10.14639/0392-100X-N1998
Objective. To evaluate the long-term quality of life (QoL) in patients operated for cholesteatoma by canal wall-up tympanoplasty (CWUT) or canal wall-down tympanoplasty (CWDT) with mastoid obliteration. Methods. QoL was evaluated by the Chronic Otitis Media Questionnaire - 12 (COMQ-12). For each patient, the total score and three partial subscores, concerning disease activity, functional impairment and general impact on the patient’s life were calculated. These scores were correlated with the surgical technique, as well as anatomical and functional results. Results. 68 procedures were classified as CWUT and 78 as CWDT with obliteration. The mean follow-up was 65 months. Total and partial COMQ-12 scores did not show any significant difference between the two groups. Correlation analysis showed a significant direct association between the postoperative Air-Bone Gap (ABG) and both the COMQ-12 total score and functional subscore in the CWUT group. Conclusions. This is the first study comparing CWUT and CWDT with obliteration with the COMQ-12, thus confirming the overlapping results in terms of QoL. These findings, together with the evidence of the significantly lower rates of recidivism, show that CWDT with obliteration should be considered as a good alternative to CWUT.
text/xml
1827-675X
1998
en
Nicola Quaranta
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
COMQ-12
Quality of life after cholesteatoma surgery: comparison between surgical techniques
Text.Serial.Journal
https://www.actaitalica.it/
42
Otology
2022-06-30
2022-01-03
2022-07-26
2022-07-26
293-299
1
Nicola Quaranta
2022/06/30
10.14639/0392-100X-N1998
293
Otolaryngology Unit, Department of BMS, Neuroscience and Sensory Organs, University of Bari, Bari, Italy
1827-675X
COMQ-12
en
299
Quality of life after cholesteatoma surgery: comparison between surgical techniques
https://www.actaitalica.it/article/download/1998/836
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:293-299; doi: 10.14639/0392-100X-N1998




Otology


Quality of life after cholesteatoma surgery:
comparison between surgical techniques
Qualità di vita dopo chirurgia del colesteatoma: confronto fra tecniche chirurgiche
Vito Pontillo1, Marialessia Damiani1, Amar Harib1, Monia Sammali1, Giusi Graziano2, Nicola Quaranta1
1
 Otolaryngology Unit, Department of BMS, Neuroscience and Sensory Organs, University of Bari, Bari, Italy; 2 Biomedical Sciences
and Human Oncology Department, University of Bari, Bari, Italy


SUMMARY
Objective. To evaluate the long-term quality of life (QoL) in patients operated for cho-
lesteatoma by canal wall-up tympanoplasty (CWUT) or canal wall-down tympanoplasty
(CWDT) with mastoid obliteration.
Methods. QoL was evaluated by the Chronic Otitis Media Questionnaire - 12 (COMQ-12).
For each patient, the total score and three partial subscores, concerning disease activity, func-
tional impairment and general impact on the patient’s life were calculated. These scores were
correlated with the surgical technique, as well as anatomical and functional results.
Results. 68 procedures were classified as CWUT and 78 as CWDT with obliteration. The
mean follow-up was 65 months. Total and partial COMQ-12 scores did not show any sig-
nificant difference between the two groups. Correlation analysis showed a significant direct
association between the postoperative Air-Bone Gap (ABG) and both the COMQ-12 total
score and functional subscore in the CWUT group.
Conclusions. This is the first study comparing CWUT and CWDT with obliteration with
the COMQ-12, thus confirming the overlapping results in terms of QoL. These findings,
together with the evidence of the significantly lower rates of recidivism, show that CWDT
with obliteration should be considered as a good alternative to CWUT.
