Cholesteatoma Classification and external resources
Cholesteatoma ICD-10 H71 ICD-9 385.32 DiseasesDB 2553 MedlinePlus 001050 eMedicine ped/384 ent/220 MeSH D002781 Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. Although these are not strictly speaking tumours or cancers they can still cause significant problems because of their erosive and expansile properties resulting in the destruction of the ossicles as well as their possible spread through the base of the skull into the brain. They are also often infected and result in chronically draining ears. Contents [hide] 1 Classification and Pathogenesis 2 Acquired Cholesteatoma 3 Epidemiology 4 Symptoms 5 Signs 6 Treatment o 6.1 General aims of treatment o 6.2 Surgical strategies 7 Prognosis 8 See also 9 References 10 External links Classification and Pathogenesis[edit] There are two types: congenital and acquired. Acquired cholesteatomas, which are more common, can be caused by pathological alteration of the ear drum leading to accumulation of keratin within the middle ear. Less commonly the disease may be a developmental abnormality, when it grows from birth behind the ear drum, in the form of a keratin-filled cyst. [1]
Congenital cholesteatoma- it arrises from the embryonic epidermal crest . cong cholesteatoma occurs at three important site- middle ear Petrous appex Cerebropontine angle. Keratin-filled cysts that grow medial to the tympanic membrane result either from birth abnormality, trauma or metaplasia. If they fulfill the following criteria they are considered to be congenital: [1]
mass medial to the tympanic membrane normal tympanic membrane no previous history of ear discharge, perforation or ear surgery Congenital cholesteatomas are more often found in the anterior aspect of the ear drum, and a vestigial structure, theepidermoid formation, from which congenital cholesteatoma may originate, has been identified in this area. [2]
Acquired Cholesteatoma[edit] More commonly, keratin accumulates in a pouch of tympanic membrane which extends into the middle ear space. This abnormal folding or 'retraction' of the tympanic membrane arises in one of the following ways: Wittmaack's theory : Invagination of tympanic membrane from the attic or posterosuperior part of pars tensa in the form of retraction pockets lead to the formation of cholesteatoma. [3]
Ruedi's theory : The basal cells of germinal layer of skin proliferate under the influence of infection and lay down keratinising squamous epithelium. [4]
Habermann's theory: The epithelium from the meatus or outer drum surface grows into the middle ear through a pre-existing perforation and form cholesteatoma. [5]
Cholesteatoma may also arise as a result of metaplasia of the middle ear mucosa [6] or implantation following trauma. Epidemiology[edit] In one study, the number of new cases of cholesteatoma in Iowa was estimated in 19756 to be just under one new case per 10,000 citizens per year. [7] Cholesteatoma affects all age groups, from infants through to the elderly. The peak incidence occurs in the second decade. [7]
Symptoms[edit] The majority (98%) of patients with cholesteatoma have ear discharge or hearing loss or both in the affected ear. Other more common conditions, such as otitis externa may also present with these symptoms, but cholesteatoma is much more serious and should not be overlooked. If a patient presents to a doctor with ear discharge and hearing loss, the doctor should consider the patient to have cholesteatoma until the disease is definitely excluded. Other less common symptoms (all less than 15%) of cholesteatoma may include: pain, balance disruption, tinnitus, ear ache,headaches and bleeding from the ear. There can also be facial nerve weakness. Balance symptoms in the presence of a cholesteatoma raises the possibility that the cholesteatoma is eroding the balance organs, which form part of the inner ear. Signs[edit] On initial inspection, an ear canal full of discharge may be all that is visible. Until the doctor has cleaned the ear and inspected the entire tympanic membrane, cholesteatoma cannot be either confirmed or excluded. Once the debris is cleared, cholesteatoma can give rise to a number of appearances. If there is significant inflammation, the tympanic membrane may be partially obscured by an aural polyp. If there is less inflammation, the cholesteatoma may present the appearance of 'semolina' discharging from a defect in the tympanic membrane. The posterior and superior parts of the tympanic membrane are most commonly affected. If the cholesteatoma has been dry, the cholesteatoma may present the appearance of 'wax over the attic'. The attic is just above the ear drum. The patient may commonly also have clinical signs of conductive hearing loss. Less frequently, there may be signs of imbalance or facial weakness. If untreated, a cholesteatoma can eat into the three small bones located in the middle ear (the malleus, incus and stapes, collectively called ossicles), which can result in nerve deterioration, deafness, imbalance and vertigo. It can also affect and erode, through the enzymes it produces, the thin bone structure that isolates the top of the ear from the brain, as well as lay the covering of the brain open to infection with serious complications (rarely even death due to brain abscess andsepticemia). Both the acquired as well as the congenital types of the disease can affect the facial nerve that extends from the brain to the face and passes through the inner and middle ear and leaves at the anterior tip of the mastoid bone, and then rises to the front of the ear and extends into the upper and lower face. Treatment[edit] Cholesteatoma is a persistent disease. Once the diagnosis of cholesteatoma is made in a patient who can tolerate a general anesthetic, the standard treatment is to surgically remove the growth. General aims of treatment[edit] The challenge of cholesteatoma surgery is to permanently remove the cholesteatoma whilst retaining or reconstructing the normal functions of the structures housed within the temporal bone. The general objective of cholesteatoma surgery has two parts. It is both directed against the underlying pathology and directed towards maintaining the normal functions of the temporal bone. These aims are conflicting and this makes cholesteatoma surgery extremely challenging. Sometimes, the situation results in a clash of surgical aims. The need to fully remove a progressive disease like cholesteatoma is the surgeon's first priority. Preservation of hearing is secondary to this primary aim. If the disease can be removed easily so that there is no increased risk of residual disease, then the ossicles may be preserved. If the disease is difficult to remove, so that there is an increased risk of residual disease, then removal of involved ossicles in order to fully clear cholesteatoma has generally been regarded as necessary and reasonable. In other words, the aims of cholesteatoma treatment form a hierarchy. The paramount objective is the complete removal of cholesteatoma. The remaining objectives, such as hearing preservation, are subordinate to the need for complete removal of cholesteatoma. This hierarchy of aims has led to the development of a wide range of strategies for the treatment of cholesteatoma. Surgical strategies[edit] The variation in technique in cholesteatoma surgery results from each surgeons' judgment whether to retain or remove certain structures housed within the temporal bone in order to facilitate the removal of cholesteatoma. This typically involves some form of mastoidectomy which may or may not involve removing the posterior ear canal wall and the ossicles. Removal of the canal wall facilitates the complete clearance of cholesteatoma from the temporal bone in three ways: 1. it removes a large surface onto which cholesteatoma may be adherent; 2. it removes a barrier behind which the cholesteatoma may be hidden; 3. it removes an impediment to the introduction of instruments used for the removal of cholesteatoma. Thus removal of the canal wall provides one of the most effective strategies for achieving the primary aim of cholesteatoma surgery, the complete removal of cholesteatoma. However, there is a trade-off, since the functional impact of canal wall removal, is also important. The removal of the ear canal wall results in: a space, the "mastoid cavity", which is less likely than the original ear canal to resist infection; exposure of the ossicles, which may allow the subsequent formation of a new cholesteatoma deep to the ossicles. To prevent this, these ossicles must be removed, which may diminish the patient's hearing. The formation of a mastoid cavity by removal of the canal wall is the simplest and most effective procedure for facilitating the removal of cholesteatoma, but may bestow the most lasting infirmity due to loss of ear function upon the patient treated in this way. The following strategies are employed to mitigate the effects of canal wall removal: 1. careful design and construction of the mastoid cavity. This is essential for the health and integrity of the protective sheet of migrating, keratising epithelium which lines the distorted ear canal. This requires the surgeon to saucerise the cavity. A high facial ridge and an inappropriately small cartilaginous meatus are obstructions to epithelial migration and are particularly high risk factors for failure of the self-cleaning mechanism of the external ear. [8]
