Case Study: Innovative Ear Reconstructions Address Cholesteatoma Pain

A patient living in Nevada with a history of cholesteatoma presented to Cleveland Clinic with excruciating ear pain and pressure. Three years prior, she had been treated for the condition, but she continued to report discomfort and was unable to tolerate air travel due to the altitude changes. At a follow-up with her original surgeon, she was told that the cholesteatoma had been removed and future therapy was not recommended despite her discomfort.

At Cleveland Clinic, she met with otologist-neurotologist Edward Doyle, MD.

“When I looked in her ear, it appeared everything was relatively OK,” says Dr. Doyle. “She had prior surgery, and I saw a couple of areas where it looked like there could be some additional disease. However, she was still reporting severe pain and drainage. In these cases where the initial surgery was done at a different organization, evaluating what was done and what the patient needs now can be challenging. You need to start from the beginning and reevaluate everything.”

He recommended exploratory surgery to understand her current condition and the details of the previous operation.

Treatment

Dr. Doyle found that her original surgeons had widened her ear canal. But in doing so they also took away part of the ear canal. Over time, as she healed, part of her skin and part of her cholesteatoma grew back into that location, which he recognized would need to be rebuilt.

“She had an area of her ear canal left open that had developed a big hole,” explains Dr. Doyle. “I knew that that was a problem, but I didn’t have high hopes that fixing this would improve her pain or relieve the fullness that she was experiencing. Once I got in there, I realized how collapsed her middle ear space was. Her eardrum had, in a sense, shrink-wrapped itself. Once I rebuilt that for her, I found numerous pockets that were blocked off, and I think addressing those is what improved her pain and pressure afterward.”

During surgery, Dr. Doyle had to rebuild several parts of the patient’s ear. He rebuilt a portion of her ear canal, her eardrum and the ossicles in her middle ear space. He also had to dilate her eustachian tube, all of which were made more complicated by the previous disease process and her prior surgery.

To repair her eardrum, Dr. Doyle used a mosaic technique and took cartilage from the tragus of the ear. The cartilage was shaved into numerous pieces and then cut to the exact size of the defect to rebuild the eardrum in multiple pieces.

“The benefit of the mosaic technique is that by rebuilding the eardrum in multiple parts, it not only enables the eardrum to heal, but it also provides structural integrity to resist some of that pull and pressure,” explains Dr. Doyle.

The biggest challenge of the case was rebuilding the patient’s ossicles, though. Her original surgeons took her incus, turned it and cut it into pieces. They tried to recreate the ossicular chain, but that approach didn’t work for this patient.

“When I got into her eardrum, the malleus and the incus were no longer connected to the stapes,” says Dr. Doyle. “Without that connection, it doesn’t matter how well the eardrum functions because there isn’t any bone movement to send sound into her ear to her brain.”

Dr. Doyle placed a long titanium partial ossicular replacement prosthesis (PORP) device on the stapes to help send the sound waves through when her eardrum moved.

In addition to the repairs, Dr. Doyle also dilated the patient’s eustachian tubes, which he hopes will help keep that area open and help aerate between the ear and the outside environment to help alleviate her feeling of ear tightness.

“The patient had a large defect in her ear canal, and with the eustachian tubes not working, her ear canal was almost acting like a vacuum,” explains Dr. Doyle. “Initially, much of the defect of her ear canal was created at the time of surgery, which was done to monitor for disease. However, it progressed to the point where we couldn’t identify if any disease was caused by that area. That was part of the reason I took her to surgery, and that defect was treated using cartilage as well.”

Takeaways

Following the surgery, the patient experienced immediate relief from pain and pressure, and her hearing also dramatically improved. The patient still experiences issues with dizziness, but Dr. Doyle believes this could be caused by a multitude of issues.

“Although I tell patients that our primary goal with these types of surgeries is to create a safe environment for the ear and that hearing loss is not the reason for the surgery, this patient’s hearing improved substantially from her first surgery,” says Dr. Doyle. “I think her quality of life is also dramatically improved, which is always the goal for these kinds of things — being able to take away her pressure and pain and allow her to stop focusing on her ear all the time.”

For Dr. Doyle, this case stands out due to the creative use of multiple surgical techniques to address complex challenges. Not only did he have to rebuild several different parts of her ear, but he also had to make sure that these reconstructed parts would work together in order to get the result he was looking for.

“These techniques are not cutting-edge or brand new,” he says. “But we had a patient who had multiple surgeries and was still having problems. We needed to identify what else could be done to help, and that can be hard because I think there’s a natural tendency among surgeons to want to do less — especially when you start to get outside of your wheelhouse. But that’s one of the benefits of coming to a major health center, like Cleveland Clinic, for treatment. We have four neurotologists on our team who can address these kinds of complex problems on a routine basis, and I think that’s a major advantage when it comes to complex surgeries like this one.”