giant cholesteatoma

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Intl. Arch. Otorhinolaryngol., São Paulo - Brazil, v.14, n.1, p. 113-122, Jan!"#$arch - 2%11.

113

Case Report

Giant Cholesteatoma: Case and Literature Review’

Report

Colesteatoma Gigante: Relato de Caso e Revisão da Literatura

Leonardo Mendes Acatauassú Nunes*, Adriano Liberman Magalhães de Barros**, RenatoValério Rodrigues Cal***, Claudio Tobias Acatauassú Nunes****, abr!cio "ini# de Lima*****$

*Doctor Graduated by the University of the State of Pará. Resident of the 1st year of Otorhinolaringology at the FederalUniversityos So Paulo U!"F#SP$#P%.*Doctor Graduated by the University of the State of Pará. Resident of the 1st year of &nesthesiology of the 'os(ital O(hir)oyola$P&.

*** Doctor Otorhinolaringologist *ith Fello*shi( in Otoneurology by the 'arvard University. Professor of the Disci(line ofOtorhinolaringology of the Federal University of Pará.**** Doctor in Otorhinolaringology by the Federal University of So Paulo. Professor &ssistant + of the Disci(line ofOtorhinolaringology of the FederalUniversity of the State of Pará.&cade,ic Professor of the -th year of %edicine of the University of the State of Pará.

"nstitution University of State ofthe Pará / U#P&. 0el, $ P& /

0ra2il.%ail &ddress )eonardo %endes &catauas3 !unes / -+1 Pedro de 4oledo5 St / &(t 116 / 7ila 8le,entino / So Paulo $ SP / 0ra2il /9"P 8OD# :+:;5 6::?. &rticle a((roved on @uly 165 6:1:.

SUMMARYIntroduction: Cholesteatomas are cystic lesions encased by stratifed squamous epithelium, flled or

eratin! "hey are classifed in con#enital, about o $%&' and acquired, (hich aresubdi)ided in primary ormed rom a tympanic retraction and secondary, ori#inatedrom epithelium mi#ration throu#h a tympanic peroration! "hey are tumeurs (ith an

e*pansi)e capacity and o bone lysis bein# able to in)ade ad+acent structures!Case Report: "his (or reports the case o -., $3 years old rom Macap/0Amap/! n au#ust $22, he0she

appeared to attendance (ith a case history o ri#ht chronic otorrhea, he0she alsoreported menin#itis and pro#ressi)e ri#ht peripherica acial paralysis! "he mastoid

tomo#raphy demonstrated an hypodense ima#e (ith density o sot tissues fllin# themiddle ear, destructin# the ossicular chain, semicircular canals, cochlea and e*tendin#

until ne*t to the pro*imal portion o the internal auditory meatus! 4e0she (as reerred tosur#ery! 5urin# the trans% operati)e it is e)idenced an e*tensi)e destruction o the

cortical layer o the mastoid, (hich (as obstructed by a mass o an yello( coloration,

etid and o the consistent aspect! Ater the lesion is remo)ed it is )erifed the presence

o fstulae o hi#h debit (ith posterior ossa! t (as proceeded (ith the fstulae closin#

(ith a bone (a* and temporal muscle shred! "he patient remained confned durin# 1&

days in use (ide antimicrobial schema! Currently, it is fnd in re#ular accompaniment

and in a #ood #eneral state!

Final Comments : "his (or aims to call attention to the ri#orous complications o these patholo#ies , (hich

despite to be common and to be a beni#n tumoral lesion can brin# se)ere sequelae to

the patient, in the e)ent o the dia#nosis and treatment not to be prematurelyperormed!

Keywords: cholesteatoma, cases report, re)ie(6 literature!

