TREATMENT OF CHOLESTEATOMA AND RETRACTION POCKETS

Treatment of retraction pockets (RP) and cholesteatomas depends on the ir nature and evolvement and the size of mastoid pneumatization. RP ar e secondary to vacillating middle ear negative pressure. Treatment whe n necessary consists of placing a ventilating tube, excision of the RP or both. In most children and adults, cholesteatoma is derived from R P (or ''atelectasis'') of the tympanic membrane, where it can be terme d ''retraction pocket'' cholesteatoma or ''secondary'' cholesteatoma. This type of cholesteatoma is associated with a non-pneumatized mastoi d coupled by negative pressure. Approximately one-third of children's cholesteatomas present clinically behind an intact drum despite a pneu matized mastoid. Pathogenetically this type may be ''congenital'' or ' 'metaplastic'' and should be best termed ''primary'' cholesteatoma. Ce ntral perforations associated with cholesteatoma are probably derived from continuous tympanic membrane destruction by infection in cases of RP cholesteatomas or due to a primary cholesteatoma bursting out from the tympanic cavity. Canal-up surgery of cholesteatoma fails in 60% o f cases at Tel Aviv University because of the inherent tendency of the tympanic membrane to retract once again. Residual disease was found i n our cases to be a lesser cause for failure. Treatment depends on the type of cholesteatoma, emphasizing small ''radicals'' in sclerotic ma stoids. When a pneumatized mastoid is encountered, a posterior tympano tomy should be considered.