Elsevier

Auris Nasus Larynx

Volume 44, Issue 2, April 2017, Pages 135-140
Auris Nasus Larynx

Staging and classification criteria for middle ear cholesteatoma proposed by the Japan Otological Society

https://doi.org/10.1016/j.anl.2016.06.012Get rights and content

Abstract

In order to provide a basis for meaningful exchange of information among those treating cholesteatoma, the Committee on Nomenclature of the Japan Otological Society (JOS) was appointed in 2004 to create a cholesteatoma staging system as simple as possible to use in clinical practice in Japan. Following the announcement of preliminary criteria for the staging of pars flaccida (attic) cholesteatoma in 2008, we proposed the 2010 JOS staging system for two major types of retraction pocket cholesteatoma, pars flaccida and pars tensa cholesteatoma. Since then, the JOS staging system has been widely used in clinical studies of cholesteatoma in Japan, allowing standardization in reporting of surgical outcomes based on the respective stages of cholesteatoma. We have recently expanded the range of cholesteatoma by adding cholesteatoma secondary to a tensa perforation and congenital cholesteatoma as the 2015 JOS staging system for middle ear cholesteatoma. Although further revisions may be required for universal acceptance of these criteria, we hope our staging system will open the way for international consensus on staging and classification of middle ear cholesteatoma in the near future.

Introduction

Middle ear cholesteatoma is characterized by a mass lesion formed by keratinizing squamous epithelium, keratin debris and varying thickness of perimatrix, with or without surrounding inflammatory reaction. Because of the multifactorial and progressive nature of the disease process, pathophysiological conditions vary considerably from case to case. Hence, the operating surgeon is required to make a subjective decision regarding the most appropriate surgical technique for the individual situation, to achieve optimal surgical goals, including disease eradiation and subsequent functional and anatomical stabilization. Classification and staging of cholesteatoma would provide a standardized assembly of a relatively homogenous group of patients, allowing rational interpretation of surgical results based on respective pathophysiological conditions of the disease process. Needless to say, proper classification criteria can only be created by a consensus-based approach, preferably with the support of an academic society, and should undergo revision over time.

Section snippets

Impact of the previous proposal of criteria (the 2010 JOS staging system) on clinical studies of cholesteatoma in Japan

The Committee on Nomenclature of the Japan Otological Society (JOS) was appointed in 2004 to create a cholesteatoma staging system as simple as possible to use in clinical practice, in order to provide a basis for meaningful exchange of information among those treating cholesteatoma. Although several criteria for cholesteatoma classification/staging have been proposed worldwide [1], [2], [3], [4], [5], none of them are simple enough nor are they authorized by an academic society. Assuming that

Background of the current revision of the previous criteria

In 2012, we were given the opportunity to present the JOS staging system during the 9th International Conference on cholesteatoma and ear surgery in Nagasaki, Japan (Chairman of the meeting, Prof. Haruo Takahashi) [9]. In one of the panel discussions entitled “Panel with response analyzer to build up international consensus on classification and staging of middle ear cholesteatoma (modulators: Prof. Nuri Ozgirgin and Prof. Naoaki Yanagihara)”, this system gained favourable responses from the

Classification of cholesteatoma

  • I.

    Acquired cholesteatoma

    • 1)

      Retraction pocket cholesteatoma (so-called primary acquired cholesteatoma)

      • a)

        Pars flaccida cholesteatoma (Attic cholesteatoma): Cholesteatoma originating in a pars flaccida retraction pocket.

      • b)

        Pars tensa cholesteatoma: Cholesteatoma originating in a pars tensa retraction pocket. The range of retraction varies from a postero-superior quadrant (sinus cholesteatoma) to a partial or an entire pars tensa adhesion.

      • c)

        Combination of pars flaccida and pars tensa cholesteatoma:

Conclusions

The 2015 JOS staging system for middle ear cholesteatoma has been developed over the past 7 years through a consensus-based process and in a step-by-step manner, led by the Committee on Nomenclature of the JOS. The original version of the criteria was prepared for pars flaccida cholesteatoma in 2008. The concept of the criteria fitted naturally into pars tensa cholesteatoma, leading us to propose the 2010 JOS staging system as a set of criteria for both types of retraction pocket cholesteatoma.

Conflict of interest

The authors have no conflict of interest to declare.

Acknowledgements

The authors acknowledge the contribution of JOS members to the vigorous cultivation of the JOS staging system over the past 7 years, and the contribution of the members of the Cholesteatoma Guidelines Group of EAONO, Nuri Özgirgin, Ewa Olszewska, Matthew Jung, Armagan Incesulu, Jeff Mulder and Holger Sudhoff for the collaborative dialogue towards future consensus between the EAONO and the JOS on this project. They would like to thank former committee members, Makito Okamaoto, Masaru Aoyagi,

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All authors belong to the Committee on Nomenclature of the Japan Otological Society (JOS). The criteria set has been approved by the JOS Board of Directors.

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