R7SUMIntrodução: Colesteatomas s8o les9es c:sticas re)estidas por epit;lio escamoso estratifcado, preenchido por

queratina! S8o classifcados em con#


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$

cortical da mastoide, a qual esta)a ocupada por massa de colora=8o amarelada, ;tida

e de aspecto consistente! 5epois de retirada da les8o )erifcou%se a presen=a de :stulas

de alto d;bito com ossa posterior! RealiBou%se o echamento das :stulas com cera de

osso e retalho de msculo temporal! A paciente fcou internada durante 1& dias em uso

de esquema antimicrobiano amplo! Atualmente encontra%se em acompanhamento

re#ular e em bom estado #eral!Comentários Finais: 7ste trabalho tem como ob+eti)o chamar a aten=8o para as #ra)es complica=9es desta

patolo#ia, que apesar de comum e de se tratar de les8o tumoral beni#na pode traBersequelas #ra)es ao paciente, caso o dia#n?stico e tratamento n8o se+am realiBados

precocemente!Palavras-chave: colesteatoma5 relatos de casos5 literatura de reviso.


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&iant chol"'t"ato(a) *a'" an+ lit"ratur" r"vi",-.

un"' "t al.

1-"R,5UC"1,-

8holesteato,as can be defined as atu,or *ith eA(ansive ca(acity and of bonelysis5 *ith the ca(acity of invade adBacentstructures leading to severe co,(licationsas ,eningitis5 neurosensory deafness and

even facial (aralysis C1.

4he annual incidence of

cholesteato,as revolves around of ; casesby 1::.::: in children and < cases by1::.::: in adults5 being ,ore (redo,inant

in the ,ale

gender C6. #(ide,iological data sho* ahigh (revalence of the cholesteato,abet*een the 8aucasian5 follo*ed by the&frican (eo(le descendants being rarely seenin &siatic (eo(le C1.

&ccording to the literature5 they can

be classified in congenital and acEuiredC;. 4he congenital re(resent 6 to - ofall cholesteato,as5 being ,ore (revalentin the ,ale seA C;1 C+. 4hey are foundin four regions of the te,(oralbonety,(anic/,astoid5 (etrous a(eA5cerebello(ontine angle and Bugular fora,enC-. Still there is a fifth locali2ationthat is little e(ithelial (earls bet*eenthe layers of the ty,(anic ,e,brane5 *hich*as described recently C>.

4he cholesteato,as acEuired aredivided in (ri,aries5 constituted fro, aty,(anic ,e,brane retraction resulting

fro, the tube dysfunction conco,itant orsecondaries5 *hich it is believed thatthey are arising fro, the e(ithelial,igration through the (revious (erforationof the ty,(anic ,e,brane C;.

4he cholesteato,as (ossesses alysis osseous ca(acity the ,echanis,res(onsible for the bone erosion is stillcontroversy and so,e hy(othesis have beenbiased5 liHe the ,echanical co,(ression5osteoclastic sti,ulation and5 the actionof cytosines and the en2y,es (roteolytic(roduction liHe the collagenases C15I.

Due to its destructive5 ho*everinsidious behavior5 of the cholesteato,a5the early diagnosis and the adeEuatehandling hel( in the (revention of itsco,(lications5 that can be since hearingloss5 and for ti,es labyrinthitis5,eningitis5 cerebral abscesses and(eri(heral facial (aralysis C15?.

"t is Hno*s that the chroniccholesteato,atosa otitis ,edia C88O% is arelatively freEuent (athology in theroutine of the othorinolaryngologist. 4hisreflects es(ecially in the &,a2onianregion5 (robably by the cli,aticcharacteristics of the heat and hu,idity5

as *ell liHe by the cultural behavior of the(o(ulation in *hat concerns the bath inrivers and igara(s5 beco,ing a lot inclinedto this illness.


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&iant chol"'t"ato(a) *a'" an+ lit"ratur" r"vi",-.

un"' "t al.

Due to the (ossibility of graveevolution of this (athology5 that in s(iteof treat of a benign tu,oral lesion5 caneA(and itself to (oint of bringirreversible seEuelae to the sicH case thediagnosis and handling are not carried outearly5 is of big i,(ortance that it bedocu,ented and that be done a revision ofthe literature about the co,(licated for,of the illness. "t is a standard ofrare affection5 (resenting itself *ith

,ore of a conco,itant co,(lication andliHe this5 if is going to co,(ileinfor,ation for facilitate the access to abigger Hno*ledge of this (athology.

4he obBective of this study isgoing to relate a case of a co,(licatedgiant cholesteato,a5 and do the revisionof literature about the (athology.

