{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:23:47Z","timestamp":1760059427016,"version":"build-2065373602"},"reference-count":44,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2025,6,12]],"date-time":"2025-06-12T00:00:00Z","timestamp":1749686400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Sapienza Progetti Ateneo medi 2024"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Cholesteatoma is a destructive middle ear pathology requiring precise surgical removal to prevent recurrence and preserve auditory function. The chemically assisted dissection (CADISS) system (AuXin Surgery, Ottignies-Louvain-la-Neuve, Belgium), based on Mesna (5%), was introduced to enhance tissue separation and minimize residual disease. Objective: This study aimed to compare the cleaning efficiency of CADISS-assisted dissection versus the conventional manual dissection of cholesteatoma from incus bone surfaces using quantitative ultrastructural analysis. Methods: This retrospective study evaluated 67 human incus samples collected during cholesteatoma surgery\u201435 treated with manual dissection and 32 with CADISS. Samples were imaged using variable pressure scanning electron microscopy (VP-SEM) in hydrated conditions. Clean area\/total area ratios were calculated and analyzed statistically using non-parametric tests. Postoperative MRI follow-up at 1 month was conducted to assess residual disease. Results: CADISS-assisted samples demonstrated significantly higher clean area\/total area ratios (mean: 0.2095 vs. 0.0478, p &lt; 0.0001). Qualitative imaging showed fewer residuals &gt; 1 mm in the CADISS group (9% vs. 77%). MRI follow-up revealed a lower recurrence rate in the CADISS group (3.1%) compared to manual dissection (11.4%). Conclusions: CADISS-assisted dissection provides superior cholesteatoma debris removal compared to manual methods, as evidenced by VP-SEM imaging and clinical follow-up. This technique may improve surgical outcomes and reduce recurrence risk in middle ear surgery.<\/jats:p>","DOI":"10.3390\/jcm14124192","type":"journal-article","created":{"date-parts":[[2025,6,12]],"date-time":"2025-06-12T11:47:07Z","timestamp":1749728827000},"page":"4192","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Improved Cholesteatoma Removal with CADISS: A Quantitative Ultrastructural Comparison Using VP-SEM"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3805-9505","authenticated-orcid":false,"given":"Michela","family":"Relucenti","sequence":"first","affiliation":[{"name":"Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University of Rome, Via Alfonso Borelli 50, 00161 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-2997-9181","authenticated-orcid":false,"given":"Ubaldo","family":"Romeo Plastina","sequence":"additional","affiliation":[{"name":"Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University of Rome, Via Alfonso Borelli 50, 00161 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pasquale","family":"Fino","sequence":"additional","affiliation":[{"name":"Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Dermatology Clinic, University of Rome \u201cLa Sapienza\u201d, 00185 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chiara","family":"Filippi","sequence":"additional","affiliation":[{"name":"Department of Neuroscience, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0740-0384","authenticated-orcid":false,"given":"Maurizio","family":"Barbara","sequence":"additional","affiliation":[{"name":"Department of Neuroscience, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Edoardo","family":"Covelli","sequence":"additional","affiliation":[{"name":"Department of Neuroscience, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1","DOI":"10.5152\/iao.2017.3363","article-title":"EAONO\/JOS joint consensus statements on the definitions, classification and staging of middle ear cholesteatoma","volume":"13","author":"Yung","year":"2017","journal-title":"J. Int. Adv. Otol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"266","DOI":"10.5152\/iao.2017.3411","article-title":"Cholesteatoma definition and classification: A literature review","volume":"13","author":"Rutkowska","year":"2017","journal-title":"J. Int. Adv. Otol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1007\/s12105-018-0915-5","article-title":"Cholesteatoma pearls: Practical points and update","volume":"12","author":"Castle","year":"2018","journal-title":"Head Neck Pathol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1186\/s13244-024-01761-1","article-title":"Beyond the otoscope: An imaging review of congenital cholesteatoma","volume":"15","author":"Vangrinsven","year":"2024","journal-title":"Insights Imaging"},{"key":"ref_5","first-page":"e63315","article-title":"Endoscopic cholesteatoma surgery","volume":"179","author":"Beckmann","year":"2022","journal-title":"J. Vis. Exp."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e370","DOI":"10.1055\/s-0043-1768202","article-title":"Inside-Out Transcanal Endoscopic Mastoidectomy: Literature Revision","volume":"27","author":"Bessa","year":"2023","journal-title":"Int. Arch. Otorhinolaryngol."