The patients were divided into Group A (C.W.R.) and Group B (C.W.D). Patients were followed up at 3 months and 6 months with otoendoscopy, CT scan, and pure tone audiometry, to look for the occurrence of any complications, to check epithelization, and for hearing assessment.

Inadequate exposure and dysfunction of the Eustachian tubes increase the risk of the postoperative formation of a retraction pocket in the pars flaccida. Our study removed the posterior canal wall integrally, resected the cholesteatoma tissue completely, and then reconstructed the posterior canal wall to reduce the risk of recurrence.

Autologous cartilage is one of the most suitable materials for posterior canal wall reconstruction and is used in this study. After shaping cartilage to fit the reconstruction site, it can easily be used. In various Otologic surgeries, cartilages (auricular cartilage and tragal cartilage) in the same surgical field have been widely used, as an additional incision is not required. The use of septal or costal cartilage has been found to produce similar postoperative results in other studies [10].

Weber and Gantz [13] reported that auricular cartilage is thinner than tragal cartilage and has a constant thickness and natural curvature, and is thus suitable for reconstruction. In addition, they found that the rate of formation of a retraction pocket was significantly lower for reconstruction with cartilage than for no reconstruction.

In the present study, we reconstructed posterior canal walls by inserting conchal cartilage. In Group A (C.W.R.), 25 (89.29%) of the 28 study subjects had an ABG of less than 25 dB after surgery, and one patient developed a postoperative retraction pocket. Thus, surgical outcomes were considered to be satisfactory and similar to other studies.

In the study by Smith et al. [11] in 1986, on Soft-Wall Reconstruction of the Posterior External Ear Canal Wall, a variable amount of soft-wall retraction was noted postoperatively in 47% of the ears. They used an autogenous bilaminar membrane to reconstruct the posterior canal wall defect.

In the study by Hosoi and Murata et al. [7, 8] in 1998 on long-term observation after soft posterior meatal wall reconstruction in ears with cholesteatoma, none of the patients experienced postoperative narrow-neck retraction pocket formation. No severe cavity or hearing problems have occurred since surgery.

In the study by Baek et al. [1] in 2016, postoperative otorrhea occurred in 5 patients (11.9%). In the study by Hatano et al. [6], some cases of tympanic membrane perforation and otitis media with effusion occurred during the follow-up period.

Canal wall down mastoidectomy with soft posterior canal wall reconstruction significantly lowers the cholesteatoma recurrence. The 3.57% (1/28 cases) of cholesteatoma recurrence rate in the Group A CWR group is an acceptable outcome in the 6-month follow-up period. It is comparable to the study by Dornhoffer et al. [2, 3]. The average follow-up period in his study was 7.8 years (6.7–9 years), with recurrence occurring in 8 ears (16%). He considered the results to be acceptable long-term results.

In the study by Takahashi et al. [12], there was no significant difference in the incidence of residual and recurrent cholesteatoma between the two groups. Postoperative pure tone audiometry was done at 3 months and 6 months after surgery in every case.

Pre-op A.B. gap

In Group A, mean± S.D., preoperative A.B. gap was 40.39±6.07dB.

In Group B, mean± S.D., preoperative A.B. gap was 42.22±6.68 dB.

Postoperatively at 3 months

In Group A, mean± S.D., AB gap was 22.32±4.32dB.

In Group B, mean± S.D., AB gap was 30.22±5.86dB.

Postoperatively at 6 months

In Group A, mean± S.D., AB gap was 15.32±4.79dB.

In Group B, mean± S.D., AB gap was 22.81±8.07dB.

Postoperatively, the A.B. gap was reduced in both Group A and Group B. There is a statistically significant reduction in postoperative A.B. gap since the p value < 0.05 at 3 months and 6 months.

In the present series, hearing improvement occurred in both groups, significantly reducing the postoperative A.B. gap in both groups. The hearing improvement was better in the posterior canal wall reconstruction group.

In the study by Takahashi et al. [12] in 2000, there was no significant difference in the two groups postoperative hearing.

Baek et al. [1] studied the efficacy of posterior canal wall reconstruction, using autologous auricular cartilage and bone pate in chronic otitis media with cholesteatoma. For all the 42 subjects, the mean preoperative and postoperative A.B. gap values were 29.4±12.8 dB and 23.4±11.7 dB, respectively. It represents a significant average improvement of 6.0 dB (p<0.05).

In the study by Dornhoffer [2, 3], C.W.R. was done in 75 patients, the recurrent disease occurred in 5%, and hearing improvement was statistically significant (p<0.05), average preoperative PTA=27.2 dB improving to 11.5 dB. No patient had worsened hearing.

Dornhoffer [2, 3] in 46 patients (50 ears), reconstruction was done using cymba cartilage. Average preop P.T.A. was 25.6±11.2 dB, short-term postoperative P.T.A. 11.0±5.7, and long-term post-operative P.T.A. 12.4±6.4 dB. There was a significant difference between pre-op and post-op values (p<0.5). Recurrent cholesteatoma was seen in 8 ears (16%), pressure-equalizing tube insertion was performed in 9 ears (18%), perforation was seen in 1 ear (2%), and poor hearing results required second-look surgery in 2 ears (4%).

Sadooghi [9] conducted a study to reevaluate the softwall reconstruction technique for CWD mastoidectomy. In his research, there was no recurrent cholesteatoma in the soft wall reconstruction group. He concluded that soft wall reconstruction is a safe method for eliminating the problems of radicalized mastoid cavities.

Period of epithelization, the time required to be dry ear, in Group A (CWR), mean ± S.D. was 49.28±6.62 days, and in Group B (CWD), it was 64.22±9.51 days. Since the p value = 0.001, i.e., p<0.05, there is a statistically significant difference in Group A and Group B epithelization.

Hence, there is early epithelization in group A soft wall reconstruction compared to the CWD and open groups.

Thus, the period of restriction from water activities is significantly lower in the C.W.R. group. The results of our study for a period of epithelization are similar to the study by Takahashi et al. [12]. The postoperative period to be dry ear was significantly shorter in the soft wall reconstruction group than in the canal wall down and open group (Student’s t test, t=2.99, p<0.01). There was no significant difference in the postoperative hearing or incidence of residual or recurrent cholesteatoma between the two groups. The limitation of this study is short-term follow-up.

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