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Ear, Nose, and Throat Disorders

Cholesteatoma

A cholesteatoma is a skin growth that occurs in an abnormal location – in the middle ear behind the eardrum (tympanic membrane). It usually results from Eustachian tube dysfunction, which causes an ingrowth of the skin of the eardrum. Cholesteatomas often take the form of a cyst or pouch which sheds layers of old skin that build up inside the ear. Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear (ossicles). Hearing loss and discharge from the ear (otorrhea) can result from continued cholesteatoma growth.

A cholesteatoma usually occurs because of the Eustachian tube (the hearing tube lined with a mucous membrane) does not function well, leading to an infection in the middle ear. The tube conveys air from the back of the nose into the middle ear to equalize ear pressure or "clear the ears." When the tube works poorly, perhaps due to allergy, a cold, smoking, or sinusitis, the air in the middle ear is absorbed by the body, creating a partial vacuum in the ear. The vacuum pressure sucks in a pouch or sac by stretching the eardrum, especially areas weakened by previous infections. This sac often becomes a cholesteatoma. A rare congenital (present at birth) form of cholesteatoma can occur in the middle ear and elsewhere, such as in the nearby skull bones. However, the type of cholesteatoma associated with ear infections is most common.

Ear cholesteatomas can be dangerous and should never be ignored. Bone erosion can cause the infection to spread into the surrounding areas, including the inner ear and brain. If untreated, deafness, dizziness, facial nerve paralysis, brain abscess, meningitis, and death can occur.

Symptoms

Initially, the ear may drain, sometimes with a foul odor. As the cholesteatoma pouch enlarges, it can cause a full feeling or pressure in the ear, alongside hearing loss. (An ache behind or in the ear, especially at night, may cause significant discomfort.) Dizziness or muscle weakness on one side of the face (the side of the infected ear) can also occur. Any, or all, of these symptoms are good reasons to seek medical evaluation.

Diagnosis

Cholesteatoma is a serious but treatable ear condition, which can only be diagnosed by a medical examination. Persisting earache, ear drainage, ear pressure, hearing loss, dizziness, or facial muscle weakness signals the need for evaluation by an otolaryngologist-head and neck surgeon.

Treatment

Initial treatment may consist of a careful cleaning of the ear, antibiotics, and eardrops. Therapy aims to stop drainage in the ear by controlling the infection. The extent or growth characteristics of a cholesteatoma must also be evaluated.

Large or complicated cholesteatomas usually require surgical treatment to protect the patient from serious complications. Hearing and balance tests and CT scans (detailed x-rays) of the mastoid / temporal bone may be necessary. These tests are performed to determine the hearing level remaining in the ear and the extent of destruction the cholesteatoma has caused.

If surgery is necessary, a tympanomastoidectomy is usually performed, under general anesthesia. The primary purpose of the surgery is to remove the cholesteatoma and infection and achieve an infection-free, dry ear. Hearing preservation or restoration is the second goal of surgery. In cases of severe ear destruction, reconstruction may not be possible. Facial nerve repair or procedures to control dizziness are rarely required. Reconstruction of the middle ear is not always possible in one operation. A second operation may be necessary six to twelve months later. The second operation will attempt to restore hearing and, at the same time, inspect the middle ear space and mastoid for remaining cholesteatoma.

Follow-up office visits after surgical treatments are necessary and important, because cholesteatoma can recur at any time. There must be lifelong periodic ear examinations.

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Last Reviewed: Feb 15, 2008

Ravi N Samy, MD, FACS Ravi N Samy, MD, FACS
Assistant Professor of Otolaryngology, Director of Skull Base Surgery Fellowship, Director of Adults Cochlear Implantation Program
College of Medicine
University of Cincinnati

David  L Steward, MD David L Steward, MD
Professor of Otolaryngology
College of Medicine
University of Cincinnati