KEY WORDS: cholesteatoma, canal wall-down, obliteration, quality of life, COMQ-12
                                                                                                     Received: January 3, 2022
                                                                                                     Accepted: March 27, 2022
RIASSUNTO
Obiettivo. Valutare la qualità di vita (QoL) a lungo termine nei pazienti sottoposti a timpa-        Correspondence
noplastica chiusa (CWU) o aperta (CWD) obliterativa per colesteatoma.                                Vito Pontillo
Metodi. La valutazione della QoL è stata eseguita tramite il Chronic Otitis Media Que-               UOC Otorinolaringoiatria Universitaria - Azienda
stionnaire-12 (COMQ-12). Per ciascun caso sono stati calcolati un punteggio totale e tre             Ospedaliero-Universitaria Consorziale Policlinico
parziali, riferiti all’attività di malattia, all’aspetto funzionale e all’impatto sulla vita. Que-   di Bari, piazza Giulio Cesare 11, 70124 Bari, Italy
sti sono stati poi correlati alla tecnica chirurgica e ai risultati anatomici e funzionali.          Tel. +39 080 5592299
                                                                                                     E-mail: pontillovito@gmail.com
Risultati. 68 procedure sono state classificate come CWU e 78 come CWD obliterativa.
Il follow-up medio è stato di 65 mesi. I punteggi parziali e totali di COMQ-12 non hanno
mostrato alcuna differenza significativa tra i due gruppi. L’analisi di correlazione ha mo-
strato, nel gruppo CWU, un’associazione diretta tra l’Air-Bone Gap (ABG) postoperatorio                How to cite this article: Pontillo V, Damiani M,
ed entrambi i punteggi di COMQ-12 totale e funzionale.                                                 Harib A, et al. Quality of life after cholesteatoma
                                                                                                       surgery: comparison between surgical tech-
Conclusioni. Questo è il primo studio che ha confrontato tecniche chiuse e aperte obli-
                                                                                                       niques. Acta Otorhinolaryngol Ital 2022;42:293-
terative attraverso l’uso del COMQ-12, confermando risultati sovrapponibili in termini                 299. https://doi.org/10.14639/0392-100X-N1998
di QoL. Questa evidenza, unita a quella del più basso rischio di recidiva, mostra come la
timpanoplastica aperta obliterativa debba essere considerata una valida alternativa alla             © Società Italiana di Otorinolaringoiatria
timpanoplastica chiusa.                                                                              e Chirurgia Cervico-Facciale

PAROLE CHIAVE: colesteatoma, timpanoplastica aperta, obliterativa, qualità di vita,
                                                                                                                    OPEN ACCESS
COMQ-12
                                                                                                     This is an open access article distributed in accordance with
                                                                                                     the CC-BY-NC-ND (Creative Commons Attribution-Non-
Introduction                                                                                         Commercial-NoDerivatives 4.0 International) license. The
                                                                                                     article can be used by giving appropriate credit and mentio-
                                                                                                     ning the license, but only for non-commercial purposes and
The surgical management of cholesteatoma remains one of the most debated                             only in the original version. For further information: https://
topics in otology. Surgery has been traditionally classified into canal wall-up                      creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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tympanoplasty (CWUT) and canal wall-down tympano-                 or cochlear fistula, large erosion of the posterior canal wall,
plasty (CWDT), depending on the preservation or removal           or facial nerve palsy 11. CWUT was performed in 128 cases
of the posterior bony wall of the external auditory canal         (45.4%), while CWDT with obliteration was carried out in
(EAC). While the preservation of the posterior EAC wall           154 cases (54.6%). Twenty-nine patients underwent a tran-
maintains an anatomically “normal” middle ear and mas-            scanal tympanoplasty and were considered in the CWUT
toid cleft, its removal allows better exposure of the middle      group. Obliteration of the mastoid cavity was always per-
ear and reduces the risk of residual and recurrent disease 1.     formed in CWDT by autologous bone paté 9. In 69.2% of
CWDT has, however, been associated with frequent side             cases (81.3% of CWUTs and 57.1% of CWDTs) surgery
effects such as debris accumulation, frequent ear discharge,      was staged, with the second stage performed at 12-18
vertigo and difficulty in hearing aid fitting 1,2.                months from the first surgery with the aim of early detection
In the recent literature, the quality of life (QoL) of patients   of residual cholesteatoma and reconstruction of the ossicular
operated on for cholesteatoma has become a increasing             chain. Histology confirmed cholesteatoma in all cases.