2. partial obliteration of the mastoid cavity. This can be performed using a wide range of materials. Many of these resorb in time, which means that the long term results of such surgery are poorer than the short term results. [9]
3. reconstruction of the ear canal wall. Canal wall reconstruction has been performed using ear canal skin alone, fascia, cartilage, titanium as well as by replacing the original intact wall. If the reconstruction is poorly performed, it may result in a high rate of recurrent cholesteatoma. [10]
4. preservation of the ear canal wall. If poorly performed, it may result in a high rate of both residual and recurrent cholesteatoma. [11]
5. reconstruction of the chain of hearing bones. [12]
Clearly, preservation and restoration of ear function at the same time as total removal of cholesteatoma requires a high level of surgical expertise. Prognosis[edit] It is important that the patient attend periodic follow-up checks, because even after careful microscopic surgical removal, cholesteatomas may recur. Such recurrence may arise many years, or even decades, after treatment. A residual cholesteatoma may develop if the initial surgery failed to completely remove the original; residual cholesteatomas typically become evident within the first few years after the initial surgery. A recurrent cholesteatoma is a new cholesteatoma that develops when the underlying causes of the initial cholesteatoma are still present. Such causes can include, for example, poor eustachian tube function, which results in retraction of the ear drum, and failure of the normal outward migration of skin. [13]
In a retrospective study of 345 patients with middle ear cholesteatoma operated on by the same surgeon, the overall 5-year recurrence rate was 11.8%. [14] In a different study with a mean follow-up period of 7.3 years, the recurrence rate was 12.3%, with the recurrence rate being higher in children than in adults. [15]
See also[edit] Chronic suppurative otitis media Otic polyp References[edit] 1. ^ Jump up to: a
b Derlacki EL, Clemis JD (1965). "Congenital cholesteatoma of the middle ear and mastoid". Annals of Otology, Rhinology, and Laryngology 74 (3): 706727.PMID 5846535. 2. Jump up^ Michaels L (1988). "Origin of congenital cholesteatoma from a normally occurring epidermoid rest in the developing middle ear". Int J Pediatr Otorhinolaryngol 15 (1): 51 65.doi:10.1016/0165-5876(88)90050-X. PMID 3286554. 3. Jump up^ "Chronic suppurative otitis media". ENT. Retrieved 12 January 2013. 4. Jump up^ Rueedi L (1959). "Cholesteatoma formation in the middle ear in animal experiments". Acta Oto-Laryngologica 50 (3 4): 233242. doi:10.3109/00016485909129191.PMID 13660782. 5. Jump up^ Haberman J (1888). "Zur Entstehung des Cholesteatoms des Mittelohrs". Archiv fuer Ohrenheilkunde 27: 4351. 6. Jump up^ Sade, J; Babiacki, A; Pinkus, G (1983). "The metaplastic and congenital origin of choesteatoma". Acta Otolaryngologica 96 (12): 119 129.doi:10.3109/00016488309132882. PMID 6193677. 7. ^ Jump up to: a
b Harker LA (1977). Cholesteatoma: an incidence study in Cholesteatoma First International Conference. Birmingham, Alabama, USA: Aesculapius Publishing Company. pp. 308309. ISBN 0-912684-11-9. 8. Jump up^ Wormald P,J Nilssen EL (1998). "The facial ridge and the discharging mastoid cavity". Annals of Otology, Rhinology, and Laryngology 108 (1): 9296. PMID 9432074. 9. Jump up^ Black B (1995). "Mastoidectomy elimination".Laryngoscope 105 (12 pt 2 Suppl 76): 1 30.doi:10.1288/00005537-199512000-00023.PMID 7500804. 10. Jump up^ Deveze A et al (2010). "Rehabilitation of canal wall down mastoidectomy using a titanium ear canal implant". Otol Neurotol 31 (2): 220 224.doi:10.1097/MAO.0b013e3181c9960d.PMID 20009781. 11. Jump up^ Jansen C (1968). "The combined approach for tympanoplasty (report on 10 years' experience)". J Laryngol Otoll 82 (9): 779 793. doi:10.1017/S0022215100069462.PMID 4878658. 12. Jump up^ Austin DF (1971). "Ossicular reconstruction". Archives of Otolaryngol 94 (6): 525 535.doi:10.1001/archotol.1971.00770070825007.PMID 5129224. 13. Jump up^ Fairley, James (7 November 2010). "Cholesteatoma and mastoid surgery". entkent.com. Retrieved 29 December 2012. 14. Jump up^ Mishiro, Y.; Sakagami, M.; Kitahara, T.; Kondoh, K.; Okumura, S. (September 2008). "The investigation of the recurrence rate of cholesteatoma using Kaplan-Meier survival analysis". Otology & Neurotology (American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology) 29 (6): 803 6. doi:10.1097/MAO.0b013e318181337f.PMID 18636031. 15. Jump up^ Vartiainen, Eero (1995). "Factors associated with recurrence of cholesteatoma". The Journal of Laryngology & Otology 109 (7). doi:10.1017/S0022215100130804. Information on Cholesteatomas Functional Orthogonal Cholesteatoma Surgery [hide] V T E Diseases of the ear and mastoid process (H60H99, 380389)
Outer ear Otitis externa Otomycosis
Middle ear and mastoid Otitis media Mastoiditis Bezold's abscess Gradenigo's syndrome Tympanosclerosis Cholesteatoma Perforated eardrum
Inner ear and central pathways Common pathway Labyrinthitis/Otitis interna
Other Auditory processing disorder Spatial hearing loss
M: EAR anat (e/p)/phys/devp noco/cong, epon proc, drug (S2)
ENTkent
Private medical services for adults and children with Ear, Nose and Throat conditions. 01233 642244
powered by
Home
Medical Information
Services and Fees
About Us
Appointments
Contact Cholesteatoma and mastoid surgery Mr James W Fairley BSc MBBS FRCS MS Consultant ENT Surgeon Contents [show] 2007 2014 JW Fairley Last updated 16 August 2014 Disclaimer All information and advice on this website is of a general nature and may not apply to you. This medical information is provided to enhance and support, not replace, individual advice from a qualified medical practitioner. Please see our Terms of Use. What is cholesteatoma? Cholesteatoma left ear. The disease has eroded the bone above and behind the upper part of the eardrum, the attic. The eardrum is also known as the tympanic membrane. I took this picture in 1988 as part of a research project into the development of cholesteatoma using a Storz Hopkins rod tele-otoscope, Xenon 300W light source, and an Olympus OM-1 SLR camera with Fujichrome 400ASA 35mm slide film. Key: c = cholesteatoma tm = tympanic membrane (eardrum) Cholesteatoma (ker-less-tea-a-toe-ma) is a progressive destructive ear disease. Most cases occur in children and young adults, but it can affect any age. Skin builds up in layers and erodes the bone of the middle ear and mastoid. In its early stages, cholesteatoma tends to attack the ossicles, the small bones conducting sound from the eardrum to the inner ear. This causes partial deafness, sometimes with unpleasant smelling discharge and pain. If the disease progresses, it can erode the inner ear causing total and permanent deafness andtinnitus. The inner ear also contains the balance organ. If cholesteatoma erodes into the balance organ, vertigo, a severe form of dizziness, results. Cholesteatoma can also attack the facial nerve causing facial paralyis. In rare cases the disease erodes upwards. The roof of the ear is the floor of the brain. If this thin plate of bone is breached, meningitis, brain abscess and death can result. The cholesteatoma is made of layers of dead skin, like an onion. Only the outer layer, known as the matrix, contains live growing skin cells. Cholesteatoma is the most serious form of chronic ear infection. It is not a tumour, though it can behave like one. It is not cancer and never spreads widely throughout the body though it can cause quite enough trouble by its local destructive effects. In most cases, the progress of cholesteatoma is slow. It can take years or even decades to eat its way slowly through the structures of the ear. Rapidly progressive disease, over a time course of a few months and sometimes weeks, is commoner in children and in the presence of active acute infection.
