Cholesteatoma – Rokowania, prognozy i postęp choroby

Cholesteatoma
Rokowania, prognozy i postęp choroby

Przewidywanie przebiegu i wyników leczenia kolesteatomy opiera się na systemach klasyfikacji takich jak Potsic i STAMCO, z których ten drugi wykazuje lepszą wartość prognostyczną w przewidywaniu nawrotów choroby. Metaanaliza obejmująca 259 pacjentów nie potwierdziła istotnej różnicy w ryzyku choroby resztkowej pomiędzy stopniami klasyfikacji Potsica, natomiast klasyfikacja STAMCO okazała się najlepszym predyktorem nawrotu kolesteatomy w badaniach ośrodka referencyjnego. Stopień zaawansowania choroby w momencie rozpoznania istotnie wpływa na rokowanie – wczesne stadium i brak wcześniejszych operacji korelują z lepszymi wynikami słuchowymi i skutecznym usunięciem kolesteatomy, podczas gdy nawroty wymagają często bardziej rozległych zabiegów, takich jak tympanomastoidektomia, z gorszymi perspektywami odzyskania słuchu.

Prognostyka przebiegu kolesteatomy

Systemy klasyfikacji w prognostyce kolesteatomy
Czynniki wpływające na rokowanie
Prognostyka kolesteatomy u dzieci
Potrzeba dalszych badań
Kolejne rozdziały

Prognostyka przebiegu kolesteatomy

Przewidywanie przebiegu i wyników leczenia kolesteatomy jest kluczowym elementem planowania terapii dla pacjentów z tym schorzeniem. Obecnie istnieje kilka systemów klasyfikacji, które próbują przewidzieć wyniki leczenia i ryzyko nawrotu choroby, jednak ich wartość prognostyczna pozostaje przedmiotem badań i dyskusji w środowisku medycznym.¹²

Systemy klasyfikacji w prognostyce kolesteatomy

Klasyfikacja Potsica jest jednym z systemów stosowanych do oceny zaawansowania kolesteatomy. Pomimo teoretycznego spełnienia pierwszych trzech kryteriów dobrego systemu oceny, aktualne dane nie potwierdzają jego wartości prognostycznej. W metaanalizie obejmującej siedem raportów i 259 pacjentów nie wykazano statystycznie istotnych różnic w proporcji choroby resztkowej między czterema stopniami klasyfikacji Potsica u pacjentów obserwowanych przez co najmniej 12 miesięcy po usunięciu kolesteatomy.³⁴

W porównaniu z klasyfikacją Potsica, system STAMCO okazał się znacząco lepszym predyktorem nawrotów kolesteatomy. Według badań przeprowadzonych w ośrodku referencyjnym trzeciego stopnia, klasyfikacja STAMCO stanowi najlepszy dostępny predyktor nawrotu kolesteatomy i jest najbardziej obiecująca w przewidywaniu kolesteatomy resztkowej. Mimo to, potrzebne są dalsze badania walidacyjne dla tych systemów klasyfikacji.⁵

Czynniki wpływające na rokowanie

Stadium zaawansowania choroby

Stopień zaawansowania kolesteatomy w momencie rozpoznania ma istotny wpływ na rokowanie. U pacjentów z wczesnym stadium choroby, którzy nie byli wcześniej operowani, szanse na dobry wynik słuchowy oraz skuteczne usunięcie kolesteatomy są bardzo wysokie. Wczesna interwencja pozwala na przeprowadzenie mniej skomplikowanego zabiegu, poprawę słuchu i jakości życia pacjenta.⁶

W przypadku pacjentów z nawracającą kolesteatomą, którzy przeszli już wcześniejsze operacje, może być konieczne wykonanie bardziej rozległego zabiegu, takiego jak tympanomastoidektomia. W takich przypadkach rokowanie dotyczące wyleczenia infekcji jest dobre, jednak odzyskanie poprzedniego poziomu słuchu jest mniej prawdopodobne.⁷

