Dealing with cholesteatomas: open techniques/ canal wall down techniques/ endoscopic ear surgery will be discussed.

Title

Twenty Years of Cholesteatoma Management in Cambodia: Results, Evolution and Future Perspectives

Background

Management of middle ear cholesteatoma in low- and middle-income countries (LMICs) remains challenging because of delayed presentation, limited access to imaging, shortage of trained otologists and difficulties in long-term follow-up. Since 2000, the ASEAR humanitarian program has progressively developed otologic care in Cambodia, providing a unique opportunity to evaluate how surgical strategies evolve as local healthcare systems mature.

Methods

We reviewed twenty years of experience from the ASEAR otology program in Cambodia. The evolution of cholesteatoma management was analyzed through three successive phases: (1) establishment of a referral surgical model with radical disease eradication, (2) development of local surgical expertise and imaging resources enabling conservative surgery, and (3) implementation of functional hearing rehabilitation. Historical surgical outcomes from the first program period (2000–2010) were reviewed and integrated with organizational and technological developments achieved over the subsequent decade.

Results

During the initial phase, more than 5,000 patients were evaluated and over 700 ear surgeries were performed during 40 short surgical missions. A retrospective analysis included 380 operated patients with a mean age of 21–23 years. Cholesteatoma represented approximately one third of operated chronic ear diseases. Severe complications at presentation were frequent, including facial paralysis, dead ear, labyrinthine fistula and intracranial infection. Despite a structured follow-up network based on local health officers, 26% of patients were lost to follow-up. Consequently, canal wall down mastoidectomy became the standard approach for most cholesteatomas, prioritizing disease eradication and safe postoperative surveillance.

The second phase corresponded to the emergence of local ENT specialists, including surgeons trained through international collaborations. However, a major limitation remained the absence of temporal bone imaging. The acquisition and implementation of a cone-beam CT scanner three years ago represented a turning point, allowing preoperative staging, postoperative surveillance and the introduction of selected canal wall up procedures for limited cholesteatomas.

The current third phase focuses on hearing rehabilitation. As local expertise continues to increase, revision surgery and ossiculoplasty are progressively being introduced, shifting the objective from simple disease control toward functional restoration.

Conclusions

The optimal surgical strategy for cholesteatoma in LMICs evolves according to healthcare infrastructure, imaging availability and local surgical expertise. In the early stages of program development, canal wall down surgery remains the safest option because follow-up is uncertain. Once reliable imaging and trained local surgeons become available, conservative techniques can be safely introduced. The final stage of program maturation is functional hearing rehabilitation. Our twenty-year experience suggests that cholesteatoma management in LMICs should be viewed as a progressive developmental pathway rather than a fixed surgical doctrine.