The outer and middle ear work like an old mechanical gramophone in reverse. They collect sound energy, and concentrate it onto the small area of the stapes footplate The normal ear and hearing The human ear is divided into three parts: outer ear middle ear inner ear Outer ear The outer ear consists of the pinna and the ear canal. The outer ear funnels sound waves in air to the eardrum. Eardrum (tympanic membrane) Normal left eardrum (tympanic membrane) The eardrum is a paper-thin membrane, shaped like a miniature satellite dish, 8-10 mm diameter. The tympanic membrane forms the boundary between outer and middle ear. Middle ear The eardrum vibrates when sounds arrive through the external ear canal. The vibrations are transmitted to the inner ear via three small bones (ossicles) suspended in the middle ear. Ossicles
Abnormally thin right eardrum damaged by glue ear and showing ossicles malleus incus andstapes The three little bones (oss-i-culls) are malleus (mal-ee-us) shaped like a hammer incus (ink-us) shaped like an anvil stapes (stay-peas) shaped like a stirrup Their job is to concentrate the sound energy, collected by the relatively large area of the eardrum, onto the tiny footplate of the stapes. The outer and middle ear work like an old mechanical gramophone in reverse. The gramophone needle picks up vibrations from the grooves in the record, passes them to a vibrating membrane, then into the large horn, and so to the outside world. The outer and middle ear collect sound from the outside world and concentrate it down to the stapes footplate. The footplate moves like a piston in the oval window, the opening of the inner ear. Inner ear The inner ear has two parts, the cochlea and the vestibular labyrinth. Cochlea The cochlea is the hearing part of the inner ear. It is a biological microphone. Sound vibrations are turned into electrical signals and sent to the brain in the nerve of hearing. Vestibular labyrinth The vestibular labyrinth of the inner ear is concerned with balance. Disturbance of the balance organ of the inner ear can cause vertigo. Eustachian tube The Eustachian tube connects the middle ear with the back of the nose. To hear normally, the eardrum and ossicles must be able to move easily. For this to occur, the middle ear must contain air at the same atmospheric pressure as the outer ear. Air in the middle ear comes from the back of the nose, via the Eustachian tube. The job of the Eustachian tube is to ventilate the middle ear, keeping the pressure in the middle ear the same as in the outer ear. Most middle ear diseases, including cholesteatoma, are associated with poor Eustachian tube function. The health of the middle ear depends on the Eustachian tube working properly. Causes of cholestatoma Cholesteatoma is skin in the wrong place. The skin that should be on the outside of the eardrum is in the middle ear. Like skin all over the body, the surface skin cells of the eardrum are dead. They are constantly replaced by new cells growing underneath. A snake sheds its outer layer of dead skin all in one go. We humans shed it a bit at a time, in flakes. Most of the dust in your house is made up of flakes of dead skin that have dropped off. If flakes of skin kept dropping off inside your ear canal, they would end up blocking it. So, the normal ear has a special way to get rid of the dead skin layers. The skin grows in such a way that the outer layers are slowly moved outwards, like a conveyor belt. If you paint a dot of ink in the middle of someones eardrum, then go back a week later and look at it, it will have moved outwards. Gradually, over a few weeks, it will work its way all the way out along the ear canal. In cholesteatoma, this normal outward movement of dead skin fails. Layer upon layer of dead skin builds up. But there shouldnt be any skin in the middle ear, it should be on the outside of the eardrum, in the outer ear. So how does the skin get into the middle ear? Atelectasis (ate-eel-ECK-ta-sis) The eardrum is thin and sucked inwards, like cling film over the ossicles, by long term failure of the Eustachian tube to ventilate the middle ear. The patient had a long history of glue ear. This is not yet cholesteatoma, there is no build-up of skin layers, normal outward migration of skin is still happening and the retraction is self-cleaning. An ear like this might or might not progress to cholesteatoma. Key: m = malleus i = incus s = stapes (STAY-peas) The commonest way for it to get there is for it to be sucked in. A partial vacuum sucks the eardrum inwards. The air pressure in the middle ear falls if the Eustachian tube isnt working properly. This sucks the eardrum inwards. The upper part of the eardrum, the attic, is thinner and weaker than the the lower part. It gets sucked in and forms a retraction pocket. Any part of the eardrum can form a retraction pocket, but they are commonest in the attic because the eardrum is naturally thinner and weaker there. Not all retraction pockets will progress to cholesteatoma, but some will. Normally, the skin of the eardrum migrates slowly outwards, like a very slow moving conveyor belt. The retraction pockets that progress to cholesteatoma are those in which the conveyor belt stops. Shed layers of dead skin begin to build up, forming layer upon layer, like an onion. Sometimes the whole of the eardrum is weak and becomes sucked in, covering the ossicles like cling film. This is called atelectasis. Most cholesteatomas start from a damaged, thinned and weakened eardrum that has been sucked inwards. Another way that skin can get into the middle ear is for it to be blown in, by a pressure wave such as an explosion. Cholesteatoma does occur in bomb blast victims, who have had their eardrums perforated and blown inwards. Another way that skin from the outside of the eardrum could get into the middle ear is for it to be pushed in by surgery, such as fitting grommets. This is rare. Cases of cholesteatoma associated with grommets are more likely to be due to an early cholesteatoma being missed when the grommets are fitted. It is not unusual for retraction pockets and glue ear to co-exist, since both conditions are caused by failure of the Eustachian tube to properly ventilate the middle ear. Occasionally a cholesteatoma develops behind a healthy eardrum from some skin cells left behind during the development of the ear in the womb. This second kind of congenital cholesteatoma is much rarer, it presents in early childhood. Some specialists believe that cholesteatoma can develop from non-skin cells in the middle ear that turn into skin because they are chronically irritated by infection. This theory is not widely accepted. Symptoms Sometimes Cholesteatoma has no symptoms and is found incidentally. The damage to the eardrum usually starts in childhood. There is often a long history of repeated ear infections. There may be discharge from the ear. This is usually smelly, a bit like cheesy feet. In fact, the build up of layers of greasy dead skin that forms the cholesteatoma is very similar to what happens if you dont clean between your toes. There is usually some loss of hearing. A slow progressive loss of hearing, especially if it is only in one ear, can creep up on you, so isnt always noticed. If the ear is kept dry, there may be little or no infection for months or years. Ear infections following swimming, dunking the head in the bath, or ear syringing, are common in cholesteatoma. Occasionally, the first symptom of cholesteatoma is when it gives rise to serious complications. Sudden onset of severe vertigo may be due to the disease eroding into the lateral semicircular canal of the inner ear. Sudden onset of severe deafness can be due to the disease eroding into the inner ear. A paralysed face could be due to the disease affecting the facial nerve in the ear. Meningitis severe headache, stiff neck and photophobia may be the presenting feature of the disease. An attic crust, right ear, seen with a tele-otoscope. The brown flaky material at the top of the eardrum is not wax, but the dried outer layers of dead skin of a cholesteatoma. An attic crust is one of the most difficult and subtle signs to spot in clinical medicine. This picture was taken with a tele-otoscope, which gives a wide angle view of the whole eardrum and the surrounding deep ear canal. The view from a normal auriscope (as used in normal practice) is much narrower, and unless the examiner moves the auriscope around to see the whole of the drum, the attic may not be seen. Even if this brownish crust were seen, very few non-specialists would recognise it, most would simply think they were looking at a piece of wax. The attic crust must be removed to see what is going on underneath. Otitis externa. Layers of wet soggy white shed skin are partially blocking the ear canal. Red swollen inflamed skin is preventing a proper view of the eardrum. The debris must be cleaned to see the eardrum. Until the eardrum has been fully examined, it is impossible to know whether or not there is an underlying middle ear disesase such as cholesteatoma.