D"7RA"UR7 R7.7E

4he ter, Jcholesteato,aK *as firstutili2ed by the Ger,an anato,ist @ohannes%ueller5 in 1?;?5 *hose *ord signifies cole/ cholesterol esteado / fatness oma /tu,or5 in other *ords5 a tu,or for,ed bygreasy tissue and crystals of cholesterolC>. 'o*ever5 since the cholesteato,aoriginates of sEua,ous Heratini2ede(itheliu, of the ty,(anic ,e,brane and$oreAternal auditory ,eatus5 *ithoutcholesterol crystals (resence or fatness inhis structure5 this ter, (asses to beincorrect C


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11&

;. 8holesteato,a of the 4ense Part/shrinHage and total adhesion of thetense (art of the ty,(anic ,e,braneinvolving the ty,(anic hole of theauditive tube.

&nother one classification (ro(osal

by S&)#' and %"))S5 in5 1


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11F

&nother one theory to the res(ectof the gro*th of a cholesteato,adefends it (lan of that this reEuireangiogenesis in the connective fabric ofthe (eri,atriA5 in such a *ay that thecells and substances of the *aterfall ofscarring be able to have an i,(ortant(a(er in the develo(,ent and gro*th ofthe cholesteato,as. 4hose trials *ouldinvolve the factor of gro*th fibroblasticb Cb/ FGF5 *hich sti,ulates the out(utof collagenases. 0eing liHe this5 the(ersistence of the infla,,ation *ouldcause a (er,anent trial of scarring inthe (eri,atriA5 the (roliferation offibroblasts C*oven of granulation andof the e(itheliu, C,atriA C1-. 4he,atriA and to (eri,atriA5 in nor,al or(athological tissues5 healthy for,ed bycollagen Hind "75 tenascin5 fibronectin5b/FGF and ,etalo(roteinases C%%P C1>.4he develo(,ent in the (roliferation ofthe ,atriA of the cholesteato,a *ould beturned out of the trial of infla,,ation5suggesting that to (eri,atriA *ould bethe ,ain factor of the develo(,ent of

the cholesteato,as C1I.

&naly2ing 61 cholesteato,as throughchain reaction of (oly,erase CP8R5i,unohistoche,ical and histology5 '&%S#"et &l. sho*ed5 in 6::;5 a (recursorscells elevation of osteoclastics and,acro(hages in the cholesteato,as. 4heanalysis of the (eri,atriA sho*ed that5in this region of the cholesteato,a5there is all of the necessary factorsfor the osteoclastogenesis and for thesti,ulation of the bone re absor(tionC1 C8M1> in the su(ra basallayers5 being that the eA(ression of this(roteic fila,ent is characteristic of hy(er(roliferative e(itheliu,s C66.

"t does not Hno* for certain if thelacH of control that leads to the hy(er(roliferation and to the alteration in thecellular differentiation is caused bydefects in genes that


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control the (roliferation5 by cytosinesliberated of infla,,atory cells5 or stillby others ,echanis,s still unHno*n CI56:.

Regarding the co,(lications causedby the cholesteato,as5 they can bedivided in t*o grou(s the intracranial /,eningitis5 abscesses and thro,bosis ofthe venous sinus / and the of the

te,(oral bone / ,astoid5 labyrinthinefistula5 (aralysis of the facial nerve5labyrinthitis and ossicular destructionC15;516.

4he ossicular destruction is the,ore co,,on bet*een the co,(lications ofthe cholesteato,as5 being that the Hindof destruction de(ends on his origin andof the its *ay of eA(ansion. &ccording tothe data of SN&R495 of 1


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4o technical o(en5 in s(ite of be,ore de(endable as regards theeradication and to the (revention of therecurrence5 does not enable the,aintenance of the anato,y and5 forti,es5 of the level of hearing(reo(erative C6-. it is i,(ortant *e*ill re,e,ber that this a((roach createsa cavity that is going to de,and a,eticulous ,edical acco,(ani,ent andlong5 beyond sue5 in general5 cares byall the life of the (atient. 'o*ever5 totechnical o(en5 *hen it co,(ared *iththe technical one closed5 (resents as,aller incidence of residuacholesteato,a C1


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Figure 1.Picture of the (atient / !otice facial

(aralysis to the right5 during atte,(t of

s,ile.

