Learning Objectives: ï Meticulous pre-operative planning and discussion with multidisciplinary team. ï Availability of appropriate instruments and experienced theater staff. ï Proficiency in lateral skull base anatomy and surgery

Introduction: Surgical management of recurrent complex cholesteatomas can be highly challenging. Our busy otology service in northeast London caters to a unique mixed racial demographic group where there is a high preponderance of such cases .In this study we would like to share the challenges we faced and our subsequent learning journey.

Methods: We undertook a retrospective review of 156 cases of revision mastoid surgeries done between January 2009 and December 2015 in our otology unit in East London.

Results: Following a review of our cases, we found that the pathologies that made surgical management challenging included dehiscent sigmoid sinus, tegmen erosion, eroded bony facial canal and lateral semicircular canal. We hereby present our pre-operative management planning, operative techniques and post-operative outcome of these complex ear cases. We also share our experience of the individualised care of these complex patients using a multidisciplinary team approach.

Conclusions: Revision mastoid surgery is challenging. A multidisciplinary team consisting of the ENT surgeon, radiologist, neurosurgeon and senior anaesthetist is helpful for pre-operative planning of complex ear cases. Moreover, intra-operative use of oto-endoscope, KTP LASER, facial nerve monitor and post-operative availability of high dependency unit are important aspects to consider for safe and appropriate management of revision mastoid surgery.