title: Management of pediatric cholesteatoma based on presentations, complications, and outcomes.
abstract: OBJECTIVE
  To highlight important aspects and paradigms in the management of paediatric cholesteatoma in a developing world setting.
  
  
  METHODS
  A retrospective audit was conducted of paediatric cholesteatomas that underwent tympanomastoid surgery between 2008 and 2012 at the Red Cross War Memorial Children's Hospital in Cape Town. The following was audited: initial presentation; cholesteatoma complications; types of surgery, intraoperative findings and outcomes of surgery in terms of hearing, otorrhoea and recidivism; and the reliability of follow-up and how this might influence the type of surgery.
  
  
  RESULTS
  Fifty-seven children aged 2-13 years with 61 cholesteatomas (4 bilateral) were reviewed. Fifty-five mastoidectomies were done; 11% presented with complicated cholesteatoma. Referrals from primary care were significantly delayed (>6 months) in 76%. Canal wall down surgery was done in 71%. Forty-five percent had improved hearing (within 15dB of better hearing ear) and a further 15% had no or only mild hearing loss. Ossicular chain involvement and ossicles encased in inflammatory tissue were associated with poorer hearing outcomes. Sixty-four percent of ears remained dry. Forty-five percent of the canal wall up, and 23% of canal wall down mastoidectomies had recidivism. Twenty-six percent of patients were lost to follow-up.
  
  
  CONCLUSIONS
  Children are likely to present with advanced cholesteatoma with ossicular chain involvement. The children present with high rates of complications, poor pre-operative hearing and have high recurrence rates post-surgery. Referral from primary health care is delayed. Canal wall down procedures may be appropriate in a setting where patient follow-up is unreliable and access to operating theatre is limited.
authors.affiliation: Division of Otolaryngology, University of Cape Town Medical School, Cape Town, South Africa. Electronic address: jkmcguire2@gmail.com.
authors.forename: J K
authors.initials: JK
authors.lastname: McGuire
authors.affiliation: Division of Otolaryngology, University of Cape Town Medical School, Cape Town, South Africa.
authors.forename: H
authors.initials: H
authors.lastname: Wasl
authors.affiliation: Division of Otolaryngology, University of Cape Town Medical School.
authors.forename: T
authors.initials: T
authors.lastname: Harris
authors.affiliation: Paediatric Otolaryngology, Red Cross Children's Hospital, Division of Otolaryngology, University of Cape Town Medical School, Cape Town, South Africa.
authors.forename: G J
authors.initials: GJ
authors.lastname: Copley
authors.affiliation: Head of Otolaryngology, University of Cape Town, Cape Town, South Africa.
authors.forename: J J
authors.initials: JJ
authors.lastname: Fagan
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D018424:Cholesteatoma, Middle Ear / Q000150:complications* / Q000601:surgery*; D003906:Developing Countries; D004429:Ear Ossicles; D005260:Female; D006309:Hearing; D034381:Hearing Loss / Q000209:etiology; D006320:Hearing Tests; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D008416:Mastoid / Q000601:surgery; D012008:Recurrence; D012017:Referral and Consultation; D012189:Retrospective Studies; D013019:South Africa; D013997:Time Factors; D016896:Treatment Outcome
keywords: Cholesteatoma; Complications; HIV; Hearing; Outcomes; Paediatric otology