Pediatric ENT Problems will be discussed.

Title

From Deaf Children to Local ENT Autonomy: Twenty Years of Pediatric Otology in Cambodia

Background

Chronic ear disease remains a major cause of preventable hearing loss in children living in low- and middle-income countries (LMICs). In Cambodia, the lack of ENT specialists, imaging facilities and surgical infrastructure initially limited access to adequate care. The ASEAR humanitarian program has provided pediatric otologic care for more than 20 years and offers a unique perspective on the evolution of hearing healthcare in a developing country.

Methods

We reviewed the evolution of the ASEAR program from 2000 to 2024 through three successive phases: establishment of a referral-based surgical program, development of local ENT training, and implementation of advanced otologic and hearing rehabilitation procedures. Historical surgical outcomes were compared with current practice after the emergence of trained Cambodian ENT surgeons and the introduction of cone-beam CT imaging.

Results

During the first phase, more than 5,000 patients were screened and over 700 ear procedures were performed. Children frequently presented with advanced chronic suppurative otitis media and cholesteatoma. Cholesteatoma represented one-third of operated cases and severe complications including facial paralysis, dead ear and intracranial infection were common. Because long-term follow-up was uncertain, disease eradication was prioritized through radical procedures.

The creation of local ENT residency programs and the training of Cambodian otologists, including Dr Sokdavy Touch, progressively transformed the model. The introduction of cone-beam CT imaging enabled more accurate staging and postoperative surveillance, allowing selected conservative cholesteatoma surgery and functional reconstruction. Current outcomes approach those reported in developed countries while reducing dependence on foreign surgical missions.

Seven bone-anchored hearing devices were implanted. Although hearing benefit was satisfactory in selected patients, a high rate of fixture loss and limited acceptance, particularly in unilateral hearing loss, highlighted the challenges of implantable hearing technologies in LMIC settings.

Conclusions

The major challenge in pediatric otology in LMICs is not only surgery but sustainable capacity building. Long-term improvements were achieved through infrastructure development, local specialist training, imaging availability and progressive transfer of expertise. The ultimate goal is to move from disease control toward durable hearing rehabilitation delivered by autonomous local teams.

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.