10.3 Cholesteatoma

Question 1

You are doing ENT list and a 12–year-old boy has been listed for mastoidectomy for cholesteatoma.

What are the issues with this case?

Answer 1

• Paediatric age group
• Prolonged operation and redo operations
• Need for hypotensive anaesthesia
• Need for facial nerve monitoring
• High incidence of PONV
• Operation near the airway—difficult to get to the airway

Question 2

What is cholesteatoma?

Answer 2

• Squamous epithelium trapped in the skull base affecting
  middle ear, temporal bone, and mastoid.
• It is a fatal destructive lesion,
  as it erodes and destroys the structures
  within the temporal bone

Question 3

What is the significance of cholesteatoma?

What happens if it is left untreated?

Answer 3

• It grows and expands at the expense of the bones and structures surrounding it.
• It causes bony erosion due to pressure effects and also enzymatic osteoclastic activity.
• It causes pressure effects and CNS complications.

Question 4

What symptoms might this child have?

Answer 4

• Painless otorrhoea
• Dizziness
• Sensorineural deafness
• Other symptoms due to pressure effects
  and invasion of surrounding structures—

brain abscess,
sigmoid sinus thrombosis,
epidural abscess,
meningitis,
facial nerve palsy

Question 5

if you plan to intubate this child, what is the problem you would encounter? How would you
overcome this?

Answer 5

Need for facial nerve monitoring calls for no muscle relaxant on board.

If we have used muscle relaxant for intubation,
then it might be difficult to use the facial nerve monitoring.

It can be overcome by:
* Use a short-acting muscle relaxant,
which would have worn off by the
time facial nerve monitoring, is needed.

• Avoid muscle relaxants altogether and
  use a potent opiate for intubation.

Question 6

What are the advantages and disadvantages of using a reinforced LMA?

Answer 6

Advantages:
Less stormy emergence, less airway stimulation

Disadvantages:
Need for controlled ventilation to control Co2,
chance of aspiration as it is not a definitive airway

Question 7

Which nerve is at risk of being damaged during this procedure?

How would you treat it?

Answer 7

The facial nerve, near its exit from the skull base through the stylomastoid
foramen, is very close to the ossicles at this level.

• Immediate decompression if nerve injury is suspected.
• Evidence for steroid use is unconvincing.

Question 8

How would you achieve hypotensive anaesthesia in this patient?

Answer 8

• 15° head tilt to prevent venous ooze
• Adrenaline infiltration by surgeons
• Controlled ventilation to decrease PaCO2
• Drugs—sevoflurane and remifentanil,
  propofol and remifentanil, labetalol infusion, etc

Question 9

What would be your choice of
analgesia and antiemesis?
Analgesia

Answer 9

• Intraoperative:
  WHO ladder —simple analgesics,
  NSAIDS,
  LA by surgeons,
  great auricular nerve block by anaesthetist,
  opioids if necessary
• Postoperative: WHO ladder

Antiemesis
* Good hydration and balanced analgesia

• Use of TIVA, avoiding N2o
• Avoidance of prolonged starvation times
• Drugs—dexamethasone, ondansetron, cyclizine, and droperidol