Canal Wall Down Reconstruction for Advanced and Revision Cholesteatoma: Disease Control and Anatomical Outcomes

Objective: To evaluate outcomes of canal wall down mastoidectomy with immediate posterior canal reconstruction (CWDR) for advanced and revision cholesteatoma, using a contemporaneous canal wall up (CWU) cohort as a non-randomised reference.

Methods: We reviewed a retrospective single-surgeon cohort of 54 ears operated for acquired cholesteatoma between 2020 and 2025: 24 underwent CWDR and 30 underwent CWU. Minimum follow-up was 12 months. Disease recurrence was defined clinically, at revision surgery, or by non-echo-planar diffusion-weighted MRI. Structural anatomical failure was defined as radical or radical-like cavity transformation. Disease severity was assessed using the ChOLE classification and a modified ChOL score excluding the frequently non-interpretable E component.

Results: CWDR ears had substantially greater baseline severity. Revision surgery was more common in CWDR than CWU (62.5% vs 26.7%, p=0.013), as were O3 ossicular destruction (83.3% vs 53.3%, p=0.024), bony dehiscence (83.3% vs 36.7%, p=0.001), and the predefined salvage phenotype (87.5% vs 30.0%, p<0.001). Disease recurrence did not differ significantly between groups (29.2% vs 23.3%, p=0.76), and median air-bone-gap change was 0 dB in both groups. Structural anatomical failure occurred only after CWDR (20.8% vs 0%, p=0.013). Modified ChOL showed a stronger exploratory recurrence signal than full ChOLE, while the E component was non-interpretable in 44% of ears.

Conclusion: In this severity-selected cohort, CWDR achieved disease-control and audiological outcomes similar to a CWU reference group despite greater baseline complexity. Structural anatomical failure should be reported separately from disease recurrence.