Cholesteatoma in 3-D.

1. In Shambaugh's primary acquired cholesteatoma, the surgical approach of choice is the direct endaural transcanal modified radical mastoidectomy and tympanoplasty in continuity. 2. In Shambaugh's classification of the secondary acquired cholesteatoma developing in a previously pneumatic mastoid with the infection of short duration, the postauricular transcortical mastoidectomy and facial recess approach and tympanoplasty in continuity is worthy of consideration if there is a reasonable possibility that the eustachian tube function may return to normal. 3. In Shambaugh's classification of a secondary acquired cholesteatoma in a large mastoid with the infection of long duration, there is probably cicatricial stenosis of the eustachian tube with a postauricular transcortical mastoidectomy and facial recess approach. It is probably a futile procedure because of the high incidence of recurrent attic retraction cholesteatoma requiring a secondary modified radical mastoidectomy. 4. Recurrent attic retraction cholesteatoma is subject to external reinfection and may cause a subperiosteal abscess or other complications many years after the primary surgery. 5. Residual cholesteatoma is the "bug bear" of any closed technique. This self-contained cyst is slow growing and may not become apparent for many years. Since it is not subject to reinfection, it is an insidious, destructive, silent lesion which may ultimately present itself as a postauricular pitting mass, erosion of the canal wall, facial paralysis, or a fistula in the labyrinth. 6. In invasive cholesteatoma and in long-standing secondary acquired cholesteatoma, the attempted preservation of the canal wall is a futile process and the surgeon is able to perform more accurate surgery with the direct primary transcanal approach to the mastoid.(ABSTRACT TRUNCATED AT 250 WORDS)