topic of interest. Besides the classical outcome measures,        All patients were submitted to clinical follow-up, while
such as recurrence rate and hearing function, different           unstaged CWUT patients or those who refused the second-
questionnaires evaluating the QoL of patients affected by         look procedure underwent HRCT 18-24 months after pri-
chronic otitis media have been proposed 3-6. The Chronic          mary surgery.
Otitis Media Questionnaire - 12 (COMQ-12) has been re-            All patients were evaluated by preoperative and serial
cently developed by Phillips 7 and validated in several lan-      postoperative micro-otoscopy and pure-tone audiometry.
guages, including Italian 8.                                      These data, together with surgical and follow-up reports,
The results of CWUT and CWDT have been reported by                were collected from medical records and integrated in an
several authors in terms of auditory outcomes, complica-          electronic database. Pure-tone average (PTA) values were
tions and recurrence rates; however, only few studies have        calculated as the mean of 0.5, 1, 2 and 4 kHz thresholds,
considered postoperative QoL 9,10.                                Air-Bone Gap (ABG) as the difference between air con-
The aim of the present study was to compare CWUT with             duction PTA (PTAAC) and bone conduction PTA (PTABC).
CWDT with mastoid obliteration in terms of long-term              Finally, Delta-BC was calculated as the difference between
postoperative QoL using the COMQ-12 questionnaire 7 and           the postoperative and preoperative average thresholds at
to correlate this score with the traditional outcome meas-        1, 2 and 4 kHz, as the possible expression of a sensori-
ures.                                                             neural damage. Functional results were expressed in terms
                                                                  of postoperative ABG and ABG improvement, calculated
                                                                  as the difference between preoperative and postoperative
Materials and methods
                                                                  ABGs. All data are presented in accordance with recom-
Two-hundred eighty-two consecutive surgical procedures            mendations from the Hearing Committee of the American
performed for middle ear and mastoid cholesteatoma at our         Academy of Otolaryngology – Head and Neck Surgery for
Department between January 2009 and December 2014                 the evaluation of conductive hearing loss 12.
were retrospectively evaluated. Such a period was chosen          From these 282 interventions, we selected cases suitable for
with the purpose of having at least 5-years of follow-up for      COMQ-12 administration, thus excluding patients younger
all patients. Patients undergoing revision or second-look         than 16 years or older than 85 years at the time of the in-
surgery or affected by congenital and petrous bone chole-         vestigation. Since the study was conducted in July 2020,
steatoma were excluded.                                           during the COVID-19 pandemic, all selected patients were
All surgeries were performed by the senior author as an           contacted by telephone. An online or printed template of
inpatient service with a retroauricolar or transcanal mi-         the previously validated Italian version of the COMQ-12
croscopic approach. All patients underwent preoperative           questionnaire 8 was addressed, together with a written
tonal audiometry and high-resolution computed tomogra-            agreement, to those who had given their oral consent by
phy (HRCT). The selection of the proper technique was             telephone. One hundred and forty-six replies were received
made pre- and intra-operatively in consideration of the ex-       by the same modalities. A power analysis confirmed that
tension of disease, anatomical conformation and presence          the number of respondents was adequate for a significant
of complications. In particular, a transcanal approach was        statistical analysis.
