Revision surgery for cholesteatoma: hints and pitfalls based on clinical experience

BACKGROUND: This study aims to identify the most frequent causes of failure in ear surgery for cholesteatomatous chronic otitis media (CCOM), through a retrospective clinical analysis and a literature review. Audiometric outcomes before and after revision surgery were also evaluated. METHODS: A retrospective study was conducted on 37 patients who underwent revision tympanoplasty with canal-wall-down (CWD) mastoidectomy for recurrent CCOM between 2017 and 2023. Intraoperative findings were analyzed to identify potential causes of failure from previous surgeries. Audiometric data, including pure-tone average (PTA) and air-bone gap (ABG), were assessed pre- and postoperatively. A literature review, following PRISMA guidelines, was also performed across major databases to identify studies reporting intraoperative findings and hearing outcomes in revision surgery for CCOM. RESULTS: In our series, the most frequent causes of failure were residual epithelial cells (83.7%), recurrent/residual cholesteatoma (81.1%), bony overhangs (81.1%), tympanic membrane perforation (81.1%), and canal stenosis (78.4%). High facial ridge and absent meatoplasty were present in 65% of cases. Postoperative audiometry showed a slight improvement, with an average ABG gain of 2.3 dB. From the literature (13 studies, 1180 ears), the most commonly reported failures included residual cholesteatoma, inadequate meatoplasty, and high facial ridge. Audiometric gains ranged between +1.7 and +12 dB. CONCLUSIONS: Surgical failures in CCOM are often due to technical issues, particularly incomplete disease removal and inadequate cavity management. Revision surgery helps achieve disease control and may offer modest hearing improvement. Greater attention to surgical detail can reduce the recurrence rate and the need for further interventions.