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Early, S., Saad, M.A., Mallidi, S., Mansour, A., Seist, R., Hasan, T., and Stankovic, K.M. (2022). A fluorescent photoimmunoconjugate for imaging of cholesteatoma. Sci. Rep., 12.","DOI":"10.1038\/s41598-022-22072-9"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1097\/MAO.0000000000002876","article-title":"Systematic Review of Endoscopic Ear Surgery Outcomes for Pediatric Cholesteatoma","volume":"42","author":"Basonbul","year":"2021","journal-title":"Otol. Neurotol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1121","DOI":"10.1177\/0194599816631941","article-title":"Pediatric endoscopic cholesteatoma surgery","volume":"154","author":"Hunter","year":"2016","journal-title":"Otolaryngol. Head Neck Surg."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Tsuchida, K., Takahashi, M., Nakazawa, T., Kurihara, S., Yamamoto, K., and Yamamoto, Y. (2024). Augmented reality-assisted transcanal endoscopic ear surgery for middle ear cholesteatoma. J. Clin. Med., 13.","DOI":"10.3390\/jcm13061780"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e46","DOI":"10.1055\/s-0035-1571205","article-title":"Giant petrous bone cholesteatoma: Combined microscopic surgery and an adjuvant endoscopic approach","volume":"77","author":"Iannella","year":"2016","journal-title":"J. Neurol. Surg. Rep."},{"key":"ref_12","first-page":"184230","article-title":"Wholly endoscopic permeatal removal of a petrous apex cholesteatoma","volume":"2014","author":"Kanzara","year":"2014","journal-title":"Case Rep. Otolaryngol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1819","DOI":"10.1097\/MAO.0000000000000514","article-title":"Chemically assisted dissection by means of Mesna in cholesteatoma surgery","volume":"35","author":"Vincenti","year":"2014","journal-title":"Otol. Neurotol."},{"key":"ref_14","first-page":"63","article-title":"The effects of Mesna on the facial nerve, an experimental animal study","volume":"14","author":"Kum","year":"2018","journal-title":"J. Int. Adv. Otol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1159\/000091472","article-title":"Practical use of Mesna in atelectatic ears and adhesive otitis media","volume":"68","author":"Bayazit","year":"2006","journal-title":"ORL"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"150","DOI":"10.4103\/2152-7806.165765","article-title":"The effects of sodium-2-mercaptoethanesulfonate application on the neural and neurovascular tissues: An experimental animal study","volume":"6","author":"Ant","year":"2015","journal-title":"Surg. Neurol. Int."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Rosenblatt, J., Reitzel, R., Viola, G., Vargas-Cruz, N., Selber, J., and Raad, I. (2017). Sodium mercaptoethane sulfonate reduces collagenolytic degradation and synergistically enhances antimicrobial durability in an antibiotic-loaded biopolymer film for prevention of surgical-site infections. BioMed Res. Int., 2017.","DOI":"10.1155\/2017\/3149536"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1752","DOI":"10.1007\/s00586-008-0802-y","article-title":"Effectiveness of a mucolythic agent as a local adjuvant in revision lumbar spine surgery","volume":"17","author":"Denaro","year":"2008","journal-title":"Eur. Spine J."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1517\/13543784.2010.485192","article-title":"Mesna for chemically assisted tissue dissection","volume":"19","author":"Casale","year":"2010","journal-title":"Expert Opin. Investig. Drugs"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"51","DOI":"10.14639\/0392-100X-N0920","article-title":"A clinical and histopathological comparison of saline, adrenaline and 2-mercaptoethanesulfonate (Mesna) in mucoperichondrial elevation: Which is superior?","volume":"41","author":"Koca","year":"2021","journal-title":"Acta Otorhinolaryngol. Ital."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1177\/01455613211042946","article-title":"Early non-EPI DW-MRI after cholesteatoma surgery","volume":"103","author":"Barbara","year":"2024","journal-title":"Ear Nose Throat J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1080\/00016489.2022.2094464","article-title":"Proposal of a magnetic resonance imaging follow-up protocol after cholesteatoma surgery: A prospective study","volume":"142","author":"Covelli","year":"2022","journal-title":"Acta Oto-Laryngol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"9371516","DOI":"10.1155\/2020\/9371516","article-title":"SEM BSE 3D Image Analysis of Human Incus Bone Affected by Cholesteatoma Ascribes to Osteoclasts the Bone Erosion and VP-SEM dEDX Analysis Reveals New Bone Formation","volume":"2020","author":"Relucenti","year":"2020","journal-title":"Scanning"},{"key":"ref_24","first-page":"219","article-title":"Microplicae-like structures of the fallopian tube in postmenopausal women as shown by electron microscopy","volume":"21","author":"Correr","year":"2006","journal-title":"Histol. Histopathol."},{"key":"ref_25","first-page":"219","article-title":"Cumulus oophorus extracellular matrix in the human oocyte: A role for adhesive proteins","volume":"110","author":"Relucenti","year":"2005","journal-title":"Ital. J. Anat. Embryol."},{"key":"ref_26","first-page":"2","article-title":"Using Cliff\u2019s Delta as a non-parametric effect size measure: An accessible web app and R tutorial","volume":"29","author":"Meissel","year":"2024","journal-title":"Pract. Assess. Res. Eval."