OBJECTIVE: The surgical strategy of cholesteatomas is still controversial. This study aimed to compare the hearing improvement and determine the prognostic factors between endoscopic and microscopic ear surgery for attic cholesteatoma via a multicenter retrospective study.

METHODS: This retrospective study included 169 patients with attic cholesteatoma who received endoscopic ear surgery (EES) or microscopic ear surgery (MES) from 12 otorhinolaryngology centers. Hearing improvement between EES and MES was evaluated, including the postoperative pure tone average (PTA) and air-bone gap (A-B Gap), as well as the hearing threshold across the low-, mid-, and high-frequency. The success rate of grafts was collected. Linear regression was performed to access the prognostic value of preoperative PTA and A-B Gap. Patients were followed up for at least 3 years.

RESULTS: The graft success rate of EES was 89.66% (78/87) versus 80.49% (66/82) for MES. The postoperative PTA and A-B Gap demonstrated significant improvement in EES compared to MES (Post-PTA: t = 3.281, P = .001; Post-A-B Gap: t = 2.197, P = .029). In the EES group, there were 59 ears (67.82%) with a postoperative A-B Gap ≤20 dB HL, which revealed a higher rate of successful hearing outcomes in EES as opposed to MES (χ2 = 9.904, P = .019). There were significantly better hearing improvement, shorter surgical times, and lower hospital stays in EES for epitympanic cholesteatoma without stapes superstructure involvement. The preoperative AC ≤79 dB and/or preoperative A-B Gap ≤52 dB was associated with a better prognosis in EES for epitympanic cholesteatoma with stapes superstructure involvement.

CONCLUSIONS: EES showed higher graft success rate, better hearing improvement, shorter surgical times and hospital stays for attic cholesteatoma, particularly without stapes superstructure involvement. The range of preoperative PTA and A-B Gap have shown the prognostic value, which maybe a favorable surgical indication for EES or MES.