performed in cases of cholesteatoma located in the mid-           The COMQ-12 is a 12-item questionnaire, divided in 4 dif-
dle ear space and limited to the posterior mesotympanum.          ferent categories: severity of symptoms, specific impact on
CWDT was preferred in case of larger cholesteatomas or            work and lifestyle, impact on the health service and general
in the presence of complications such as large labyrinthine       impact of the disease on the patient. Based on the degree of



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inconvenience or frequency of symptoms, each question is          (p = 0.035); recurrent cholesteatoma was recorded in 6
scored on a six-point scale from 0 (no impact or sporadic         cases in the CWUT group (8.8%) and in no case in the
occurrence) to 5 (most severe impact or daily occurrence).        CWDT group (0%) (p = 0.009); other long-term anatomi-
Thus, the total score (range 0-60) was calculated for each        cal complications, such as tympanic membrane retraction
case by adding the single answer scores (COMQ-12_tot).            or lateralisation, granulations, or serous otitis media, had
In addition, to facilitate the connection with surgical out-      occurred in 9 patients (13.2%) treated by CWUT and in 10
comes, we calculated three subscores: COMQ-12_disease             (12.8%) treated by CWDT (p = 0.941). All patients who de-
activity from the sum of the scores of Q1, Q2 and Q5,             veloped recurrent cholesteatoma had previously undergone
COMQ-12_functional from the sum of Q3, Q4, Q6 and Q7,             a CWUT with mastoidectomy and were treated by revision
and COMQ-12_daily life impact from the sum of Q8, Q9,             mastoidectomy and CWDT.
Q10, Q11 and Q12.                                                 Table I reports the hearing results obtained in the two groups
                                                                  at 6 weeks after surgery and at the last clinical follow-up. A
Statistical analysis                                              significant postoperative change of PTABC was found in the
Categorical or dichotomous variables were expressed as            CWDT group (p = 0.014), but not in the CWUT group. Never-
absolute number and percentage (N, %). Continuous varia-          theless, the Delta-BC was not significantly different in the two
bles were expressed as mean ± standard deviation (μ ± SD).        techniques (p = 0.18). A significant postoperative improve-
Chi-square or Fisher’s exact tests and Mann-Whitney test          ment in PTAAC was recorded in the CWUT group (p = 0.003),
were used to compare categorical and continuous variables,        but not in CWDT patients. The difference between the mean
respectively, in the two groups of patients. Mixed effect         postoperative AC and BC PTA in the two groups was statisti-
models were used to assess the postoperative and long-term        cally significant (p < 0.05). Preoperative ABG was not differ-
changes in terms of ABG between the two groups of inter-          ent between the two groups, while the 6-week postoperative
est (CWUT and CWDT). Pearson correlation coefficient              ABG was 21 ± 12.2 dB and 25.2 ± 14.6 dB, respectively, in
was used for the comparison between independent continu-          the CWUT and CWDT group (p = 0.046).
ous variables. A p-value < 0.05 was considered statistically      At long-term follow-up, the mean ABG was not differ-
significant. The software R (version 3.5.2) was used for          ent between the two groups. Conductive hearing loss was
statistical analysis.                                             stable over time in the CWDT group (p = 0.29), while in
                                                                  the CWUT group a deterioration of the mean ABG was
                                                                  recorded at the last follow-up (27.0 ± 12.9 dB) in com-
Results
                                                                  parison to the early postoperative period (21.0 ± 12.2 dB)
We received 146 questionnaire replies from a total of 137         (p = 0.002).
patients. The power analysis showed that the study had a          The mean scores (± standard deviation) of each question in
power of 85% to detect an effect size of 0.5 in terms of          the two groups are reported in Table II, together with the
COMQ-12 scores between the two groups, at 5% alpha                total COMQ-12 score and the aggregate scores for disease
level using two-tailed test.                                      activity, functional and daily life impact questions. Statisti-
The mean age at the time of the surgery was 40 years              cal analysis did not show a significant difference between
(range = 7-79; SD 20.5) and the male/female ratio was             the two groups, except for question 6, given that patients
1.49 (82 males and 55 females). Sixty-eight procedures            treated by CWDT complained of a greater impact of diz-
were classified as CWUT and 78 as CWDT with oblit-                ziness on their quality of life compared to CWUT patients
eration. Two patients had undergone both the procedures           (0.51 vs 0.21). Moreover, it should be noted that, regardless
in the two ears. One patient in the CWUT group and 6 in           of the surgical technique, the highest scores were recorded
the CWDT group were operated with the same procedure              in Q3 (“hearing at home”), Q4 (“hearing in groups”) and
on both ears. In the CWUT group, the mean age was 33.9            Q12 (“general well being”).
