The pros and cons of canal wall up versus canal wall down mastoidectomy for cholesteatoma

Introduction It is widely accepted that cholesteatoma almost invariably requires surgical management. There has been ongoing debate regarding the optimal technique since intact canal wall or canal wall up (CWU) mastoidectomy was developed in the decade following the widespread introduction of the operating microscope in 1953. At the time of the national comparative audit of mastoid surgery overseen by the Royal College of Surgeons of England in 1991, 80% of procedures performed by participating surgeons in England and Wales for cholesteatoma were canal wall down (CWD) and 9% were CWU.1 Choice of technique depends on factors relating to the surgeon, the patient and the disease process. A plethora of literature cites the benefits and pitfalls of CWU, CWD and CWD with mastoid obliteration/canal wall reconstruction techniques. This article aims to review the arguments for and against CWU versus CWD surgery for cholesteatoma by addressing a number of factors which are affected by the technique performed. Repeat operations CWU surgery can provide very limited exposure (see below), particularly in cases with poorly developed zygomatic root cells and a low tegmen.2 A second look procedure is generally advocated 9 to 12 months after the primary surgery to remove any residual or recurrent cholesteatoma, which may not be seen behind the anatomically normal canal wall, or to confirm its absence. Reconstruction of the hearing mechanism may also be performed at the second look procedure. Conversely the aim of the CWD technique is to perform one-stage surgery. Recurrent disease can be seen more easily in an outpatient setting owing to the communication of the mastoid cavity with the external auditory canal. Hence revision surgery can be reserved for cases of established recurrence and the total number of procedures required is lower. CWD surgery should therefore be considered in frail patients or those with significant comorbidity who are not thought to be fit enough for more than one operative procedure. Similarly it is beneficial in patients who are unlikely to attend for follow up or in areas where healthcare provision is poor. The pros and cons of canal wall up versus canal wall down mastoidectomy for cholesteatoma