A 43-year-old with cholesteatoma has pressure-induced vertigo and a 6 mm lateral semicircular-canal fistula on CT. Bone-conduction thresholds are serviceable. At surgery, matrix is densely adherent over the fistula but there is no purulence. What is the best operative strategy?
A cholesteatoma fistula demands disease clearance balanced against labyrinth preservation: the adherent matrix is handled last, gently and under immediate cover.
A. Leave all cholesteatoma in situ permanently: Uncontrolled matrix risks progression, infection and further labyrinthine injury.
B. Strip the matrix first with a dry burr directly on the membranous labyrinth: Traction and drilling over an unprotected fistula risk profound sensorineural loss.
C. Clear disease elsewhere first, remove matrix over the fistula last using atraumatic technique, then seal the defect: Delayed, controlled matrix removal minimises manipulation; irrigation, avoidance of suction on the fistula and prompt multilayer sealing protect residual function.
D. Perform labyrinthectomy because every fistula sacrifices hearing: A lateral-canal fistula with serviceable cochlear reserve can often be managed hearing-preservingly.
E. Convert automatically to a radical cavity without considering anatomy or follow-up: Approach is individualised; fistula protection and complete safe disease control matter more than a reflex cavity choice.
If the ear had no useful hearing and extensive suppurative labyrinthitis, labyrinthectomy with definitive cholesteatoma clearance could be appropriate.
Independent Clinora educational preparation material; not official JCIE content, an accredited programme, or a substitute for local policy and specialist clinical judgement.
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