years (range = 7-73) and the male/female ratio was 1.68 (42       Table III shows the rates of response to each question. The
males and 25 females). In the CWDT group, the mean age            percentage of patients for whom the postoperative ear con-
was 46.2 years (range = 8-79) and the male/female ratio           dition heavily impacted in daily activities (Q8, answer 5,
was 1.4 (42 males and 30 females).                                “Most days in the week”) was 14.1% in the CWD group
The mean clinical follow-up was 65 months (range 6-136),          versus 5.9% in the CWU group. Similarly, in 6.4% of pa-
while the mean time between the last surgery and the sur-         tients who had undergone a CWD technique water expo-
vey reply was 83.1 months (range 30-138).                         sure had frequent repercussions in lifestyle (Q9, answer
Residual cholesteatoma occurred in 12 patients treated            5, “Most days in the week”), versus 1.5% of patients in
by CWUT (17.6%) and in 5 treated by CWDT (6.4%)                   the CWUT group. Finally, 9% (vs. 5.9% CWU) of patients



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Table I. Hearing outcomes in the CWU and CWD groups.
                                                                         CWU                                   CWD                                 p-value
                                                                                                                                                (CWU vs CWD)
 Pre-op PTABC (m ± SD)                                               20.7 ± 13.1                           23.9 ± 13.7                                0.13
 Post-op PTABC (m ± SD)                                              21.1 ± 11.7                           28.6±18.0                                  0.01
 p-value (pre- vs post-op)                                               0.53                                 0.014
 Delta-BC PTA (m ± SD)                                                -0.9 ± 7.5                           -5.5 ± 15.6                               0.18
 Pre-op PTAAC (m ± SD)                                               48.6 ± 19.1                           51.8 ± 21.5                               0.41
 Post-op PTAAC (m ± SD)                                              42.1 ± 17.7                           53.5 ± 24.9                               0.008
 Last PTAAC (m ± SD)                                                 50.2 ± 19.6                           52.1 ± 24.0                               0.954
 p-value (pre- vs post-op)                                              0.003                                  0.74
 p-value (post-op vs last)                                              0.001                                 0.121
 Pre-op ABG (m ± SD)                                                 27.9 ± 13.3                           27.9 ± 12.2                               0.82
 Post-op ABG (m ± SD)                                                21.0 ± 12.2                           25.2 ± 14.6                               0.046
 Last ABG (m± SD)                                                    27.0 ± 12.9                           25.5 ± 13.4                               0.52
 p-value (pre- vs post-op)                                              0.001                                 0.067
 p-value (post-op vs last)                                              0.002                                 0.294
 ABG Gain m ± SD)                                                     6.9 ± 14.5                            2.9 ± 12.3                                0.15
PTABC: bone conduction Pure Tone Average; PTAAC: air conduction Pure Tone Average; ABG: Air-Bone Gap; CWU: Canal Wall-Up; CWD: Canal Wall-Down; μ: mean; SD: standard devia-
tion.



Table II. COMQ-12 single questions, partial and total scores in CWU and CWD groups.