Figure 2.Picture of the (atient / &fterentreaty for close the eyes5 notice theinco,(lete locHing of the eyelid right5sho*ing the (eri(heral affection of the(aralysis.

of @une of 6::?. 4he results *ere studiedfro, the ,anual of the (atientcharacteri2ing5 therefore5 a retros(ectiveresearch. Of this " docu,ent5 *erecollected the follo*ing infor,ationidentification Cinitial5 age5 seA5 race5,arital status5 occu(ation5 origin5religion ,ain co,(laint history of the(resent illness (ersonal ,orbid recordfa,ily record habits of life andconditions of d*elling general (hysicaleAa, eAa, co,(le,entary eAa,sdifferential diagnosis definitediagnosis thera(eutic institutedevolution.

4he diagnosis and co,(le,entaryeAa,s *ere carried out in the de(endencesof the 'U0FS and in others centers andhos(itals accredited and Eualified by the(ublic net.

4he *orH also included revision of the

literature5 for *hich *ere utili2ed the

databases %#D)"!# and )")&8S.

CAS7 GR7S7-"A"-

"dentification O!75 fe,ale seA5 6+years5 brunette sHin5 natural and originatingin %aca(á$&P5 single5 catholic5 *orHer ofthe ho,e.


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%ain 8o,(laint Right chronic

othorrea.

'istory of the Present "llnessPatient *as ad,itted in 6;$:?$6::I in theService of Otorhinolaryngology of theUniversity 'os(ital 0ettina Ferro deSou2a5 after referral. "t co,es(resenting5 there are a((roAi,ately siAyears5 chart of chronic otitis ,edia to

the right5 constant. "t affir,ed alsofreEuent e(isodes of headache. Referredhistory of bacterial ,eningitis to the 1<years5 and u((er and lo*er facial(aralysis in right he,ifacial5 since the 61years5 in agree,ent observed in theFigures 1 and 6.

4o the otorhinolaryngological eAa,initial of the ad,ission5 did not (resentalterations in oral cavity and orofarynAto (revious rhinosco(y also *as sho*nnor,al. 4o the otological eAa,5 it *asnoticed the left ear *ith area ofty,(anosclerosis and light shrinHage ofty,(anic ,e,brane in anteroinferiorEuadrant. 4o the right5 observed itself the(resence of abundant festering secretion.&fter as(iration under ,icrosco(y5 sho*s

u(/itself (resence of (oly( in ,ediu, earright.

4o sicH it (resented a 8o,(uteri2ed

4o,ogra(hy C48 of the cavity ,astoid thatattested Josteolytic lesion beco,ing

o(aEue the ,astoids cells and the

ty,(anic


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Figure 3. 8o,(uteri2ed to,ogra(hy of,astoid / 4c (reo(erative5 in coronal cut5sho*ing u( hi(odense i,age *ith density ofsoft tissue to the right5 filling the ,eddleear and destroying all the trabeculate of the,astoid.

Figure 4. 8o,(uteri2ed to,ogra(hy of,astoid / 4c (reo(erative5 in coronal cut5sho*ing u( hi(odense i,age *ith density ofsoft tissue to the right5 filling the ,eddleear and destroying the ossicular chain andthe 8hauss s(ur.

cavity right5 *ith bone destruction andof the ossicular blocHs. 8ontinuitysolution (resence of the eAternalcortical layer5 *ith continuity bet*eencranial boA and ,astoids cellssubseEuent by cortical erosion.8olesteato,aK.

0eing that5 *ere reEuested(reo(eratives eAa,s C8085 glucose5 urea5creatinine5 sodiu,5 (otassiu, and A/ rayof chest before a clearly surgical(icture5 as *ell liHe a ne* one 48 of,astoid5 for verify (ossible evolution ofthe *ound observed in the first eAa,.

"n 6>$:


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8onclusion 4he as(ect to,ogra(hic

is co,(atible *ith eAtensive

cholesteato,a to the right. Figures ; and

+.

