The technique shapes the years that follow.
Some surgeons keep or rebuild the canal wall and then fill the mastoid with bone chips and bone paste, sealing the spaces where cholesteatoma could hide. A Belgian series of 271 patients treated this way found residual cholesteatoma on MRI in 3.3 percent by five years.
Warning signs after ear surgery
Weakness of the face on the operated side, severe spinning dizziness, a sudden drop in hearing, fever with headache or neck stiffness, or a swollen red area behind the ear need the surgeon the same day.
What do the studies show?
No randomized trial exists.
Surgeons have argued over the two techniques for decades, and the evidence comes from cohorts and reviews of them. Their direction is consistent, with fewer returns of cholesteatoma after canal wall down surgery. Each study treated different patients with different disease. The best choice for one ear depends on that ear, the hearing in both ears, the patient's age and how easily they can return for checks, and the surgeon weighs all of these with the patient before deciding.
Recurrence with each technique
Pooled studies point one way. Cholesteatoma came back 2.87 times as frequently after canal wall up surgery as after canal wall down in a meta-analysis. A planned two-stage canal wall up operation matched a single canal wall down. A Dutch systematic review of seven studies in adults found recurrence of 16.7 to 61.0 percent after canal wall up against 0 to 13.2 percent after canal wall down in six of them. One study found the opposite.
We advocate that greater consideration should be given to the canal wall down procedure in initial surgical management.
Meta-analysis, Audiology and Neurotology, 2013
Hearing after surgery
- The state of the hearing bones, especially whether the stapes is intact.
- Eardrum healing.
- Whether reconstruction is done at once or in a second stage.
- The hearing of the inner ear before surgery, which surgery cannot improve.
Many additional factors in patient care will define the best treatment decision, such as residual hearing and access to health care.
Systematic review, The Laryngoscope, 2016
Follow-up for many years
MRI instead of a second-look operation
Scans now spare many patients a second operation.
Diffusion-weighted MRI, a special technique, shows cholesteatoma as a bright spot. A British study of 50 patients found it identified residual disease with 83 percent sensitivity and 82 percent specificity, and newer non-echo-planar versions detect smaller deposits. Many patients now have scans in place of a planned second operation, which is especially useful for patients who live abroad.
- MRI one year after surgery.
- A second MRI at three years.
- A third at five years, since some deposits grow slowly.
Days, cost and the trip
Plan seven to ten days in Istanbul. One night in hospital follows the operation, the dressing behind the ear comes off after a few days, and the packing in the ear canal is checked or removed before you fly. Many surgeons advise waiting a week after middle ear reconstruction before flying, chewing or swallowing during descent to ease pressure.
Cost depends on the extent of disease, the technique, any reconstruction or second stage, the hospital stay and MRI follow-up. Your own figure follows the free review of your CT scan.
One coordinator plans the visit, from the visa invitation letter sent ten days ahead to the transfer and a hotel near the hospital for you and a companion. The team works in seven languages with halal meals and a prayer room available, and a female doctor is assigned on request when the schedule allows. Back home, the surgeon reviews your follow-up MRI and hearing tests and stays reachable on the same WhatsApp number, and the schedule of scans at one, three and five years is set before you leave, with a written explanation for your local radiologist of the MRI sequence needed, since a standard ear MRI misses small cholesteatoma deposits and a wrong scan gives false reassurance at exactly the moment when early detection would still allow a small, simple operation.
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Key numbers from the studies
| Question |
Finding |
| Return of cholesteatoma, canal wall up against down |
2.87 times higher with canal wall up |
| MRI for residual disease, British study |
83 percent sensitivity, 82 percent specificity |
| Residual disease after obliteration, 271 patients |
3.3 percent by five years |
Recovery at home
Recovery is gentle.
Keep the ear dry until the surgeon allows water at the first check, and avoid nose blowing and heavy lifting for two weeks. Mild dizziness, a blocked feeling and a little discharge are common in the first weeks.
Mastoidectomy FAQ
Why is mastoidectomy needed for cholesteatoma?
Cholesteatoma grows into the mastoid and erodes bone. Only surgery removes it, and the mastoid must be opened to clear it completely.
What is the difference between canal wall up and canal wall down?
Canal wall up keeps the ear canal wall and a normal-looking ear, with a higher chance of disease returning. Canal wall down removes it, lowering recurrence but leaving a cavity that needs cleaning.
Will my hearing improve after mastoidectomy?
The main goal is a safe, dry ear. Hearing may improve with reconstruction, depending on the hearing bones and the inner ear.
Do I need a second operation?
Not always. MRI scans at one, three and five years can replace a planned second-look operation in many patients.
How long will I stay in Istanbul?
Seven to ten days, including the first check before flying.
Can my family come with me?
Yes. A companion stays at the hotel we arrange, close enough to visit every day, and many patients find it helpful in the first days when dizziness and the dressing make simple tasks harder.
References
- Tomlin J, Chang D, McCutcheon B, Harris J. Surgical technique and recurrence in cholesteatoma: a meta-analysis. Audiology and Neurotology. 2013;18(3):135-142.
- Kerckhoffs KG, Kommer MB, van Strien TH, et al. The disease recurrence rate after the canal wall up or canal wall down technique in adults. Laryngoscope. 2016;126(4):980-987.
- Jindal M, Doshi J, Srivastav M, et al. Diffusion-weighted magnetic resonance imaging in the management of cholesteatoma. European Archives of Oto-Rhino-Laryngology. 2010;267(2):181-185.
- van der Toom HFE, van Dinther JJS, Zarowski A, et al. Radiological Follow-up After the Bony Obliteration Tympanoplasty in Detecting Residual Cholesteatoma: Towards an Optimal Postoperative MR Imaging Protocol. Otology and Neurotology. 2022;43(1):e79-e87.
- Jamshidi A, Hasanzadeh A, Zonnour A, Dabiri S, Yazdani N. Iatrogenic facial nerve injury in mastoidectomy: The impact of variables on the outcome. American Journal of Otolaryngology. 2022;43(4):103472.