Suspicious for infected cholesteatoma. Red granulation tissue overlying the bone of the left ear canal, behind the eardrum. Layers of wet soggy white shed skin are stuck to the eardrum. The debris must be cleaned to see the eardrum. In this case it was too painful to complete the cleaning in out-patients. Microsuction under a general anaesthetic confirmed the diagnosis. Signs Medical signs are things that can be seen or noticed during examination by the doctor. There are several signs of cholesteatoma, but no one single appearance. Cholesteatoma can take many forms as it evolves. One classic sign of cholesteatoma is an attic crust. This is a brown flake of dried skin in the upper part of the eardrum. An attic crust is an extremely difficult and subtle sign to spot. Very few non-specialists would notice it. Even if they saw it, they would think it just a piece of dried skin or wax. ENT specialists are taught to never trust an attic crust Unless it becomes actively infected, cholesteatoma is usually missed altogether on examining the ear. If it becomes infected, then there may be signs of otitis externa (inflammation of the skin of the outer ear canal). Signs of otitis externa include:
o discharge o build up of debris o swelling o reddening o narrowing of the ear canal Until otitis externa has been treated, it is impossible to know if we are dealing with an underlying cholesteatoma, because the eardrum is not visible. The ear canal is is swollen and blocked with infected material and dead skin. Diagnosis Apparently normal left tympanic membrane as seen through an operating microscope as it would be lined up to fit a grommet. Only the pars tensa the lower trhee quarters of the eardrum is visible with the speculum pointing in this direction. Same left ear with microscope swivelled 60 degrees upward to view attic. Severe attic retraction with perforation and possible early cholesteatoma skin edges are on the body of the incus. This young man had normal hearing and no history of any problems with the left ear. He came about his right ear, with a long history of recurrent infections with smelly discharge. A large active cholesteatoma was found on the right. The left ear was only examined for the sake of completeness. It shows early signs of developing the same condition.
Shah grommet in position lower part of left eardrum, seen through the operating microscope. The attic is not seen when the speculum is lined up to look at the grommet Cholesteatoma is very difficult to diagnose in its early stages, even for ENT specialists. It is rare for a General Practitioner (primary care, family doctor) to be able to diagnose this condition. Most times, it isnt even suspected. Cholesteatoma is a rare condition. Ear infections in children are common. Most children will get some ear infections, hardly any of them will develop cholesteatoma. The average GP will see hundreds of ear infections, but only one cholesteatoma every ten to twenty years. Hence, it is not at the top of the list of diagnostic possibilities. Usually, it is not even suspected. The diagnosis usually comes to light only after many years of repeated infections. It is made by an ENT specialist examination, using an operating microscope. Cholesteatoma cannot be diagnosed without seeing the whole of the eardrum in close-up detail. Anything blocking the ear canal, such as wax or infective debris, must be cleaned away to get a proper view of the eardrum. In adults, this can usually be done awake as anout-patient microsuction. Microsuction can be painful, especially if the ear is infected. In children, a general anaesthetic is usually needed. Sometimes the diagnosis of cholesteatoma is discovered on the operating table, when a child has been admitted for grommets insertion. Sometimes, it is discovered on the operating table when an adult patient is admitted for a myringoplasty (repair of perforated eardrum). A perforated eardrum may be seen in the out-patient clinic, and the patient advised to have it repaired. It is only when the patient is under the anaesthetic, and the eardrum is lifted up to repair it, that the cholesteatoma is discovered. Even under the operating microscope and with the patient fully anaesthetised, a cholesteatoma can easily be missed. Most cholesteatomas start in the attic the upper part of the eardrum. Grommets are fitted in the lower part. The attic is not in view when the speculum is lined up to fit the grommet. The opening into the cholesteatoma sac can be very tiny a millimetre in diameter and if the cholesteatoma is not actively infected it will not be obvious unless the surgeon makes a point of looking for it. I have taught over a hundred junior doctors ear surgery, some at quite an advanced stage in their training, and have been surprised at how many of them fail to check the attic properly during grommet surgery. I believe that many of the cholesteatomas said to be caused by grommet insertion (a rare complication) were present at the time of the grommet fitting but were not noticed.
Audiometry (Hearing tests) Child hearing test in a sound proofed booth Tuning fork test part of Rinnes test. Bone conduction of sound is often better than air conduction if the ossicles have been destroyed by cholesteatoma. Hearing tests are part of the assessment of any ear condition. Pure tone audiometry with air conduction and bone conduction is the main test we use. The test doesnt diagnose the condition, but does tell us how much hearing has been lost, and whether it is a conductive hearing loss (usually due to damage to the eardrum and ossicles) or a sensorineural hearing loss due to damage to the inner ear. We need to measure and know how much hearing has been lost, and how much remains, to help advise on the likely outcome of treatment. If the loss of hearing is due to damage to the inner ear, it will definitely be permanent. A conductive loss can sometimes be improved, but it is not usually possible to improve the hearing by treating cholesteatoma. In most cases we can prevent things from getting worse. Hearing tests before and after treatment are important in assessing the results of what we do.
