I think cholesteatoma/epidermoids represent the failure to bridge and repair a fistula from inside to outside of the body.  The Stop signal for tissue repair is missing.  The classic example of this general mechanism is illustrated after some cases of lumbar puncture, due most likely to failure to close off the CSF fistula.   If this simple theory is correct, then any residual tissue after ear surgery is irrelevant.   What matters is that the surgeon does not aggravate or create a CSF or perilymph fistula.

Thank you sir. But the primary aim in cholesteatoma surgery is disease clearance, residual in sinus tympani ,anterior epitympanum etc are known to cause symptomatic ear disease ;many times requiring second look surgeries.

So if those residuals can cause disease why wouldn't small epithelial pearls at umbo In the middle ear not progress to a middle ear cholesteatoma. After all they are made of live  squamous epithelium...

Since the primary surgery was not for cholesteatoma, it acceptable to think that the bone in the maleus handle is not micro- invaded, and so it acceptable to spare it. What you say is therefore the correct action (spare the bone in the umbus). That is how I learned and done for the past 15 years. I am always diligent when removing the skin from the under surface of the maleus, but one must assume that it is impossible to remove every single cell. I assume that the reason for not finding significant cholesteatoma cases (five I know of, and none apparently from the umbus) is that cholesteatoma is a complex phenomenon that includes inflammation and bone erosion, and you find neither in a simple clean perforation. Also, the fascia is grafted underlay, and so any skin cell remains on the outside and will tend to spread over the graft and not under it.

Finally, I’ve seen pearls in the incision on the canal, usually some months after surgery, and those are easily removed with a fine needle.

So, answering your question, if you’re thorough when removing the skin, and if graft the fascia well under the maleus, it is unlikely to find an iatrogenic cholesteatoma. And as to surgical exploration, you don’t need to do it, unless you strongly suspect of cholesteatoma (either from observation or from CT/MRI), not even after cholesteatoma surgery (1).

1. Crowson MG1, Ramprasad VH1, Chapurin N1, Cunningham CD 3rd1, Kaylie DM1. Cost analysis and outcomes of a second-look tympanoplasty-mastoidectomy strategy for cholesteatoma. Laryngoscope. 2016 Mar 1. doi: 10.1002/lary.25941. [Epub ahead of print]

"why wouldn't small epithelial pearls at umbo In the middle ear not progress to a middle ear cholesteatoma."

Body tissues do not grow continuously, they have a natural termination (except for cancers).  So if epithelial tissue grows uncontrollably, this must be because the normal Stop mechanism is missing, as it would be over an unbridgeable fistula.

Agree with Anthony Gordon that the normal stop mechanism is missing in cholesteatoma. Some cholesteatoma is almost as  aggressive as cancers. Even after placing a graft under the malleus one may get a small cholesteatoma that may not always be easy to remove. Placing the graft superficial to the malleus would increase the the possibility epithelial pearl. 

Post-tympanoplasty middle ear cholesteatoma is an iatrogenic type which can be avoided by careful removal of adherent epithelium to handle of malleus & its umbo & the use of underlay grafting medial to the handle with amputating the tip of handle.  So I agree with Dr. João Subtil .

Sir if we amputate the tip wouldn't  it affect our hearing results  to a certain degree?. 

Also my doubt is does the epithelial pearl continue to grow at the same rate as the removed cholesteatoma?ie aggressive cholesteatoma will have aggressive pearls ? 

Even after successful tympanoplasty without development of cholesteatoma the preop CHL will not improve 100%. Also, after our underlay grafting medial to handle of malleus, the hearing outcome will not improve to the same extent as if the overlay grafting lateral to handle of malleus is used. Of my opinion amputating the tip will affect hearing result if it was applied with the overlay rather than the underlay technique but I have no any documentation & your question is a good idea of new research comparing postop hearing results with & without tip amputation.

Regarding your second portion of your question do you mean the recurrence after removal of cholesteatoma. 

In my observations, a small amount of epithelium on the undersurface of the umbo does not necessarily lead to a pearl. Even when it does happen in most cases it looks like a small pearl and rarely progresses or even warrants treatment. This is completely different from pearls or residua in the middle ear. Those grow relentlessly and must always be actively managed. I think this has to do with the normal biology of each of these epithelia. However I think that it is usually safer to completely and carefully denude the handle of malleus even if you amputate the very tip of the umbo to get clean bone. This usually does not greatly affect hearing results especially if you have prevented any anterior blunting or fibrosis

Hi Kartil

Great question. The umbo has the fibrous layer tightly applied so this needs to be cut if the TM is to removed entirely from the malleus. I regularly do this but I take care to make sure the squamous layer remains intact. I have not yet had an implantation cholesteatoma using this technique.

I hope this helps!

Regards

DP

Thank you sir.

epithelial pearl 

the above picture - left otoendoscopic view of a 37 year old female who had undergone left ear type 1 tympanoplasty 3 years back. Patient came with complaints of fullness and minimal ear discharge. 

Hrct and mri- suggestive of middle ear cholesteatoma. She was operated today.

What is the incidence of such symptomatic epithelial pearl after underlay tympanoplasty in your practice ?? or in general ? how do u manage them ??