"n this ,o,ent5 *as reEuested

&uthori2ation for 'os(ital &d,ission

C&"' for the achieve,ent of

tiy(ano,astoidecto,y5 as *ell liHe(reanesthetic evaluation.

"n the day :1$1:$6::I *as carried out(reanesthetic evaluation5 and the (atient*as Eualified as being J&S& 1KG5 and liHethis5 liberated for the o(erative act.

Surgical Procedure C1:$1:$6::IPatient under general anesthesia5 andhabitual (re(aration5 carried outinfiltration retro auricular and archedincision about 6 c, of the auricular(avilion D. Dissection to the bone(lan5 incision in subseEuent *all of %and beginning of (erforation of the,astoid. Since the cortical layer of the,astoid5 it *as already identified thecholesteato,a5 *ith eA(ansion that has

included the subseEuent *all of the %(artially destroyed5 and filling all the,ediu, boA5 *ith destruction of theossicular chain CFigure -. 0onedestruction above the lateralse,icircular channel5 destruction of thefallo(ian channel5 *ithout sign of facialnerve. 4y,(anic teg,en dis(layed5 andeA(osition of the dura ,ater.SubseEuently to the labyrinthine blocH5there *as bone destruction *ith erosion

of the subseEuent grave5 *ith the(resence of abundant liEuorrea.

Nhen the lesion is re,oved co,(letelyCFigure >5 the liEuorrea5 ho*ever5re,ained. "t *as atte,(ted the locHing ofthe liEuorical fistula *ith te,(oral,uscle scra(5 graft of fascia5 Gelfoa,H

and *aA of bone. "t *as carried out thebroad canalo(lasty5 (lace,ent of gau2eabsorbed in FuracinH Cnitrofura2ona inthe auditory ,eatus and concoctedcurative co,(ressive.

"t *as reEuested the transference forthe Unit of "ntensive 4hera(y C"!4#!S"7#

8&R# U!"4 of the


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Figure 5."ntra o(erative / 0eginning of the

(erforation of the ,astoid *ith vie*ing of

the cholesteato,a.

Figure 6.Surgical (iece / 0igger (ortion of the

cholesteato,a5 *ithdra*n co,(letely.

University 'os(ital @oo de 0arros 0arretoC'U@005 due to the unavailability of the"!4#!S"7# 8&R# U!"4 of the 'U@005 the(atient *as allocated in isolation5 evolving*ith (icture of ,eningitis5 high fever andtris,us5 in the first day of ad,ission. She*as obtained i,(roves of the sy,(to,s inher ela(se of his ad,ission5 having re,ainedinterned by fifteen days5 under the use ofa broad antibiotic thera(eutic (lan.

"n :1$11$6::I5 a ,onth aftersurgery5 the (atient returns for the firstconsultation of (ost/o(erative5 (resentingi,(rove,ent of the headache5 ho*ever5still referring (ain in the localities ofthe surgery. 4hey *ere secluded the(oints of the surgery5 *hen good as(ect*as observed of the o(erative lesion5*ithout secretions5 *ith good scarring.

"n the second consultation ofacco,(ani,ent of the (ost/o(erative one5in 66$11$6::I the (atient referredi,(rove,ent accentuated of the headache5relating5 ho*ever5 drainage of festeringsecretion by the eAternal auditory ,eatus5confir,ed by the (hysical eAa,. "t *as,aintained the to(ical use of PanotilHC(oly,iAyn 05 neo,icyn5 fludrocortisona andlidocaine5 and scheduled return after :;,onths.

"n her return5 already in the day1+$:6$6::?5 the (atient (resented e(isodesof headache and intense otalgia5 as *ellliHe festering othorrea to the right. 4othe otosco(y5 *as observed the (resence offestering secretion5 as *ell liHe bone *aA,anifestation Cutili2ed in the surgical(rocedure by the eAternal auditory ,eatus."t *as diagnosed a co,(lication of thesurgical (rocedure by liEuorical fistula of(osterior fossa. "t *as reEuested ne* 48 of

,astoid5 and (rescribed 8i(rofonH

Cci(rofloAacine -::,g5 Predsi,H

C(rednisolona 6:,g5 and 4yeleAH C(araceta,oland codeine.