Czynniki prognostyczne w kolesteatmie nawrotowej

Osiągnięcie zadowalających wyników słuchowych po operacji rewizyjnej kolesteatomy nawrotowej pozostaje wyzwaniem. Wieloczynnikowa analiza regresji logistycznej wykazała następujące niezależne czynniki predykcyjne dla zadowalającego słuchu po operacji nawrotowej kolesteatomy:⁸

Obecność napowietrzenia w jamie bębenkowej (iloraz szans [OR] [95% przedział ufności {CI}]: 13,287 [1,113-158,604], p=0,0409)⁹
Brak gęstości tkanki miękkiej zajmującej okienko owalne (OR [95% CI]: 13,445 [3,178-56,887], p=0,0040)¹⁰
Przedoperacyjna wartość ABG (air-bone gap) ≤22,5 dB w średniej z czterech częstotliwości (OR [95% CI]: 9,339 [2,026-43,050], p=0,0042)¹¹

Wiarygodna przedoperacyjna ocena oparta na tomografii komputerowej (CT) i pomiarze ABG może ułatwić podejmowanie decyzji dotyczących prawdopodobieństwa skutecznej rewizyjnej ossikuloplastyki lub odpowiedniego przedoperacyjnego poradnictwa, w tym wczesnej rehabilitacji słuchu za pomocą aparatów słuchowych lub wdrożenia implantowanego sprzętu słuchowego podczas operacji nawrotu.¹²

Prognostyka kolesteatomy u dzieci

W populacji pediatrycznej, czynniki demograficzne i stopień zaawansowania kolesteatomy mają większy wpływ na ryzyko nawrotu niż rodzaj przeprowadzonej operacji. Młody wiek i bardziej rozległa kolesteomta zwiększają ryzyko nawrotu choroby u dzieci.¹³

Chociaż można oczekiwać, że różne formy operacji wyrostka sutkowatego mogą mieć różny wpływ na homeostazę ciśnienia w uchu środkowym, a w konsekwencji wpływać na ryzyko późniejszej retrakcji i nawrotu kolesteatomy, analiza wieloczynnikowa pokazuje, że inne czynniki ryzyka mają bardziej znaczący wpływ na rozwój nawrotu.¹⁴

Wyniki słuchowe po operacji kolesteatomy u dzieci

Badania dotyczące wyników słuchowych u dzieci leczonych chirurgicznie z powodu kolesteatomy wykazały, że lepsze wyniki słuchowe bez nawrotu choroby osiągano w przypadku:¹⁵

Operacji z zachowaniem ściany przewodu słuchowego (canal wall up, CWU)
Mniejszego początkowego uszkodzenia kosteczek słuchowych
Lepszego słuchu przedoperacyjnego

Gorszy stan początkowy choroby zwiększał prawdopodobieństwo wykonania operacji z usunięciem ściany przewodu słuchowego (canal wall down, CWD). Szersze zastosowanie ossikuloplastyki w kohorcie CWU (51% vs 5% w CWD) może częściowo wyjaśniać lepsze wyniki w tej grupie.¹⁶

Potrzeba dalszych badań

Pomimo dostępności różnych systemów klasyfikacji i identyfikacji czynników prognostycznych, nadal istnieje potrzeba przeprowadzenia ukierunkowanych badań w celu uzyskania wyższego poziomu dowodów. Konieczne są prospektywne, dobrze zaplanowane badania z rygorystycznie udokumentowaną obserwacją, aby określić rzeczywistą zdolność systemów klasyfikacji do przewidywania wystąpienia choroby resztkowej.¹⁷¹⁸

Wiarygodna prognostyka kolesteatomy pozostaje ważnym celem w otochirurgii, gdyż mogłaby znacząco poprawić planowanie leczenia, informowanie pacjentów o przewidywanych wynikach oraz potencjalnie zmniejszyć częstość nawrotów poprzez dostosowanie strategii chirurgicznych do indywidualnych czynników ryzyka pacjenta.¹⁹²⁰