 Question / Score                                                               m ± SD                                                              p-value
                                                                         CWU                                   CWD
 Q1 (“Ear discharge”)                                                0.47 ± 1.04                           0.27 ± 0.73                               0.352
 Q2 (“Ear odour”)                                                    0.38 ± 1.06                           0.19 ± 0.63                               0.653
 Q3 (“Hearing at home”)                                              1.44 ± 1.46                           1.46 ± 1.42                               0.863
 Q4 (“Hearing in groups”)                                            1.56 ± 1.57                           1.58 ± 1.34                               0.616
 Q5 (“Ear discomfort”)                                               0.28 ± 0.84                           0.18 ± 0.68                               0.721
 Q6 (“Dizziness”)                                                    0.21 ± 0.68                           0.51 ± 1.11                               0.026
 Q7 (“Tinnitus”)                                                     0.60 ± 1.22                           0.78 ± 1.18                               0.134
 Q8 (“Daily activities”)                                             0.85 ± 1.53                           1.06 ± 1.85                               0.938
 Q9 (“Water exposure”)                                               0.63 ± 1.31                           0.77 ± 1.50                               0.584
 Q10 (“GP attendance”)                                               0.32 ± 0.74                           0.18 ± 0.48                               0.288
 Q11 (“Drug requirements”)                                           0.15 ± 0.55                           0.10 ± 0.38                               0.810
 Q12 (“General well being”)                                          1.62 ± 1.68                           1.97 ± 1.63                               0.133
 COMQ-12_Disease activity                                             1.1 ± 2.4                             0.6 ± 1.8                               0.2928
 COMQ-12_Functional                                                   3.8 ± 3.5                              4.3±3.6                                0.2952
 COMQ-12_Daily life impact                                            3.6 ± 3.7                             4.1 ± 3.6                               0.3282
 COMQ-12_tot                                                          8.5 ± 7.6                             9.1 ± 7.3                               0.4708
CWU: Canal Wall-Up; CWD: Canal Wall-Down; µ: mean; SD: standard deviation.



submitted to a CWD procedure felt that their ear problem                                group, a significant direct association between the postop-
gets them down (Q12). All other questions showed overlap-                               erative ABG and both the COMQ-12 total score and func-
ping distributions.                                                                     tional subscore, with an increase of 0.17 (95% CI [0.03,
Correlation analysis between total and aggregate COMQ-12                                0.32], p = 0.019) and 0.01 (95% CI [0.02, 0.15], p = 0.014)
scores and postoperative ABG did not show any significant                               in COMQ-12 total and functional scores respectively, for
association in the CWDT group. Instead, in the CWUT                                     every unit increase in the postoperative ABG.



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Table III. Questionnaire response rates in the CWU and CWD groups.
 Question/Score                                                                                      %
                                                                  CWU                                                              CWD
                                     0          1           2            3           4         5          0        1          2           3       4          5
 Q1 (“Ear discharge”)              77.9       8.8          4.4          7.4        0.0         1.5       83.3     11.5      1.3          2.6     1.3       0.0
 Q2 (“Ear odour”)                  86.8       1.5           2.9         5.9        1.5         1.5       88.5     6.4       3.8          0.0     1.3       0.0
 Q3 (“Hearing at home”)            36.8       22.1         16.2         11.8       11.8        1.5       34.6     21.8      20.5         10.3    11.5      1.3
 Q4 (“Hearing in groups”)          38.2       16.2         16.2         13.2       13.2        2.9       23.1     33.3      21.8         7.7     12.8      1.3
 Q5 (“Ear discomfort”)             88.2       2.9           2.9         4.4        1.5         0.0       89.7     6.4       2.6          0.0     0.0       1.3
 Q6 (“Dizziness”)                  89.7       4.4           1.5         4.4        0.0         0.0       75.6     11.5      3.8          6.4     0.0       2.6
 Q7 (“Tinnitus”)                   75.0       7.4           7.4         4.4        4.4         1.5       60.3     17.9      10.3         6.4     5.1       0.0
 Q8 (“Daily activities”)           67.6       11.8          5.9         2.9        5.9         5.9       69.2     7.7       1.3          5.1     2.6       14.1
 Q9 (“Water exposure”)             73.5       13.2          1.5         1.5        8.8         1.5       70.5     12.8      3.8          1.3     5.1       6.4
 Q10 (“GP attendance”)             79.4       13.2          2.9         4.4        0.0         0.0       85.9     10.3      3.8          0.0     0.0       0.0
 Q11 (“Drug requirements”)         91.2       5.9           0.0         2.9        0.0         0.0       92.3     5.1       2.6          0.0     0.0       0.0
 Q12 (“General well being”)        38.2       17.6         14.7         8.8        14.7        5.9       26.9     15.4      19.2         19.2    10.3      9.0
CWU: Canal Wall-Up; CWD: Canal Wall-Down; %: percentage.



