Reconstruction of the Canal wall in CWU Tympanoplasty for Cholesteatoma with Titanium Sheeting

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To the Editor:
We carefully read the article of Black and Gutteridge presenting a titanium sheeting (non-FDA approved) for reconstructing the canal wall in canal wall-up tympanoplasty (1). For decades, we know that reconstructing the canal wall in intact canal wall procedures is essential to minimize the rate of recurrent cholesteatoma in the attic or mastoid (2). Reconstructing the canal is still a challenging issue. Several procedures have already been reported, but none clearly showed its superiority (3–7). Reconstruction can be attempted through different ways, sometimes in association, with or without mastoid obliteration: surrounding musculoperiostal flap, autologous bone chips or bone pate, cartilage, bioactive glass ceramic, hydroxyapatite, titanium. For optimal results, the reconstruction has to be well tolerated, particularly for synthetic material, and stable over time. The device presented in the current article seems to respond to these needs, by covering the titanium sheeting with cartilage and stabilizing it with the U-clip. On the other hand, the device must not hamper the mandatory follow-up or a potential revision. The article of Black and Gutteridge does not clearly address these major issues, especially the relationship between imaging and implanted metal devices. Thanks to the development of powerful imaging techniques, i.e., high-resolution computed tomography scan and magnetic resonance imaging (MRI) with specific protocols (diffusion-weighted images and delayed postcontrast T1-weighted images), the postoperative follow-up of middle ear cholesteatoma has dramatically changed from routine second look surgery to mini-invasive follow-up based on serial clinical and radiological evaluation, to avoid unnecessary surgical revision (1,8–10). It is well known that metallic devices generate artifacts with computed tomography scan and even more with MRI. Such artifacts can shadow critical regions of the ear where a residual cholesteatoma could develop. It is also very important to know the MRI safety characteristics of the titanium sheet and U-clip for at least 1.5, 3 Teslas. Among the 40 patients consisting of the Blake and Gutteridge cohort, 36 underwent revision surgery, whereas others were monitored with MRI (1). We guess the strong predominance of revision procedure was related to the purpose of the study and its retrospective design, but we assume that today, in routine practice, the ratio between revision surgery and MRI scanning would be reversed. Given the major place of imaging, especially MRI, in the postoperative follow-up of middle ear cholesteatoma, we do think the authors should clarify these issues; otherwise, it might lead to strong limitations for the development of this interesting device.

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