Kolejne rozdziały

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Materiały źródłowe

#1 Predicting residual cholesteatoma with the Potsic staging system still lacks evidence: a systematic review and meta-analysis – PubMed
https://pubmed.ncbi.nlm.nih.gov/38351408/
No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging system’s applicability for outcome prediction could not be proven based on the available data. […] Targeted studies are needed for a higher level of evidence.
#2 Predicting residual cholesteatoma with the Potsic staging system still lacks evidence: a systematic review and meta-analysis
https://pmc.ncbi.nlm.nih.gov/articles/PMC11211107/
No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging systems applicability for outcome prediction could not be proven based on the available data. […] The primary synthesis described in our protocol assessed whether Potsic stage at presentation was predictive of residual disease. […] In our meta-analysis of seven reports involving 259 patients, we were unable to detect a statistically significant difference in the proportion of residual disease between the four Potsic stages, based on data from patients who were followed for at least 12 months after cholesteatoma removal. […] Although the staging system published by Potsic et al. theoretically meets the authors first three criteria for a good staging system, based on data published so far, we cannot confirm its prognostic value.
#3 Predicting residual cholesteatoma with the Potsic staging system still lacks evidence: a systematic review and meta-analysis
https://pmc.ncbi.nlm.nih.gov/articles/PMC11211107/
No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging systems applicability for outcome prediction could not be proven based on the available data. […] The primary synthesis described in our protocol assessed whether Potsic stage at presentation was predictive of residual disease. […] In our meta-analysis of seven reports involving 259 patients, we were unable to detect a statistically significant difference in the proportion of residual disease between the four Potsic stages, based on data from patients who were followed for at least 12 months after cholesteatoma removal. […] Although the staging system published by Potsic et al. theoretically meets the authors first three criteria for a good staging system, based on data published so far, we cannot confirm its prognostic value.
#4
https://link.springer.com/article/10.1007/s00405-024-08478-3
No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging systems applicability for outcome prediction could not be proven based on the available data. […] The primary synthesis described in our protocol assessed whether Potsic stage at presentation was predictive of residual disease. […] In our systematic review and meta-analysis, we found that although the staging system published by Potsic et al. theoretically meets the authors first three criteria for a good staging system, based on data published so far, we cannot confirm its prognostic value. Therefore, prospective, well-designed studies are necessary with rigorously documented follow-up to determine this staging systems true ability to predict occurrence of residual disease.
#5
https://journals.lww.com/otology-neurotology/Fulltext/2020/04000/A_Retrospective_Analysis_and_Comparison_of_the.17.aspx?generateEpub=Article%7Cotology-neurotology:2020:04000:00017%7C10.1097/mao.0000000000002549%7C
To evaluate and compare the STAM classification, STAMCO classification and the EAONO/JOS staging system as predictors for cholesteatoma recidivism and postoperative hearing, using a large patient cohort in our tertiary referral center. […] For predicting recurrent cholesteatoma, the STAMCO classification was significantly superior compared to the other two instruments. […] Based on our study, the STAMCO classification represents the best available predictor for recurrent cholesteatoma and holds most promise for predicting residual cholesteatoma. […] More studies are needed to assess the validation of these classifications.
#6 What You Need to Know About Cholesteatoma, a Rare Growth in the Ear | Mount Sinai Today
https://health.mountsinai.org/blog/what-you-need-to-know-about-cholesteatoma/
Cholesteatoma disease can be quite variable. In patients with recurrent cholesteatoma who have already undergone prior surgeries, it is possible that they will need to undergo a more extensive procedure like a tympanomastoidectomyâa procedure that repairs the middle ear in patients with chronic ear infections. In those cases, the prognosis for ending the infection is high but regaining prior hearing is not as good. […] However, in a patient with an early stage of the disease that has not been operated on, the odds of achieving a good hearing outcome as well as successful removal of the cholesteatoma is quite high. […] If you come in early, the procedure is more straightforward. By addressing the problem, we can improve a patientâs hearing and quality of life.
