Mastoid obliteration versus canal wall down or canal wall up mastoidectomy for cholesteatoma: Systematic review and meta-analysis

Abstract

Background: There is ongoing debate over the optimal surgical approach for cholesteatoma treatment^1-5. The aim of this review was to determine whether canal-wall down with mastoid obliteration is associated with favourable outcomes compared to either canal-wall down without obliteration or canal-wall up. The primary outcome was cholesteatoma reoccurrence with secondary outcomes including otorrhoea, reoperation and patient-reported outcome measures.

Methods: Medline, Embase, Cochrane databases and clinicaltrials.gov were searched for studies reporting outcomes of patients undergoing primary CWD-MO for cholesteatoma and directly compared with CWD and CWU mastoidectomies. Data were collated and meta-analysis performed.

Results: 2379 patients were included from 12 studies that met the inclusion criteria. CWD-MO was found to be associated with significantly less risk of recurrence when compared to CWU (OR = 0.330 (95 % CI 0.191-0.570, p < 0.001). When compared to CWD, CWD-MO was associate with significantly lower incidence of persistent otorrhoea (OR 0.405 (95 % CI 0.232-0.706, p < 0.001) while the rates of recurrence were comparable (OR: 1.231 [95 % CI: 0.550-2.757] p = 0.613). Otorrhoea rates between CWD-MO and CWU were equivalent as was reoperation. Quality of life and hearing outcomes were variably reported.

Conclusions: This systematic review demonstrates that CWD-MO technique achieves lower recurrence rates comparable to CWD approaches and superior to CWU, while offering improved long-term control of otorrhoea. The final procedural choice should be decided based on surgeon experience, skill set and individual patient factors. To address the risk of selection bias, a randomised controlled trial is needed to answer this important research question.

Keywords: Canal wall down; Canal wall up; Cholesteatoma; Mastoid obliteration; Mastoidectomy; Otology.