CT scan A CT scan is a form of X-Ray imaging which allows us to see the body in much clearer detail than plain X-Rays. The CT scan splits the image into thin layers, sliced like a salami, so that we can see much greater detail and pinpoint what is happening at any given point. It is only in recent years that scanners have been able to produce slices thin enough to give us useful information on the state of the middle ear. Some ear surgeons always require a CT scan before operating. In the days before CT scans, some ear surgeons always wanted mastoid X-rays before operating. I have never found them all that useful. Even with the best scanners, we dont get anywhere near as good a view as we get with the operating microscope during surgery full colour, three dimensional and up to 40 times magnification. It is impossible to tell with a scan whether some part of the ossicular chain is fixed this can only be determined by trying to move it during surgery. Many of the patients referred to me for ear surgery have already had scans. They rarely make any difference to what I plan on doing. I do not need a scan as a matter of routine. A CT scan is needed if we suspect complications, especially if we suspect there may be spread of disease into the brain.
Medical treatments Cholesteatoma can only be cured by surgery. No drug will remove the disease. If the ear becomes infected, the infection can be treated medically with antibiotics.Inflammation can be treated medically with steroids. Drugs for infection and inflammation of the ear are given in three main ways: topical ear drops and sprays, ointments by mouth medicine and tablets by injection intravenous antibiotics may be needed in more severe infections, especially if the inflammation spreads into the surrounding structures. If you are prescribed ear drops, make sure you use them properly, otherwise they probably wont work. Microsuction treatment Microsuction of the ear as an out-patient procedure Wax removal using microsuction
Wax removal using a fine round ended hook
An alternative to microsuction often used in children with runny, discharging ears is to gently mop out the ear with a cotton wool applicator. Illumination is from light shone over the childs shoulder and focussed onto the ear by a head mirror worn by the surgeon. The view is nothing like as good, and we cant normally reach right down to the eardrum, but it is less scary for the child. Microsuction is an examination and treatment of the ear using a high powered binocular operating microscope. We use very fine delicate instruments, including a miniature vacuum cleaner. This Hoovering of the ear is usually done as an out-patient procedure. Sometimes, and especially in younger children, it is done as a day case surgery under general anaesthetic. Microsuction of the ear is carried out to diagnose the condition of the ear accurately using
o binocular vision for 3-d stereoscopic view o high power magnification o very bright illumination to remove material blocking the ear canal such as
o wax o infected debris, pus and fungal material o dead skin layers including cholesteatoma o foreign bodies o to apply medicationto the ear You may be asked to use ear drops beforehand. This will make the treatment easier for you. You do need to lie very still. Despite all our efforts to be as gentle as possible, it will be noisy, and may be painful. It usually causes some short lived vertigo, lasting no more than a minute or so. Dont get up until the nurse says so you may be dizzy. You should be ok to drive afterwards but may need to wait until any dizziness has settled. Repeated microsuction is important in the the long term follow up cholesteatoma patients. Rather like going to the dentist, very few people look forward to the experience, but it is effective and necessary.
Mastoidectomy Combined approach mastoidectomy and tympanoplasty for cholesteatoma, right ear, in an 8 year old child. From behind the ear, the outer ear has been moved forward. Most of the mastoid air cells have been drilled out to expose the disease in the attic. The bony wall separating the ear canal from the mastoid has been preserved. The middle ear is actively inflamed and filled with red granulation tissue. The most difficult part of the operation is yet to come, the disease has to be carefully taken off the underlying ossicles. At this stage we dont know the state of the ossicular chain. It will be difficult because of the active inflammation, which is likely to bleed. Even a drop of blood is like a lake under the high powered microscope. The laser will help remove the granulations with minimal bleeding. Key: C = cholesteatoma e = external ear canal. Mastoidectomy (mass-toyed-ECK- tuh-mee, mastoid for short) is the operation to remove cholesteatoma. The mastoid is the bone behind the ear. It is part of the temporal bone, which forms the base of the skull and contains all the structures of the ear, as well as the facial nerve and some big blood vessels that go into the brain. The normal mastoid contains a honeycomb arrangement of air cells, which connect with air in the middle ear. The attic, just above the eardrum, is where the middle ear meets the mastoid. The attic contains the head of the malleus and the body of the incus. These two ossicles are very commonly surrounded by cholesteatoma. To remove cholesteatoma, we usually need to drill out the mastoid. This gets us behind the disease so we can remove it. The whole area is quite small, about the size of your thumb, and it contains some very delicate clockwork. The aims of cholesteatoma surgery are 1. To remove the disease 2. To prevent future complications such as facial paralysis, total and permanent deafness, dizziness, spread of infection into the brain 3. To give you a dry ear, that doesnt keep getting infected 4. As far as possible, to preserve what remains of the normal structures of the ear 5. To give you as good hearing possible Removing the disease takes priority. The surgeon has to tread a fine line between getting rid of the disease while preserving what he can of the hearing mechanism. Although cholesteatoma is not a tumour, it behaves like one. Unless the cholesteatoma is removed completely, it will come back. The surest way to get rid of the disease would be to drill out everything be radical. But that would make you very deaf, and could damage the other structures we are trying to protect, like the balance organ and facial nerve. Cholesteatoma tends to infiltrate in lots of different directions. Sometimes it wraps itself around the ossicles. The most reliable way to make sure we dont leave any behind on the ossicles would be to remove them altogether but that would make you more deaf. In a radical mastoidectomy, all the ossicles are removed, except the footplate of the stapes. In some severe cases of cholesteatoma, the ossicles have already been eaten away by the disease so it makes no difference, they are gone anyway. Some of the most difficult areas to remove cholesteatoma are facial nerve stapes footplate lateral semicircular canal There is a risk of damaging the very structures we are trying to save. But if we dont remove the disease, it would very likely cause damage anyway. Techniques of mastoid surgery
Examination and cleaning of the ear with the operating microscope, speculum and suction prior to mastoid surgery
Drilling right mastoid
Teaching mastoid surgery with binocular operating microscope and KTP LASER Before antibiotics, mastoid surgery was commonly done in desparate circumstances for acute infection, a mastoid abscess. Our predecessors had nothing better than a hammer and gouge, and no magnification other than some spectacle loups. It was counted a success if the patient usually a young child survived. No delicate work could be done, and most survivors were deafened. It was only after the introduction of the binocular operating microscope in the 1950s that modern delicate controlled microsurgery of the ear became possible. Even with all the latest high powered microscopes, lasers and modern anaesthetics, mastoid surgery is very difficult. Surgeons have to train for years to get good at it. Like all ear surgeons trained since the 1960s I did my basic training (in the 1980s) on temporal bones from cadavers (dead bodies). Although some might find that macabre, Id prefer the learning curve to be on my dead granny, rather than on my live child. The margin of error in mastoid surgery is measured in fractions of a millimetre. Anatomy varies considerably, and a surgeon needs to practice on lots of bones before embarking on live patients. Simulators and plastic bones just arent up to it. Unfortunately, in the UK, a public attitude has become established against the use of post-mortem tissues, which has led to a severe shortage of temporal bones for the next generation of ear surgeons to train on. I teach trainee surgeons ear surgery on live patients every week, sometimes two or three cases. The operations take anywhere between one to six hours. The average is around three hours. Approaches The two main approaches for cholesteatoma surgery are the endaural, also known as canal wall down or modified radical mastoidectomy, and the postauricular, also known as the canal wall up or combined approach mastoidectomy and tympanoplasty. Endaural / canal wall down / small cavity / modified radical mastoidectomy In the endaural approach, the cut is made in the roof of the ear canal, extending up in front of the ear into the hairline. The disease is followed from where it is visible (usually the upper part of the eadrum) into the mastoid. Bone of the canal wall is drilled away to expose the disease. This creates a mastoid cavity. We try and keep the cavity as small as possible, and make the opening to the ear as large as possible, to help with ventilation and cleaning afterwards. A shallow, smooth walled cavity is much easier to keep clean, and there is less risk of cholesteatoma coming back afterwards. Postauricular / canal wall up / combined approach tympanoplasty technique In the postauricular approach, the cut is behind the ear. The mastoid is opened by drilling into the bone overlying it. The ear canal wall, separating the external ear canal from the mastoid, is preserved. This gives a more normal looking ear and avoids a cavity which can be difficult to clean, especially in children. This method is technically a little more difficult, and is less reliable in getting rid of all the cholesteatoma at the first attempt. It is usually necessary to have a second look operation, about a year afterwards, if this technique is used. I use both of these methods for mastoid surgery. The choice depends on various factors. The site of the disease and the degree of destruction that has already happened are important. The age and circumstances of the patient are also taken into consideration. By and large, we prefer the postauricular approach initially in children and younger adults, provided there hasnt already been too much destruction. For older patients with medical problems causing difficulties with repeated operations we prefer the endaural modified radical approach. In both cases, we use the KTP laser to help get rid of skin cells from from awkward areas like the ossicles.
