INTRODUCTION
Cholesteatoma is a mass located in the tympanic cavity and/or mastoid cavity, composed of keratinized stratified squamous epithelium, subepithelial connective tissue, and progressively accumulated keratin debris, with or without an associated inflammatory reaction. Surgery remains the treatment of choice, with the primary objectives being complete eradication of the disease, creation of a safe and dry ear, prevention of recurrence, and preservation or restoration of hearing whenever possible.¹?²
Surgical management of cholesteatoma is traditionally divided into two approaches: the Canal Wall Down (CWD) technique and the Canal Wall Up (CWU) technique.³ A long-standing debate exists regarding the superiority of one technique over the other in achieving optimal anatomical and functional outcomes.³??
In the CWU technique, preservation of the posterior canal wall maintains the normal anatomy of the external auditory canal and middle ear cavity. This approach allows patients to avoid frequent ear cleaning and minimizes restrictions related to water exposure. However, CWU is associated with a higher risk of residual or recurrent cholesteatoma, often necessitating revision surgery. Furthermore, recurrent disease within a CWU cavity may remain undetected for prolonged periods due to limited surgical visualization.?
Several studies have reported varying recurrence rates following surgery. A recent review including six studies demonstrated higher recidivism rates in CWU procedures (16.7–61%) compared with CWD procedures (0–13.2%).???
Canal Wall Down Mastoidectomy (CWDM) offers several advantages, including more complete disease eradication, easier visualization of hidden cholesteatoma sites, reduced formation of retraction pockets, earlier detection of recurrent disease, and improved long-term surgical outcomes.??? Although postoperative hearing improvement may be limited in some cases, successful tympanoplasty or ossiculoplasty can reconstruct the hearing mechanism and significantly improve auditory function.¹??
Despite these advantages, the CWD technique is associated with certain drawbacks. Common postoperative issues include accumulation of keratin debris requiring periodic cleaning, increased susceptibility to infections following water exposure, dizziness induced by temperature changes within the external auditory canal, and discomfort while using hearing aids.? To address these limitations, various obliteration techniques have been developed using materials such as bone pâté, musculo-periosteal flaps, cartilage, silicone materials, hydroxyapatite, and bioactive glass.??¹?
The present study was undertaken to analyze the long-term anatomical and functional outcomes of Canal Wall Down Tympanoplasty in the management of tympano-mastoid cholesteatoma and to identify prognostic factors influencing surgical outcomes.
Additionally, this study aimed to evaluate the outcomes of Canal Wall Down Mastoidectomy in patients suffering from chronic active otitis media associated with cholesteatoma.
MATERIALS AND METHODS
This cross-sectional study was conducted in the Department of ENT and Head–Neck Surgery, Shaheed Ziaur Rahman Medical College Hospital, Bogura, Bangladesh, from July 2017 to January 2020.
A total of 76 patients diagnosed with chronic otitis media associated with cholesteatoma were enrolled in the study. All participants underwent detailed clinical evaluation including micro-otoscopy and pure-tone audiometry. The diagnosis of cholesteatoma was confirmed through microscopic examination and computed tomography (CT) scanning of the temporal bone.
All patients were considered suitable candidates for surgical intervention. The Canal Wall Down (CWD) technique was selected because of extensive disease involvement, unfavorable anatomical conditions, and/or erosion of the external auditory canal. Canal Wall Down Mastoidectomy combined with tympanoplasty was performed as a single-stage procedure. Partial obliteration of the neo-mastoid cavity was achieved using bone dust and cartilage grafts.
Standard pure-tone audiometry was performed in all patients over the conventional frequency range of 0.25–8 kHz. Pure Tone Average (PTA) values were calculated using the mean hearing thresholds at 0.5, 1, 2, and 4 kHz.
Audiological assessments were conducted 24 hours before surgery and repeated 12 months postoperatively. Hearing outcomes were evaluated by comparing preoperative and postoperative PTA values.
The Chronic Ear Survey (CES) questionnaire was translated from English into Bengali and administered to all participants before surgery and again one year after surgery. Differences in questionnaire scores were analyzed to assess changes in disease-specific quality of life.
Each CES item was normalized to a scale ranging from 0 to 100, with higher scores indicating better outcomes. Total CES scores and individual subscale scores were calculated by averaging responses according to the number of questions within each category.
Exclusion Criteria
The following patients were excluded from the study:


Patients undergoing revision surgery.


Patients with bilateral disease treated using different surgical techniques in each ear.


Patients diagnosed with petrous apex cholesteatoma.


Patients with other medical conditions that could significantly affect quality of life assessments.


Statistical Analysis
Data analysis was performed using Statistical Package for the Social Sciences (SPSS) software.
The Mann–Whitney U test was used to compare parametric mean values between groups, while paired t-tests were applied to assess changes within groups. Correlations between CES scores and objective air-conduction (AC) hearing thresholds were evaluated using Spearman’s rank correlation analysis.
A p-value of less than 0.05 was considered statistically significant.