#7 What You Need to Know About Cholesteatoma, a Rare Growth in the Ear | Mount Sinai Today
https://health.mountsinai.org/blog/what-you-need-to-know-about-cholesteatoma/
Cholesteatoma disease can be quite variable. In patients with recurrent cholesteatoma who have already undergone prior surgeries, it is possible that they will need to undergo a more extensive procedure like a tympanomastoidectomyâa procedure that repairs the middle ear in patients with chronic ear infections. In those cases, the prognosis for ending the infection is high but regaining prior hearing is not as good. […] However, in a patient with an early stage of the disease that has not been operated on, the odds of achieving a good hearing outcome as well as successful removal of the cholesteatoma is quite high. […] If you come in early, the procedure is more straightforward. By addressing the problem, we can improve a patientâs hearing and quality of life.
#8
https://link.springer.com/article/10.1007/s00405-022-07760-6
In cholesteatoma recidivism, achieving satisfactory hearing outcome after revision surgery remains challenging. […] The current study aimed to identify prognostic factors affecting hearing outcomes after surgery for cholesteatoma recidivism. […] Multivariate logistic regression analysis revealed the following independent predictive factors for satisfactory hearing: presence of aeration in the tympanic cavity (odds ratio [OR] [95% confidence interval {CI}]: 13.287 [1.113158.604], p=0.0409), absence of soft-tissue density occupying the oval window (OR [95% CI]: 13.445 [3.17856.887], p=0.0040), and 22.5 dB preoperative ABG in four-frequency average (OR [95% CI]: 9.339 [2.02643.050], p=0.0042). […] For cholesteatoma recidivism, reliable preoperative prediction based on CT and ABG would facilitate decision-making regarding the probability of efficient revision ossiculoplasty or appropriate preoperative counseling, including early hearing rehabilitation using hearing aids or implementation of simultaneous implantable hearing equipment during surgery for recidivism.
#9
https://link.springer.com/article/10.1007/s00405-022-07760-6
In cholesteatoma recidivism, achieving satisfactory hearing outcome after revision surgery remains challenging. […] The current study aimed to identify prognostic factors affecting hearing outcomes after surgery for cholesteatoma recidivism. […] Multivariate logistic regression analysis revealed the following independent predictive factors for satisfactory hearing: presence of aeration in the tympanic cavity (odds ratio [OR] [95% confidence interval {CI}]: 13.287 [1.113158.604], p=0.0409), absence of soft-tissue density occupying the oval window (OR [95% CI]: 13.445 [3.17856.887], p=0.0040), and 22.5 dB preoperative ABG in four-frequency average (OR [95% CI]: 9.339 [2.02643.050], p=0.0042). […] For cholesteatoma recidivism, reliable preoperative prediction based on CT and ABG would facilitate decision-making regarding the probability of efficient revision ossiculoplasty or appropriate preoperative counseling, including early hearing rehabilitation using hearing aids or implementation of simultaneous implantable hearing equipment during surgery for recidivism.
#10
https://link.springer.com/article/10.1007/s00405-022-07760-6
In cholesteatoma recidivism, achieving satisfactory hearing outcome after revision surgery remains challenging. […] The current study aimed to identify prognostic factors affecting hearing outcomes after surgery for cholesteatoma recidivism. […] Multivariate logistic regression analysis revealed the following independent predictive factors for satisfactory hearing: presence of aeration in the tympanic cavity (odds ratio [OR] [95% confidence interval {CI}]: 13.287 [1.113158.604], p=0.0409), absence of soft-tissue density occupying the oval window (OR [95% CI]: 13.445 [3.17856.887], p=0.0040), and 22.5 dB preoperative ABG in four-frequency average (OR [95% CI]: 9.339 [2.02643.050], p=0.0042). […] For cholesteatoma recidivism, reliable preoperative prediction based on CT and ABG would facilitate decision-making regarding the probability of efficient revision ossiculoplasty or appropriate preoperative counseling, including early hearing rehabilitation using hearing aids or implementation of simultaneous implantable hearing equipment during surgery for recidivism.