Tympanoplasty Tympanoplasty (TIM-pan-o-plas-tea) is surgery to rebuild the damaged structures of the middle ear, including the eardrum and ossicles. There are limits to what can be achieved. A rebuilt middle ear seldom works as well as the original. Repairing the eardrum is myringoplasty (mi-RING-o-plas-tea). Rebuilding or replacing the ossicles is ossiculoplasty (oss-SICK-you-low-plas-tea). Tympanoplasty is the general term that covers both. Often, we dont know how much reconstruction will be needed, or possible, until we are part way through the operation. Sometimes, tympanoplasty is done together with mastoidectomy, as part of the same operation. Other times it is done at a later stage, as a second operation, once we are satisfied that the cholesteatoma has been removed and any infection has settled.
Ossiculoplasty Artificial ear bone in place, left ear. Titanium metal prosthesis positioned between stapes head and cartilage reinforced eardrum. Kurz Variac system, trimmed to 1.75mm length. Key: m = malleus head i = incus body c = cartilage slice reinforcing eardrum s = stapes head L = Lateral semicircular canal Ossiculoplasty (oss-SICK-you-low-plas-tea) is an attempt to rebuild the damaged chain of tiny bones that conduct sound from the eardrum to the inner ear. The surgeon is faced with a three dimensional, microscopic jigsaw puzzle, where the pieces dont interlock, and some are missing. The aim is to achieve a stable but mobile mechanical linkage, reconnecting the reconstructed eardrum to the inner ear. There are many techniques for ossiculoplasty, depending on the exact situation found at surgery. Damaged bones can sometimes be taken out, cleaned, re-shaped and put back in a different way. The results not very reliable, because the little bone tends to fall off where it was put. Missing pieces can sometimes be replaced with materials taken from nearby, such as cartilage from the outer ear. Artificial bones prostheses made of various plastics, cements or metals can also be used. Fractions of a millimetre will determine success or failure. We then have the healing process to contend with. Even if initially successful, in the weeks and months following surgery, there will be scarring. This can easily pull things apart, or alternatively stiffen up and imobilise the reconstruction. Further ear infection can break down the repair. Cholesteatoma might recur. If the eardrum has been repaired, but the Eustachian tube is still not working, there may be middle ear effusion, retraction, and / or atelectasis. If a foreign material has been used in the reconstruction, there is a fair chance that the body will reject it and push it out. All these things take their toll on the long-term results. Even in the best hands, less than 50% achieve socially acceptable hearing from ossiculoplasty. If the stapes (the third and most delicate bone in the chain) has been damaged, the prospects of restoring useful hearing by ossiculoplasty are very poor indeed. Many UK ear surgeons wont even attempt ossiculoplasty, since the chances of success are low, and there are signficant risks of damaging the inner ear permanently by manipulating the ossicular chain in the attempt to rebuild it. My own view is that it is reasonable to attempt ossiculoplasty, if the situation on the table looks favourable. If the ossiculoplasty fails to give satisfactory hearing, we have the BAHA (Bone Anchored Hearing Aid osseointegrated titanium auditory implant) to fall back upon. KTP LASER KTP LASER in use during mastoid surgery, right ear KTP LASER right mastoid. Surgeons view down microscope. Green light is turned red by a filter to protect the surgeons eyes. The tip of the LASER fibre measures 0.2mm across. A fine suction tube is held near the tip to evacuate smoke The KTP laser is a very useful tool in cholesteatoma surgery. It allows us to vapourise disease from the ossicles without touching them. That is better than having to physically scrape disease off the ossicles, which is like hitting the microphone and risks noise damage to the inner ear. The laser can be passed down extremely fine fibreoptic fibres. We use a 0.2mm fibre in ear surgery. The fibre is placed inside a fine hollow hand-held instrument. The curved tip can be placed with extreme accuracy into narrow awkward tiny crevices where cholesteatoma lurks. There are some areas where we cant use the laser. If the cholesteatoma is directly on the facial nerve, we cant use laser to burn it off because that would injure the nerve. I have been using the KTP laser in ear surgery since 1996. I only carry out mastoid surgery in hospitals where the KTP laser is available.
