Microsurgical Management of Middle Ear and Petrous Bone Cholesteatoma

Review by L Flood
Middlesborough, UK

Most readers will be familiar with the first and second editions of Middle Ear and Mastoid Microsurgery from these authors, also published by Thieme. Those books dealt with the full range of middle-ear procedures, but this sizable book focuses on cholesteatoma and its unique challenges. Other than one Japanese author (who trained locally), the contributors are all from Piacenza and Rome, Italy.

The Preface stresses that surgery is unavoidable in cholesteatoma, even in the most unfit, and local anaesthetic is generally favoured by this team in all cases, regardless of status. I did like to read ‘Many surgeons stick to a single procedure such as canal wall up or down, but we think that is not reasonable’. They later say that one needs to adapt the technique to the patient and not the converse, which is very welcome advice. The Preface highlights features in this book, such as a chapter on subtotal petrosectomy and blind sac closure, one on cochlear implant and cholesteatoma (that I did not expect, I freely admit), and another on petrous bone cholesteatoma. That term they favour over petrous apex cholesteatoma, and, while I was not entirely convinced by the terminology, I was impressed by the size of the coverage. This made up over 240 of the total of 688 text pages, essentially comprising over one-third of the book.

The opening chapter illustrates anatomy, using very high quality photographs of temporal bone dissections, accompanied by high-resolution computed tomography (CT) scans. A chapter on diagnosis follows, providing otoendoscopic pictures of various retraction packets, with the corresponding CT scans to show the extent of disease, which gets progressively more advanced as one reads on.

A chapter on the operating theatre set-up featured many a pearl of wisdom. I did, however, experience a moment of nostalgia, seeing a 35 mm film camera attached to a microscope. Just finding the film would be a challenge these days. I almost cheered out loud on reading ‘Generally we do not use facial nerve monitoring in middle ear surgery’ and later ‘We think it may even carry risks for beginners’. Section 4.1.1 almost justifies the cost of the book in itself, covering the techniques to be employed when wielding a drill. There is just so much common sense and wisdom in this book’s coverage.

The chapters then follow a common format, taking the reader through a series of different approaches to cholesteatoma, whether canal wall up or down, congenital cholesteatoma, external canal wall cholesteatoma, or its complications. Very high quality colour photographs illustrate a sequence through each operation, three photographs to a page, with explanatory text in boxes. Each chapter then closes with hints and pitfalls (often consisting of a whole page of bullet points), and, finally, references to online videos. This description really does not do justice to the huge content, which is better appreciated by handling the book if given the chance

I particularly liked the coverage of treatment of cholesteatoma complications, although I would have liked some coverage of sigmoid sinus thrombophlebitis, which is surprisingly absent here. I noted the idea that, with a small fistula into the lateral canal, overlying matrix can be preserved, even with an intact canal wall approach. Their management results in spontaneous resolution, at a second-look, in 70 per cent of cases, and avoids the risks of opening the labyrinth. How I wish I had known that back in the day. One then reads about how to deal with tegmen erosion and dural herniation, or facial nerve damage. There is a CT scan to make one cringe, showing some very poor drilling of a mastoid, ‘performed elsewhere’ it is stressed, with the damage resulting and the surgical repair needed.

This is a massive book, and, as its title suggests, it takes the reader well beyond the traditional atticoantrostomy or modified radical mastoidectomy procedures of our training years. The pearls of wisdom from decades of experience are a real highlight, and the highly illustrated format makes for very easy reading. Obviously, this is a ‘must’ for any unit training in otology, but it is a very inspiring read even for those of us with that bit more experience.

Amazon Link: Microsurgical Management of Middle Ear and Petrous Bone Cholesteatoma
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