Discussion                                                                                term-follow-up, residual and recurrent cholesteatoma
                                                                                          rates were higher in CWUT; in fact, 8.8% of patients de-
The surgical treatment of cholesteatoma aims at complete
                                                                                          veloped recurrent cholesteatoma and were submitted to
eradication of the disease, creation of a safe and dry exter-
                                                                                          revision CWDT.
nal ear and, when possible, maintenance or restoration of
                                                                                          Other authors have compared postoperative QoL of pa-
conductive hearing.
                                                                                          tients submitted to tympanoplasty for cholesteatoma. Lu-
CWUT, CWDT and radical mastoidectomies are the three
                                                                                          cidi et al. 10 compared CWDT without mastoid obliteration
main techniques used to treat cholesteatoma and the ef-
                                                                                          with CWUT by two different QoL questionnaires, namely
fectiveness of each has been traditionally evaluated by
                                                                                          the Chronic Ear Survey (CES) and Chronic Otitis Media
recidivism, rate and postoperative hearing function. The
concept of health-related QoL has gained increasing inter-                                Outcome Test 15 (COMOT-15). CWDT patients showed
est in the last decades in all fields of otolaryngology and                               significantly lower symptoms subscale score of the CES
several questionnaires have been proposed and validated                                   at 3 months of follow-up, with the difference not being
to measure the QoL in patients affected by chronic middle                                 significant at 12-month follow-up. The authors explained
ear disease 3-6. The use of these patient-reported outcome                                this finding by the delayed healing of the surgical cavity
measures, together with the recidivism rate and hearing                                   in CWD patients, exposing them to water restrictions, fre-
function, may help to better evaluate the results of different                            quent postoperative medical examinations and a higher risk
surgical techniques.                                                                      of early postoperative otorrhoea. The analysis of the CO-
It has been shown by several authors that CWDT proce-                                     MOT-15 administered at 12 months after surgery showed
dures are associated with a lower risk of residual chole-                                 that CWDT patients reported significantly lower scores in
steatoma since they allow a better exposure of the mid-                                   the “hearing function” subsection that were confirmed by
dle ear and, in particular, of hidden anatomical regions                                  the significantly higher postoperative PTA of the CWDT
such as the anterior epitympanic space and the posterior                                  group.
mesotympanum, while exteriorisation of the mastoid and                                    Lailach et al. 13, using the COMOT-15, did not show any
epitympanic space reduces the risk of recurrent cholestea-                                significant difference in postoperative QoL for three differ-
toma 1. The presence of a large mastoid cavity has, how-                                  ent surgical techniques (transcanal tympanoplasty, CWUT
ever, been associated with frequent debris accumulation                                   and CWDT with obliteration), but demonstrated that “hear-
and discharge, vertigo induced by sudden temperature                                      ing function” was the most impaired domain in all patients.
changes in the EAC and difficulty in hearing aid fitting 1,2;                             The COMOT-15, as reported by the same authors, does not
therefore, a modification of the standard technique by the                                however evaluate activity restriction in detail, in contrast to
introduction of mastoid obliteration has been proposed to                                 CES or COMQ-12, and therefore does not evaluate all the
overcome these problems 2. In the present series, at long                                 domains of QoL of these patients.