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"372","DOI":"10.1177\/000348940010900406","article-title":"Surgical planning of the treatment of cholesteatoma and postoperative follow-up","volume":"109","year":"2000","journal-title":"Ann. Otol. Rhinol. Laryngol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1034","DOI":"10.1177\/0194599817729136","article-title":"Residual cholesteatoma during second-look procedures following primary pediatric endoscopic ear surgery","volume":"157","author":"Cohen","year":"2017","journal-title":"Otolaryngology"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"466","DOI":"10.1097\/MAO.0000000000003476","article-title":"Comparative analysis of recidivism after endoscopic and microscopic-based cholesteatoma resection","volume":"43","author":"Manzoor","year":"2022","journal-title":"Otol. Neurotol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"980","DOI":"10.1002\/lary.25591","article-title":"The disease recurrence rate after the canal wall up or canal wall down technique in adults","volume":"126","author":"Kerckhoffs","year":"2015","journal-title":"Laryngoscope"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1426","DOI":"10.3906\/sag-1904-109","article-title":"Canal wall down versus canal wall up surgeries in the treatment of middle ear cholesteatoma","volume":"49","author":"Karamert","year":"2019","journal-title":"Turk. J. Med. Sci."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2867","DOI":"10.1002\/lary.27258","article-title":"Clinical and cost utility of an intraoperative endoscopic second look in cholesteatoma surgery","volume":"128","author":"Bennett","year":"2018","journal-title":"Laryngoscope"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"914","DOI":"10.1177\/0194599816630548","article-title":"Biofilm\u2019s role in chronic cholesteatomatous otitis media","volume":"154","author":"Galli","year":"2016","journal-title":"Otolaryngology"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Popescu, C., V\u0103ru\u021b, R.M., Puticiu, M., Belghiru, V.I., Banicioiu, M., Rotaru, L.T., Popescu, M., Cosmin, A.C., and Popescu, A.I.S. (2024). Comprehensive management of cholesteatoma in otitis media: Diagnostic challenges, imaging advances, and surgical outcome. J. Clin. Med., 13.","DOI":"10.3390\/jcm13226791"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1017\/S0022215109992763","article-title":"Acquired cholesteatoma pathogenesis: Stepwise explanations","volume":"124","author":"Louw","year":"2010","journal-title":"J. Laryngol. Otol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1205","DOI":"10.1002\/lary.25048","article-title":"Systematic review of outcomes following observational and operative endoscopic middle ear surgery","volume":"125","author":"Kozin","year":"2015","journal-title":"Laryngoscope"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"104718","DOI":"10.1016\/j.amsu.2022.104718","article-title":"The utility of the CADISS\u00ae system in the dissection of epidural fibrosis in revision lumbar spine surgery (A case series)","volume":"83","author":"Makhchoune","year":"2022","journal-title":"Ann. Med. Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1002\/ohn.1025","article-title":"Outcomes in Pediatric Cholesteatoma","volume":"172","author":"Miller","year":"2025","journal-title":"Otolaryngol. Head Neck Surg."},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Lin, L.-J., Chen, B.-C., Chen, C.-Y., Chen, P.-R., and Chou, Y.-F. (2024). Ossicular Reconstruction with Various Degrees of Malleus Preservation in Patients With Chronic Otitis Media. Ear Nose Throat J., ahead of print.","DOI":"10.1177\/01455613241230843"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1016\/j.bjorl.2018.09.005","article-title":"Ossicular chain reconstruction in chronic otitis media: Hearing results and analysis of prognostic factors","volume":"86","author":"Kotzias","year":"2020","journal-title":"Braz. J. Otorhinolaryngol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1097\/MAO.0b013e31818201af","article-title":"Audiologic results of surgery for cholesteatoma: Short- and long-term follow-up of influential factors","volume":"29","author":"Stankovic","year":"2008","journal-title":"Otol. Neurotol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"2568","DOI":"10.1002\/lary.23510","article-title":"How long is long enough to follow up children after cholesteatoma surgery? A 29-year study","volume":"122","author":"Kuo","year":"2012","journal-title":"Laryngoscope"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e12522","DOI":"10.7717\/peerj.12522","article-title":"Long-term follow-up of applying autologous bone grafts for reconstructing tympanomastoid defects in functional cholesteatoma surgery","volume":"9","author":"Lan","year":"2021","journal-title":"PeerJ"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1016\/j.ijporl.2017.12.016","article-title":"The anatomic applicability of transcanal endoscopic ear surgery in children","volume":"105","author":"Sun","year":"2018","journal-title":"Int. J. Pediatr. Otorhinolaryngol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/12\/4192\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:50:53Z","timestamp":1760032253000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/12\/4192"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,12]]},"references-count":44,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["jcm14124192"],"URL":"https:\/\/doi.org\/10.3390\/jcm14124192","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2025,6,12]]}}}