#11
https://link.springer.com/article/10.1007/s00405-022-07760-6
In cholesteatoma recidivism, achieving satisfactory hearing outcome after revision surgery remains challenging. […] The current study aimed to identify prognostic factors affecting hearing outcomes after surgery for cholesteatoma recidivism. […] Multivariate logistic regression analysis revealed the following independent predictive factors for satisfactory hearing: presence of aeration in the tympanic cavity (odds ratio [OR] [95% confidence interval {CI}]: 13.287 [1.113158.604], p=0.0409), absence of soft-tissue density occupying the oval window (OR [95% CI]: 13.445 [3.17856.887], p=0.0040), and 22.5 dB preoperative ABG in four-frequency average (OR [95% CI]: 9.339 [2.02643.050], p=0.0042). […] For cholesteatoma recidivism, reliable preoperative prediction based on CT and ABG would facilitate decision-making regarding the probability of efficient revision ossiculoplasty or appropriate preoperative counseling, including early hearing rehabilitation using hearing aids or implementation of simultaneous implantable hearing equipment during surgery for recidivism.
#12
https://link.springer.com/article/10.1007/s00405-022-07760-6
In cholesteatoma recidivism, achieving satisfactory hearing outcome after revision surgery remains challenging. […] The current study aimed to identify prognostic factors affecting hearing outcomes after surgery for cholesteatoma recidivism. […] Multivariate logistic regression analysis revealed the following independent predictive factors for satisfactory hearing: presence of aeration in the tympanic cavity (odds ratio [OR] [95% confidence interval {CI}]: 13.287 [1.113158.604], p=0.0409), absence of soft-tissue density occupying the oval window (OR [95% CI]: 13.445 [3.17856.887], p=0.0040), and 22.5 dB preoperative ABG in four-frequency average (OR [95% CI]: 9.339 [2.02643.050], p=0.0042). […] For cholesteatoma recidivism, reliable preoperative prediction based on CT and ABG would facilitate decision-making regarding the probability of efficient revision ossiculoplasty or appropriate preoperative counseling, including early hearing rehabilitation using hearing aids or implementation of simultaneous implantable hearing equipment during surgery for recidivism.
#13 Cholesteatoma Severity Determines the Risk of Recurrent Paediatric Cholesteatoma More Than the Surgical Approach
https://www.mdpi.com/2077-0383/13/3/836
Cholesteatoma Severity Determines the Risk of Recurrent Paediatric Cholesteatoma More Than the Surgical Approach. […] Young age and more extensive cholesteatoma increase the risk of recurrent cholesteatoma in children. […] When controlling for these factors, surgical approach does not have a significant effect on this outcome. […] The primary finding of this study is that demographic characteristics of the children and the severity of the cholesteatoma appear to influence the risk of recurrent cholesteatoma more significantly than the type of surgery completed. […] Although different forms of mastoid surgery might be expected to have different effects on middle ear pressure homeostasis and consequently influence the risk of subsequent retraction and recurrent cholesteatoma, multivariate analysis shows that the other risk factors have a more significant effect on the development of recurrence.
#14 Cholesteatoma Severity Determines the Risk of Recurrent Paediatric Cholesteatoma More Than the Surgical Approach
https://www.mdpi.com/2077-0383/13/3/836
Cholesteatoma Severity Determines the Risk of Recurrent Paediatric Cholesteatoma More Than the Surgical Approach. […] Young age and more extensive cholesteatoma increase the risk of recurrent cholesteatoma in children. […] When controlling for these factors, surgical approach does not have a significant effect on this outcome. […] The primary finding of this study is that demographic characteristics of the children and the severity of the cholesteatoma appear to influence the risk of recurrent cholesteatoma more significantly than the type of surgery completed. […] Although different forms of mastoid surgery might be expected to have different effects on middle ear pressure homeostasis and consequently influence the risk of subsequent retraction and recurrent cholesteatoma, multivariate analysis shows that the other risk factors have a more significant effect on the development of recurrence.
#15 A multivariate analysis of the factors predicting hearing outcome after surgery for cholesteatoma in children | The Journal of Laryngology & Otology | Cambridge Core