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"n the day 6


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,e,branes5 eubasica ,arch5 eulálica5 ingood general state5 acyanotic5 anicteric5afebrile5 conditions of nutrition andsatisfactory hydration. )iyn(hadeno(athyin right occi(ital chain5 ,ovable5(ainless.

Otorhinolaryngological eAa, Patient(resenting u((er and lo*er facial (aralysis

of the right he,iface5 of the (eri(heralHind5 (resenting sign of 0ell5 detour ofthe oral rhy,e for the left one5 andco,(lete absence of the tonicity and,uscular ans*er to the right.

4o the orosco(y5 the (atient(resents oral cavity *ithout visible*ounds5 *ith language of nor,al as(ect5to(ical (haryngeal tonsil and of nor,alsi2e5 orofarynA *ithout alterations.Previous rhinosco(y also *ithout nasal,ucous ,e,brane alteration evidences5festering secretions or batters.

4o the left otosco(y5 it *as noticedthe left ear *ith area of ty,(anosclerosisand light shrinHage of ty,(anic ,e,brane inanteroinferior Euadrant. 4he right otosco(ysho*ed u( the vie*ing of broad radicalcavity5 *ithout secretions5 fistulas orothers (hlogistic signs.

8o,(le,entary eAa,s 8o,(uteri2ed

4o,ogra(hy of %astoid CPreo(erative see

'istory of the Present "llnessK

#volution 4he (atient co,es being

acco,(anied

since %arch 6I5 6::? *ith,onthly visits to the Service ofOtorhinolaryngology of the University'os(ital 0ettina Ferro de Sou2a5 (resentingin this ti,e of acco,(ani,ent nointensification of the initial sy,(to,s5such as right otalgy5 intense headache orfestering othorrea. She is satisfied *ithher (resent health state5 co,,itted *iththe acco,(ani,ent of her (athology in thereferred service.

5SCUSS-

4he cholesteato,as can be definedliHe cystic lesions redressed of sEua,ouse(itheliu, stratified and filled byaccu,ulation of eAfoliated Heratin5 *itheA(ansive ca(acity and of lysis bone5 ingeneral located inside the ,ediu, ear orother areas (neu,ati2ed of the bone stor,5being able to ho*ever invade adBacentstructures5 causing to grave co,(licationsas ,eningitis5 deafness and to facial(aralysis CS8'UM!#8'45 1


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cases for 1::5::: in infants5 relates a

bigger incidence in ,en C6.

&ccording to e(ide,iological facts5the (o(ulation ,ore attacHed by thechronic otitis ,edia cholesteato,atosa isgoing to be the descendants of8aucasians5 follo*ed by the &frican blacH(o(ulation. Due to the strongcharacteristic of inter,arriage of the

0ra2ilian (o(ulation5 and to the fact ofthe (atient to be brunette5 *e *ould beable to consider ours as according tothe e(ide,iology of the illness C1.

"t is Hno*s that the big (art ofthe cholesteato,as is of the HindacEuired5 be (ri,ary or secondary5 and inthis as(ect5 the case in study also goesto the ,eeting of the revision since isa ,atter of a cholesteato,a acEuired5(receded by the account of chronic otitis,edia5 there are a((roAi,ately siAyears5 *ith otorrhea constant in this(eriod C. 4he (atient in re(ort (resented(ractically all the co,(licationsKof thete,(o/ ral boneK5 as the ossiculardestruction5 ,astoiditis5 labyrinthine

fistula5 and (aralysis of the facial nerve5by destruction of this nerve and yourchannel. "t (resented also intra cranialco,(lications5 as the liEuorical fistula andthe ,eningitis. 4his fact reinforces thei,(ortance of the re(ort by the unusualand severe evolution of this (athology5 inthis ranH.

