**Question:** A 30-year old male is having Attic cholesteatoma of left ear with lateral sinus thrombophlebitis. Which of the following will be the operation of choice?

A. Middle ear exploration + mastoidectomy + cholesteatoma removal
B. Extended mastoidectomy
C. Lateral sinus decompression
D. Total ear canal wall down mastoidectomy

**Core Concept:**
Attic cholesteatoma is a type of non-cancerous skin growth that occurs in the middle ear, typically affecting the attic region of the middle ear. This condition presents with complications such as lateral sinus thrombophlebitis, which is a serious complication resulting from the spread of bacteria from the middle ear to the adjacent structures, including the sinus.

**Why the Correct Answer is Right:**
The correct answer, D - Total ear canal wall down mastoidectomy, is chosen due to the complex nature of the patient's condition. In such cases, this type of mastoidectomy ensures complete removal of the cholesteatoma, thus preventing its recurrence and minimizing the risk of further complications. This procedure involves removing not only the middle ear but also the surrounding structures up to the ear canal wall. This is necessary for thorough cleaning of the middle ear cleft, mastoid antrum, and mastoid air cells to prevent bacterial spread and reduce the risk of complications like lateral sinus thrombophlebitis.

**Why Each Wrong Option is Incorrect:**

A - Middle ear exploration + mastoidectomy + cholesteatoma removal: While middle ear exploration and mastoidectomy are essential steps in treating cholesteatoma, removing only the cholesteatoma without addressing the ear canal wall down part of the procedure increases the chances of cholesteatoma recurrence.

B - Extended mastoidectomy: This procedure targets more extensive structures than necessary in this case, which increases the risk of complications such as facial nerve injury, damage to the ossicles, and hearing loss.

C - Lateral sinus decompression: Although decompression of the lateral sinus is important in cases of sinus thrombophlebitis, performing a mastoidectomy without addressing the cholesteatoma and ear canal wall down aspect of the surgery leads to the risk of cholesteatoma recurrence and incomplete treatment.

**Clinical Pearls:**

Complications related to cholesteatoma surgery and lateral sinus thrombophlebitis highlight the importance of a thorough mastoidectomy and addressing the ear canal wall down aspect of the surgery. Incomplete surgery can lead to cholesteatoma recurrence and further complications like sinus thrombophlebitis, facial nerve injury, ossicle damage, and hearing loss. Therefore, a comprehensive mastoidectomy, including ear canal wall down approach, is crucial to ensure complete removal of the cholesteatoma and prevent complications associated with incomplete surgery.