) published consensus recommendations on the definition, classification and stages of MEC in 2017. In 2018, the classification of middle ear surgery was presented under the auspices of the International Otology Outcome Group. The leading problem of MEC surgery remains the high recurrence rate, which ranges from 5 to 32% depending on the type of surgical intervention. The main purpose of this article is to describe the new EAONO/JOS classification of MEC and SAMEO-ATO middle ear surgical interventions with an analysis of their possible clinical significance in determining the risk of cholesteatoma recurrence as well as the prognosis for hearing recovery after surgery.
... Surgical techniques in the study included transcanal atticotomy and CWD and CWU mastoidectomies. Fukuda et al. (2019) investigated prognostic factors for hearing outcomes in patients with pars flaccida cholesteatoma according to the EAONO/JOS system. They noted favorable hearing outcomes in patients with early-stage cholesteatoma. ...
Objectives
This study investigated the long-term surgical outcomes of functional cholesteatoma surgery with canal wall reconstruction using autologous bone grafts as the primary material in patients with acquired cholesteatoma.
Subjects and Methods
Medical charts were retrospectively reviewed for all patients admitted to one institution for surgical intervention between 2010 and 2018. We analyzed 66 patients (66 ears) who underwent functional tympanomastoidectomy involving the use of autologous bone grafts for canal wall defect reconstruction. Surgical outcomes were evaluated by comparing preoperative audiometric results with follow-up data (at least 36 months after surgery). Logistic regression analyses were performed to determine prognostic factors related to long-term hearing success. These factors included classification and stage of cholesteatoma, stapes condition, ossicular chain damage, active infection of the middle ear, state of the contralateral ear, preoperative hearing thresholds, gender, and age.
Results
The mean follow-up period was 49.2 months. The recidivism rate was 6% (four of 66 ears). The pure-tone average significantly improved from 50.78 ± 19.98 to 40.81 ± 21.22 dB hearing level (HL; p < 0.001). Air–bone gaps significantly improved from 26.26 ± 10.53 to 17.58 ± 8.21 dB HL ( p < 0.001). In multivariate logistic regression analysis, early-stage disease ( p = 0.021) and pars flaccida cholesteatoma ( p = 0.036) exhibited statistically significant correlations with successful hearing preservation.
Conclusion
Functional cholesteatoma surgery with autologous bone grafts reconstruction is an effective approach to significantly improve hearing with low recidivism rates. Localized disease and pars flaccida cholesteatoma were two independent predictors of successful hearing preservation.
... Recently, prognostic factors for short-term hearing outcomes of ossicular chain reconstruction for "pars flaccida cholesteatoma" as classified by the EAONO/JOS staging system have been reported [14]. The rate of successful hearing improvement significantly decreased with increase in EAONO/JOS stage. ...
PurposeTo establish a standardized reporting system of cholesteatoma, the ChOLE classification has recently been introduced. We here aimed to systematically investigate the association between the ChOLE classification and (i) hearing, (ii) recidivism rate, and (iii) postoperative complications. These data may increase the utility of the ChOLE classification in clinical practice and research by stratifying patients according to expected outcomes or risks for complications.Methods
In this prospective multicentric study, we included adult patients undergoing tympanomastoid surgery due to cholesteatoma. Main outcome measures included the association of the ChOLE classification system with (i) audiometric data including air conduction (AC) and bone conduction (BC) pure-tone average (PTA), and the air–bone gap (ABG), (ii) recidivism and complication.ResultsA total of 160 patients suffering from cholesteatoma were included. ChOLE stage distribution was stage I in 23 (14%), stage II in 128 (80%), and stage III in 9 (6%) patients. The ChOLE stage was associated with the postoperative AC PTA (p = 0.05) and the postoperative BC PTA (p = 0.02). Further, the status of the ossicular chain after surgery (ChOLE subdivision “O”) was associated with both the postoperative ABG (p = 0.0001) and the postoperative AC PTA (p = 0.003). Moreover, we found an association between complications (ChOLE subdivision “L) and both the postoperative BC PTA (p = 0.04) and the postoperative ABG (p = 0.04). No association between the ChOLE stage was found to both cholesteatoma recidivism and surgical complications.Conclusion
The ChOLE classification is a new system to classify cholesteatomas. We provide evidence that hearing outcomes vary among different ChOLE stages. In particular, hearing outcomes are associated with the ChOLE subdivision “O” and “L”. Thus, the ChOLE classification system has a predictive value regarding hearing outcomes.
... As hearing improvement is not the main goal of cholesteatoma surgery (1), we chose to omit this from our review. Recently, Fukuda et al. (28) demonstrated a low EAONO-JOS stage to be a favorable factor in postoperative hearing outcome. However, a relatively small group of patients was included, comprising of mostly stage 2 cholesteatoma. ...
Objective:
To assess the prognostic value of the Japanese Otological Society (JOS), EAONO-JOS, and STAMCO classifications in predicting the severity of acquired cholesteatoma and to identify other factors that could influence residual and recurrent cholesteatoma, as well as adverse events (AE).