%acrosco(ically5 the cholesteato,a(resents/itself

as a round cystic *ound or

oval *ith configuration and suchvariables5 and is characteri2ed liHe acyst e(ider,al5 of (rogressive andinde(endent gro*th5 *ith destruction ofthe adBacent tissue5 in s(ecial the bonetissue5 *ith tendency to a((eal C1. 4hisdescri(tion is in (art reinforced by thefind o(erative and histo(athological ofthe case related5 *hich *as (resentedliHe a lesion of -c, in his biggerdia,eter5 of as(ect e(ider,oid5 irregular5,ultifaceted5 of rough and friableconsistency. "t is observed a (rogressivegro*th of the lesion5 to *hich deter,inedthe co,(lete destruction of the ossicular

chain of the ,iddle ear5 destruction of thes(ur of 8hauss5 as *ell liHe all thetrabeculate of the ,astoid. 4he referredlesion destroys the *alls of these,icircular channels and of the cochlea5and it eAtends to Boin to the (ortion(roAi,al of the internal auditory ,eatus."t is notice also the destruction in the*alls of the channel of the facial nerve.4hese finds reinforce the erosive anddestructive characteristic5 in generalfound in cholesteato,as5 *ith (referenceby the destruction of bone tissues C1;.


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&ccording to the histologicaldescri(tion of )"% and Saunders5 in 1


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diseased tissues5 si,ilarly as *asa((roached to the (atient in Euestion.For such obBective5 a range oftechniEues already *as described5 being*orth hardly detach of the ,astoidecto,yo(en or closed.

4he selection of *hich (rocedure*ill be carried out is based in theHind5 in the ranH and in the stretch ofthe cholesteato,a in the auditiveevaluation (reo(erative in theeAistence or not of co,(licationsassociated in the state of the earcontra lateral in asse,bly *ith thefunction of the auditive tube and ranHof (neu,ati2ation of the ,astoid. 4hatchoice also *ill de(end on the generalconditions of the (atient5 of its age5of its origin and of its (rofession C>.

4o technical o(en it *ould be ableto be ,ore de(endable as regards theeradication and to the (revention of therecurrence5 ho*ever does not enable the,aintenance of the anato,y and5 forti,es5 of the level of (reo(erativehearing. 'o*ever5 in case of of the(atient here studied5 the indication ofthe technical o(en one did not givebarely by the (revention of therecurrence5 but yes ,ust undeniable theeAtensive anato,ical co,(ro,ise of her,iddle ear5 including *ith co,(licationsthat beca,e i,(ossible the a((roach ofthe (atient by the techniEue closed. Neshould not forget that that a((roachCo(en creates a cavity that is going tode,and a ,eticulous ,edical acco,(ani,ent

and long5 beyond sue5 in general5 caresby all the life of the (atient5 being ali,iting factor for so,e s(orts ass*i,,ing and dive. 0eyond that5 totechnical o(en5 *hen co,(ared *ith thetechnical one closed5 (resents a s,allerincidence of cholesteato,a residual5 *hatsHi,(y is desired for a (atient thatalready eA(erienced severe co,(licationsof its illness and that is going to freeitself of this illness5 as far as

(ossible5 in agree,ent *as te,(ted.

!aturally5 the short ti,e of (ost/o(erative acco,(ani,ent of the (atient(revents us fro, *e *ill certify that sheis co,(letely free of the illness suchaffir,ative reEuires a *ell bigger ti,e ofacco,(ani,ent. 'o*ever5 in this shortfollo*ing of barely three ,onths5 heraccounts are of indis(utable i,(rove,entof the sy,(to,s (resented5 as *ell liHeabsence of the intensification of thefestering otorrhea to the ,o,ent.

I-AD C-S57RA"-S

&fter revision of literature aboutthe giant cholesteato,a andcertification of the destructive andinvasive ca(acity of this lesion5 that ins(ite of rare5 can cause to ,orbiditygrave and seEuela5 it is note thei,(ortance of the docu,entation of a caseas this5 *here the lesion (rovoHeddefor,ities and (eri(heral facial(aralysis5 *hose descri(tion in the,edical literature is rare.


19/20

JJDKRAG4CAD R7I7R7-C7S

1.Ferlito O5 Devaney MO5 Rinaldo &5 %ilroy 85Nenig 05 "urato S5 %c8abe 0F.8linico(athological consultation earcholesteato,a versus cholesterolgranulo,a. &nn Otol Rhinol )aryngol. 1


20/20

1+. Fried,ann ". #(ider,oid cholesteato,a

and granulo,a. &nn Otol Rhinol )aryngol.

1

giant cholesteatoma

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