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Our group has previously shown, using the CES question-          COMQ-12, a questionnaire that evaluates the QoL of
naire, that postoperative QoL was not significantly differ-      patients in terms of disease activity, functional impair-
ent after CWUT and CWDT with obliteration 9 and has              ment and general impact on the life such as long-term
attributed these results to the obliteration of the mastoid      GP attendance and medical treatments needed. In fact,
bowl that, by reducing the size of the cavity, diminished        the utility of the COMQ-12 in the evaluation of QoL of
the problems associated with large open cavities. However,       patients affected by middle ear disease has been recently
symptoms such as dizziness and tinnitus were not evalu-          demonstrated by a multinational collaboration 16,17. In ad-
ated by the CES.                                                 dition, in the present study the scores of the COMQ-12
In the present study we showed, by the use of COMQ-12,           questionnaire were correlated with the anatomical and
that CWDT with mastoid obliteration is associated with           functional results, demonstrating a strict relationship
good QoL even at long-term follow-up, that is not signifi-       between the ABG and total and functional score of the
cantly different from CWUT. The only question where we           COMQ-12.
found a significant difference was related to the impact of
dizziness that was higher in the CWDT group; however,
the low mean score (0.51 ± 1.11) underlines the minimal          Conclusions
impact of this symptom on the QoL, as also reported by           This study confirms that CWDT procedures with mastoid
other authors after mastoid obliteration 14. Despite the low     obliteration lead to similar results in terms of QoL com-
prevalence of dizziness, the thermal labyrinthine stimula-       pared to CWUT techniques. Hearing loss remains the most
tion can explain this finding, especially in case of long-term   important post-operative complaint of these patients. Nev-
resorption of the bone dust.                                     ertheless, the overlapping results in terms of QoL and the
Baetens et al. 15 evaluated the QoL in a group of patients       significantly lower rates of residual and recurrent chole-
undergoing CWUT with mastoid bony obliteration by                steatoma, suggest that CWDT with obliteration is a good
the COMQ-12. Although the technique implies the total            alternative to CWUT when indicated.
obliteration of the mastoid cavity and maintenance of
the posterior canal wall, the authors reported a postoper-       Acknowledgements
ative average score of 9.38 ± 7.73 which is very similar
                                                                 We thank the staff of our department who contributed to the
to our results (8.5 ± 7.6 in CWU and 9.1 ± 7.3 in CWD)
                                                                 medical care of the included patients.
and found that the most affected domains were “hear-
ing at home” (Q3) and “hearing in groups” (Q4). Also
                                                                 Conflict of interest statement
in the present series, we found that Q3 and Q4 scores
                                                                 The authors declare no conflict of interest.
had the highest values in both groups. A significant posi-
tive correlation between COMQ-12 scores and postop-
                                                                 Funding
erative ABG was evident in the CWUT group, in which
                                                                 This research did not receive any specific grant from fund-
for every dB there was an increase of 0.17 and 0.01 of
the total and functional scores, respectively. Postopera-        ing agencies in the public, commercial, or not-for-profit
tive hearing loss remains the most important factor im-          sectors.
pairing QoL in cholesteatoma patients regardless of the
technique used.                                                  Authors’ contributions
This study presents some limitations. First of all, we an-       VP and NQ have developed the study design, created the
alysed the QoL of a sample of patients who were retro-           database, collected the data and equally contributed to the
spectively selected from an electronic database; the mixed       writing of the manuscript. MD, AH and MS have parteci-
nature of the data collection, together with the limited size    pated in data collection. GG has performed the statistical
of the population and the inevitable lack in randomisation       analysis.
may bias the results. Moreover, a comparison between pre-
operative and postoperative QoL was not possible, since we       Ethical consideration
had not collected questionnaires at the time of the surgery.     The study was approved by the local Ethics Committee of
Finally, QoL results were collected at an extremely variable     Policlinico di Bari (PROT 4799/2019) and carried out in
postoperative time.                                              accordance with the Declaration of Helsinki. All patients
Despite these limitations, we believe that this study            received appropriate and comprehensible information
has several strengths. First, this is the first study com-       about the study, the surgical procedures and tests, and gave
paring CWUT and CWDT with obliteration using the                 their written consent.



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                                                                      Intact-canal wall tympanoplasty versus canal wall-down tympanoplasty with obliteration




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