What are the risks of surgery for cholesteatoma? Consultant anaesthetist, anaesthetic machine and monitoring equipment, Chaucer Hospital All operations carry risks. There are also risks of not operating, especially in a progressive destructive disease like cholesteatoma. At worst, you could die or suffer brain damage but you are more likely to be injured in a road accident. A general anaesthetic carries a minimal risk, with consultant anaesthetists using modern drugs and monitoring equipment. General risks of a long operation under general anaesthetic include Heart and lung problems Deep vein thrombosis Stroke None of these are likely unless there is some pre-existing medical condition. All these risks are higher in smokers, and you should stop smoking before any operation. If there are worries about your particular medical condition, we recommend a pre-operative assessment by the anaesthetist before deciding on surgical treatment. Sometimes we may need pre-operative tests such as X-Rays, electrocardiogram and blood tests. These investigations are not usually needed in younger patients. Further information on General Anaesthesia for children Further information on General Anaesthesia for adults Specific risks of Mastoid surgery The same structures that are at risk from the disease are at risk from the operation to remove it. The operation has serious potential risks including: total and permanent deafness in the operated ear severe tinnitus balance disturbance and vertigo facial nerve paralysis meningitis and / or brain abscess None of these serious complications are likely, but they can and do happen occasionally. The chances of further damage from a controlled operation by a skilled surgeon using modern equipment are less that the risk of leaving the disease to progress for the rest of your life unless your life expectancy is short. There are also side effects of the surgery. The following arent really risks as such, they are just things that are going to happen that you probably wont like. Numbness or tingling of the side of the tongue on the operated side. This is due to damage to the corda tympani, a small nerve that takes a detour through the middle ear on its way from the brain to the side of the tongue. The corda is always stretched and often cut during mastoid surgery. The ear itself will feel numb, as will the scalp above the ear. This is because the nerves that run in the skin are cut during the operation. The numbness usually gets better after a year or so. The shape of your outer ear may alter. The opening to the ear canal is often deliberately enlarged, a meatoplasty (me-ATE-o-plass-tea). Sometimes the ear moves position slightly on the head, and may fold either tighter against the head or stick out a little more depending on how the scar heals up. Infection can set into the wound, this could progress to a cauliflower ear. What is the alternative to mastoid surgery? Nothing except mastoid surgery can cure cholesteatoma. But it may be possible to keep it under reasonable control by repeated microsuction treatment in out patients. This option is sometimes advised for older infirm patients, especially if their general medical condition makes a long operation difficult and risky, and whose shorter life expectancy makes the probability of developing serious complications less. This strategy can include the option of carrying out mastoid surgery, to try and salvage the situation, only if serious complications actually happen. Before coming into hospital for ear surgery If you smoke, you should give up, because smokers are more likely to suffer complications after operation. Parents should also consider giving up, as children must not be exposed to passive smoking during recovery. Make sure you have supplies of soluble paracetamol (Calpol for children) for when you come home. Do not plan anything important during the two weeks after operation. If you normally wear a hearing aid in the ear that is to be operated, remember you wont be able to wear it for several weeks or months. Also, the shape of your ear canal is likely to change and it may no longer fit you afterwards. Wearing spectacles could be difficult in the first 24 hours because of the head bandage. You might need to bend the arm outward, or temporarily remove it and wear them over the bridge of the nose. Before the operation Pre-operative checklists and handover of patient from ward sister to operating theatre nurse, Chaucer Hospital Remember to bring any medicines with you to hospital. You will not be allowed anything to eat for about six hours before operation, but you can drink clear fluids up to two hours before. The six hour rule does not apply to medicines these should be taken as usual. When you come into hospital, you will be seen by the nurse who will ask various questions about your general health and attach an identity bracelet to your wrist. Similar questions will be asked by the Resident Medical Officer, and possibly by the anaesthetist. Please dont get upset if you are asked the same question several times. This is a routine to help avoid mistakes like an airport checking your travel documents more than once. You will be examined and checks made to ensure you are fit for anaesthetic. If you have any worries or questions, this is a good time to ask.
After the operation After the operation, you will wake up in the recovery area, where a nurse will look after you. You will be asked to spit out the plastic tube in your mouth. You will probably have a head bandage on. You may feel sick and dizzy. This is quite normal and will stop after a while. When you are sufficiently awake, you will return to the ward. You will stay in bed for several hours. You will feel thirsty and tired, and you may be sick. The nurse will attend you frequently to check your pulse and breathing. If you are in any discomfort, please let the nurse know as she can you an injection to help relieve it. You will be allowed to drink as soon as the nurse is happy with your condition. You will be advised not to have too much initially as it might make you sick. Food is started as soon as you are able.
How long will I be in hospital? Most patients operated in the morning are able to go home later the same day. If your operation is done in the afternoon, or if your recovery is slow, you may need to stay in overnight. Your head bandage will normally be taken down before you go home, and you will be given a stretch headband with disposable gauze pads to be changed each day.
What restrictions are there afterwards? You will need two weeks off school or work. You mustnt drive for at least 48 hours, and longer if you are still feeling dizzy or tired. You must strictly avoid getting any water in the ear for at least three months, maybe longer You shouldnt fly for three months What can I expect at home after the operation? You can expect to feel tired. You may be a little unsteady on your feet. You wont be able to hear very well from the operated ear, it will be packed with a dressing. You will probably hear tinnitus, various sounds in the operated ear. Ear surgery is not especially painful. You will get the odd twinge of pain on chewing or if you happen to lie on the wound. Strong painkillers arent normally needed, you may use paracetamol as required. Be careful you dont take more than maximimum recommended dose. Looking after the wound and your dressings Keep the ear dry. You can have your hair washed, carefully by someone who can keep the water away from your operated ear. They may have to miss out the part immediately next to the ear. Protect the wound by wearing your stretch headband and disposable dressing pads, you should receive a supply of these on discharge from the hospital. You may get some seeping of yellow or brownish fluid from the ear, or slight bloodstaining. This is normal. You should change the disposable pads under your stretch headband at least daily, more often if there is a lot of seepage. The dressing we put in the ear is BIPP. This stands for Bismuth Iodoform Paraffin Paste. It has a distinctive hospital antiseptic smell, which some find reassuring and others dislike. BIPP is a very good antiseptic and can be left safely in wounds for months without going off, unlike some other dressings. The paste is impregnated on a ribbon gauze. We usually place several pieces of gauze on top of one another. If the BIPP ribbon gauze dressing starts coming out sometimes it gets stuck onto your outer dressing just cut it off near the ear with a clean pair of scissors. There will be plenty more inside. If you get increasingly severe pain, or a smelly, nasty discharge, that might mean infection and you should contact us urgently for advice. If the outer ear begins to itch severely, and starts to go red and blisters, that usually indicates you have become allergic to BIPP. This tends to happen only to patients who have had previous ear surgery and become sensitised to BIPP. BIPP allergy with red swelling and blistering of skin around ear dressing You should contact us urgently for advice if you think you might have developed a BIPP allergy. The dressing will have to be removed, and you will need treatment with antihistamines and maybe steroids. Looking after yourself After a day or two of rest, begin gentle exercise. Start just pottering around the house, then short walks outside, but avoid strenuous physical activity. Keep away from crowds or anyone with a cold, flu or other infection. Keep strictly away from cigarette smoke. Avoid dirty or dusty environments. Take any antibiotics as prescribed for the full course. First post-operative visit Healing postauricular incision two weeks following mastoid surgery. Stitches ready for removal. Yellow / brown BIPP ribbon gauze and blue silastic sheet dressing in ear canal, seen under operating microscope two weeks following mastoid surgery Your first out-patient visit will normally be two to three weeks after the operation. We will remove your stitches, and packs from the ear. This is done under the microscope. It is very delicate. You will need to