https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/multivariate-analysis-of-the-factors-predicting-hearing-outcome-after-surgery-for-cholesteatoma-in-children/CB17FF1D10847AAC10577890A61A34CF
Objective: To explore factors influencing hearing outcomes in children treated by canal wall up (CWU) and canal wall down (CWD) mastoid surgery. […] Conclusion: Disease-free hearing was better with CWU-surgery, less initial ossicular damage, and better pre-operative hearing. Worse initial disease increased the likelihood of CWD surgery. Wider use of ossiculoplasty in the CWU cohort (51 per cent vs 5 per cent) may partially explain the superior results.
#16 A multivariate analysis of the factors predicting hearing outcome after surgery for cholesteatoma in children | The Journal of Laryngology & Otology | Cambridge Core
https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/multivariate-analysis-of-the-factors-predicting-hearing-outcome-after-surgery-for-cholesteatoma-in-children/CB17FF1D10847AAC10577890A61A34CF
Objective: To explore factors influencing hearing outcomes in children treated by canal wall up (CWU) and canal wall down (CWD) mastoid surgery. […] Conclusion: Disease-free hearing was better with CWU-surgery, less initial ossicular damage, and better pre-operative hearing. Worse initial disease increased the likelihood of CWD surgery. Wider use of ossiculoplasty in the CWU cohort (51 per cent vs 5 per cent) may partially explain the superior results.
#17 Predicting residual cholesteatoma with the Potsic staging system still lacks evidence: a systematic review and meta-analysis – PubMed
https://pubmed.ncbi.nlm.nih.gov/38351408/
No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging system’s applicability for outcome prediction could not be proven based on the available data. […] Targeted studies are needed for a higher level of evidence.
#18
https://link.springer.com/article/10.1007/s00405-024-08478-3
No statistically significant difference was found in the proportions of residual disease between Potsic stages, thus the staging systems applicability for outcome prediction could not be proven based on the available data. […] The primary synthesis described in our protocol assessed whether Potsic stage at presentation was predictive of residual disease. […] In our systematic review and meta-analysis, we found that although the staging system published by Potsic et al. theoretically meets the authors first three criteria for a good staging system, based on data published so far, we cannot confirm its prognostic value. Therefore, prospective, well-designed studies are necessary with rigorously documented follow-up to determine this staging systems true ability to predict occurrence of residual disease.
#19
https://journals.lww.com/otology-neurotology/Fulltext/2020/04000/A_Retrospective_Analysis_and_Comparison_of_the.17.aspx?generateEpub=Article%7Cotology-neurotology:2020:04000:00017%7C10.1097/mao.0000000000002549%7C
To evaluate and compare the STAM classification, STAMCO classification and the EAONO/JOS staging system as predictors for cholesteatoma recidivism and postoperative hearing, using a large patient cohort in our tertiary referral center. […] For predicting recurrent cholesteatoma, the STAMCO classification was significantly superior compared to the other two instruments. […] Based on our study, the STAMCO classification represents the best available predictor for recurrent cholesteatoma and holds most promise for predicting residual cholesteatoma. […] More studies are needed to assess the validation of these classifications.
#20
https://link.springer.com/article/10.1007/s00405-022-07760-6
In cholesteatoma recidivism, achieving satisfactory hearing outcome after revision surgery remains challenging. […] The current study aimed to identify prognostic factors affecting hearing outcomes after surgery for cholesteatoma recidivism. […] Multivariate logistic regression analysis revealed the following independent predictive factors for satisfactory hearing: presence of aeration in the tympanic cavity (odds ratio [OR] [95% confidence interval {CI}]: 13.287 [1.113158.604], p=0.0409), absence of soft-tissue density occupying the oval window (OR [95% CI]: 13.445 [3.17856.887], p=0.0040), and 22.5 dB preoperative ABG in four-frequency average (OR [95% CI]: 9.339 [2.02643.050], p=0.0042). […] For cholesteatoma recidivism, reliable preoperative prediction based on CT and ABG would facilitate decision-making regarding the probability of efficient revision ossiculoplasty or appropriate preoperative counseling, including early hearing rehabilitation using hearing aids or implementation of simultaneous implantable hearing equipment during surgery for recidivism.