Recurrence rate and hearing outcomes of endoscopic-assisted intact canal wall up tympanomastoidectomy versus canal wall down tympanomastoidectomy in cholesteatoma: comparative study

Abstract Background The surgical management of cholesteatoma presents a classic dilemma between canal wall down (CWD) mastoidectomy, which offers low recurrence at the cost of anatomical and functional integrity, and canal wall up (CWU) mastoidectomy, which preserves hearing but has a historically higher recurrence rate. The introduction of the endoscope may mitigate the risks of CWU surgery by improving visualization of hidden recesses. This investigation aims to compare the recurrence rates and hearing outcomes of endoscopic-assisted canal wall up (EACWU) versus CWD tympanomastoidectomy. Methods This prospective, randomized clinical trial included 50 adult cases with cholesteatoma. Cases were randomly allocated to 2 groups: Group A (25 cases) underwent EACWU tympanomastoidectomy, and Group B (25 cases) underwent CWD tympanomastoidectomy. Preoperative assessment for all cases included otoscopic/endoscopic examination, CT of the petrous region, and pure-tone audiometry (PTA). The primary outcomes were disease recurrence, assessed via clinical and endoscopic follow-up, and hearing outcome, measured by changes in the air-bone gap (ABG) and air conduction (AC) thresholds at the 8th week postoperatively. Results Recurrence occurred in 8% of cases in the EACWU group compared with 4% in the CWD group, a difference that was not statistically significant ( p  = 0.55). The EACWU group demonstrated a substantial postoperative hearing improvement, with the mean ABG decreasing from 34.80 dB to 18.08 dB (a mean closure of 16.72 dB, p  < 0.0001). Conversely, the CWD group experienced a significant hearing decline, with the mean ABG increasing from 32.40 dB to 42.00 dB ( p  < 0.0001). Postoperative ABG and AC thresholds were markedly better in the EACWU group relative to the CWD group ( p  < 0.0001 for both). Conclusion Endoscopic-assisted CWU tympanomastoidectomy offers a superior hearing outcome compared to CWD mastoidectomy, with a comparably low rate of disease recurrence. This evidence supports the use of EACWU as a primary surgical option for suitable cases with cholesteatoma to achieve both disease eradication and functional preservation.