Method:
A retrospective chart review of patients undergoing primary cholesteatoma surgery in our tertiary referral center. Primary outcome measures were based on three groups of follow-up (FU): Group A, studying residual cholesteatoma, FU > 52 weeks of last-look surgery or magnetic resonance imaging, diffusion-weighted imaging; group B, studying recurrent disease, FU > 52 weeks of last outpatient clinic visit; and group C, studying AE, FU > 12 weeks after surgery. Cholesteatomata were staged according to the JOS, EAONO-JOS, and STAMCO classifications. Kaplan-Meier curves were used to determine the prognostic value of the various classifications and to identify other determining factors, while correcting for FU.
Results:
FU was found to be a significant confounder. No correlation was found between staging and the occurrence of residual or recurrent disease, nor the occurrence of AE. Type of surgery was a significant determinant of all three primary outcome measures. A higher age was associated with a lower risk of residual disease.
Conclusion:
In our population the JOS, EAONO-JOS, and STAMCO classifications have limited prognostic value. Three main confounders were identified that pose a challenge in developing a universal classification: FU, surgery type, and age. Cholesteatoma staging should be postponed until a system is developed which significantly correlates cholesteatoma stage to cholesteatoma severity, to have implications for management strategies.
... Even though two recent studies investigated the association of the cholesteatoma extent and hearing outcomes [16,17], only few studies evaluated the impact of cholesteatoma surgery on health-related quality of life (HRQoL) [1,[18][19][20]. To our knowledge, no studies exist investigating the association between cholesteatoma stages as defined by a classification system and HRQoL. ...
Objectives
To investigate the association between the “ChOLE” classification, hearing outcomes and disease-specific health-related quality of life (HRQoL).Methods
In two tertiary referral centers, patients requiring primary or revision surgery for cholesteatoma were assessed for eligibility. Audiometric assessment was performed pre- and postoperatively. The ChOLE classification was determined intraoperatively and via the preoperative CT scan. HRQoL was assessed pre- and postoperatively using the Zurich Chronic Middle Ear Inventory (ZCMEI-21).ResultsA total of 87 patients (mean age 45.2 years, SD 16.2) were included in this study. ChOLE stage I cholesteatoma was found in 8 (9%), stage II cholesteatoma was found in 65 (75%), and stage III cholesteatoma was found in 14 (16%) patients. Postoperatively, the mean air–bone gap (0.5, 1, 2, 3 kHz) was significantly smaller than before surgery (14.3 dB vs. 23.0 dB; p = 0.0007). The mean ZCMEI-21 total score significantly decreased after surgery (26.8 vs. 20.7, p = 0.004). No correlation between the ZCMEI-21 total score and both the ChOLE stage and the extent of the cholesteatoma (ChOLE subdivision “Ch”) was found. A trend towards worse HRQoL associated with a poorer status of the ossicular chain (ChOLE subdivision “O”) was observed. The audiometric outcomes were not associated with the extent of the cholesteatoma. The ChOLE subdivision describing the ossicular status showed a strong association with the pre- and postoperative air conduction (AC) thresholds. Further, the ZCMEI-21 total score and its hearing subscore correlated with the AC thresholds.Conclusion
The ChOLE classification does not show a clear association with HRQoL measured by the ZCMEI-21. The HRQoL neither seems to be associated with the extent of the disease nor with the ossicular chain status. Yet, surgical therapy significantly improved HRQoL by means of reduced ZCMEI-21 total scores, which were strongly associated with the AC thresholds. Intraoperative assessment of a cholesteatoma using the ChOLE classification and HRQoL complement each other and provide useful information.
... Further, they did not mention about the hearing outcome. Fukuda et al. focused on hearing in 34 pars flaccida cholesteatoma patients and found a significant correlation between the outcome and the EAONO/JOS stage [11] . Several studies have described cholesteatoma definitions and classifications. ...
... Fukuda et al. evaluated 34 patients with pars flaccida RPC and found that in the early stages, the hearing outcome was better. They also concluded that the EAONO/JOS staging system could be used as a prognostic indicator for hearing outcomes [11] . Our findings support these findings. ...
Objectives:
This study aimed to evaluate the intraoperative findings, recurrence rate, and hearing outcome of cholesteatoma surgery and correlate them with the newly proposed EAONO/JOS Joint Consensus Statement.
Materials and methods:
The records of 407 patients diagnosed with chronic otitis media and cholesteatoma between 2009 and 2017 were reviewed. After the exclusion of records with unsatisfactory surgical notes and anamnesis, 353 patients were included in the study. The 290 patients who had undergone primary surgery and 63 who had undergone revision surgery were evaluated separately.
Results:
Total 162 of 290 (56%) patients had retraction pocket cholesteatoma and 128 of 290 (44%) patients had non-retraction pocket cholesteatoma. Eighty (28%) patients had stage I, 114 (39%) had stage II, 91 (31%) had stage III, and 5 (2%) had stage VI disease. The recurrence rate was 6.9% (20/290). The average age of these patients at the time of the second operation was 23.31±10.3 years. Twelve patients had (60%) recurrent cholesteatoma, and eight (40%) had residual cholesteatoma. Hearing outcome and surgical technique were significantly associated with the disease stage; however, the recurrence rate showed no such association.
Conclusion:
We concluded that the EAONO/JOS staging system is beneficial for estimating the postoperative hearing results and planning the surgical technique. However, there was no significant relationship between the recurrence rate and the EAONO/JOS staging system. We believe that additional factors, such as infection, ossicles, and invasion, predict the recurrence. Widespread use of the EAONO/JOS staging system will enable better evaluation of surgical outcomes and prognosis.