lie still. Sometimes there is a brief twinge of pain as we take out the dressing. We may need to admit younger children to hospital as a day case, to carry out this treatment under a short general anaesthetic. The operated area is very delicate intitially. Depending on the method of surgery, it may take several weeks or even up to three months for it to heal. During this time, there is a risk of picking up an infection. You must strictly avoid getting any water in the ear, especially bath water which is a soup of germs from the rest of the body. Do not under any circumstances dunk your head in the bath. For a few weeks after the dressing has been removed, we recommend protecting the ear from cold winds by placing a fresh piece of cotton wool in the canal when outdoors. Indoors, at home, you may leave it uncovered. We dont normally recommend any medication as a routine. If, however, you get an increasingly severe earache, or if your ear develops an unpleasant smelly discharge, that ususally means an infection has set in. This would normally be treated with antibiotic / steroid combination ear drops or spray. If you are going away or think you might have difficulities in attending for urgent treatment, we will prescribe a supply of the medication for you to have on standby. We would expect you to contact us as soon as possible if you have to start using the medication, as you may need to have your appointment brought forward. Long term follow-up and second stage surgery A pearl of cholesteatama. Routine follow-up ear examination under the microscope in out-patients, 9 months following mastoidectomy and tympanoplasty surgery in which the ossicles were preserved and the eardrum rebuilt. The small white area at the upper part of the rebuilt eardrum is a pearl of cholesteatoma. The pearl had formed from a tiny fragment of cholesteatoma that hadnt been removed at the first operation. The patient had no symptoms from it at this stage. A second operation was advised, and the pearl was removed, it was limited to a small area and the ossicles were once again preserved. If it had been neglected until it caused symptoms, it is unlikely the hearing could have been saved. Cartilage graft used to reconstuct the outer attic wall, left ear, five years following mastoid surgery. To the non-specialist it looks just like the cholesteatoma, but it isnt. This ear is safe and healthy. Key: m = malleus handle C = cartilage graft Having mastoid surgery is not the end of the matter. Cholesteatoma can come back, many years or even decades after initially successful surgery. It is essential for cholesteatoma patients to have long term follow up by a specialist who knows how to diagnose the disease. There are two ways the disease can come back: 1. Residual cholesteatoma. It wasnt completely removed at the first surgery. It can be very difficult to remove every last skin cell when we are trying to avoid further damage to the ear. Usually, residual cholesteatoma will show up within a year or two, but it may be much longer. With some techniques, especially if we do reconstruction that hides where the disease was, you may be advised to have a second stage operation a year after the first. This will detect a small cholesteatoma that developed from the odd stray skin cell. It forms a pearl. If this pearl is discovered at an early stage, it might be possible to simply winkle it out. If it was left until it became symptomatic, there may be further loss of hearing. 2. Recurrent cholesteatoma. A second, new cholesteatoma develops, because the underlying problems that caused the first cholesteatoma, such as poor Eustachian Tube function, the eardrum getting sucked in, and failure of the normal outward migration of skin, are still there. This may not show up for decades. As well as looking out for recurrent disease, many cholesteatoma patients need regular cleaning of the ear in order to prevent that build-up of dead skin layers. Cleaning is best done by microsuction. Ear syringing is not very good at removing adherent layers of dead skin, and might well set off infection by getting them wet. Patients vary considerably in how often they need their ears cleaned. Some will manage with only once a year, others may need it every two or three months. The average is between six and nine months. Its not so different from having to go to the dentist to get your teeth de-scaled. Neglected mastoid cavities are dangerous. Some of the most serious complications I have seen were in patients who neglected to have their ears cleaned following mastoid surgery for cholesteatoma.
Hearing aids and BAHA osseointegrated auditory implant
Most cholesteatoma patients have hearing loss. Even after successful surgery, it is very unlikely that hearing will be 100%. If only one ear is affected, you might just cope with having a deaf side. But if both ears are affected, or if hearing properly on both sides is important to you, some form of hearing aid is usually needed. Normal hearing aids can help, but the sound quality isnt always great, and they often cause infection. Blocking the ear canal with a hearing aid mould makes it moist. This encourages germs. Just imagine the state of your feet if you wore plastic shoes all day. Many cholesteatoma patients find that they cant wear hearing aids because they cause infection, with painful, discharging ears. They have to stop wearing the hearing aid, get treatment for the infection with microsuction and antibiotic / steroid ear drops, and are unable to hear properly for weeks. Once the infection clears up, they go back to wearing the hearing aid, then the whole miserable cycle repeats itself. The situation is worse if both ears have been operated. Some audiologists try to get around the problem of blockage by using loose fitting or vented moulds. This often results in feedback and whistling when the volume is turned up. Also, even partial blockage of the ear canal reduces ventilation and encourages infection. A bone conductor hearing aid uses bone conduction to put sound directly into the inner ear, bypassing the middle ear problem. Old fashioned bone conductor hearing aids are placed on metal springs like an Alice band, or sometimes built into a pair of spectacles. They are cumbersome, and very uncomforatble to wear for any length of time, because they have to press very hard. They can cause pain, headaches and ulceration of the skin. Sound quality is muffled by the soft tissue of the scalp. The most effective way of getting around this problem is to put sound directly into the bone of the skull, by the titanium screw of a BAHA osseointegrated auditory implant. Disclaimer All information and advice on this website is of a general nature and may not apply to you. There is no substitute for an individual consultation. We recommend that you see your General Practitioner if you would like to be referred.
We comply with the HONcode standard for trustworthy health information: verify here. Disclaimer All information and advice on this website is of a general nature and may not apply to you. This medical information is provided to enhance and support, not replace, individual advice from a qualified medical practitioner. Please see ourTerms of Use.es About us ENT Kent Partnership 2014 Specialist in Ear Surgery Home About John Hamilton Locations Specialised Ear Surgery Patient Information Contact Links Functional Orthogonal Cholesteatoma Surgery John Hamilton's approach to preserving hearing in cholesteatoma surgery
What is cholesteatoma? Where does cholesteatoma occur? What are the consequences of cholesteatoma? How does cholesteatoma behave? How is cholesteatoma diagnosed? What structures are in the temporal bone? What is the treatment for cholesteatoma? What are the aims of cholesteatoma surgery? Is it possible to measure how well cholesteatoma surgery is performed? How effective is conventional surgery at removing cholesteatoma? What advances may improve the situation? How much does the laser improve the removal of cholesteatoma? Does the laser improve hearing results after cholesteatoma? How is cholesteatoma removed from the hearing bones? How is cholesteatoma removed from the epitympanic gutter? How much does the laser improve hearing after cholesteatoma surgery? Summary
What is cholesteatoma?
In most cases, cholesteatoma results from abnormal growth of the skin of the ear drum into the skull. The resulting sac continually generates skin cells. These stagnate causing relentless or recurrent ear discharge. The inflammation caused by the infected skin causes erosion of the structures within the skull.
top
Where does cholesteatoma occur? Cholesteatoma is the accumulation of skin debris within the middle ear. The middle ear occupies much of the temporal bone which is the main bone on each side of the base of the skull. Cholesteatoma does not occur anywhere else. top
What are the consequences of cholesteatoma? In addition to ear discharge a patient with cholesteatoma may notice symptoms caused by destruction of the structures within the skull. The commonest of these symptoms is hearing loss. Less common symptoms include dizzyness, tinnitus and facial weakness. Most people are surprised to learn that cholesteatoma rarely causes pain. If an abscess forms, it causes pain and swelling around the ear and can result in meningitis or other infection of the brain. When cholesteatoma is neglected such serious complications can cause death. top
How does cholesteatoma behave? Cholesteatoma causes inflammation. Inflammation causes erosion of bone, so the cholesteatoma progressively enlarges. It also causes scarring so that the cholesteatoma becomes firmly attached to the structures in the temporal bone. At any time, the indolent suppuration of the dead skin within the cholesteatoma may erupt into an abscess. top
How is cholesteatoma diagnosed? Other ear disorders, such as ear drum perforation and ear canal infection also cause hearing loss and ear discharge. The following features should raise suspicion that cholesteatoma is present: Relentless ear discharge despite treatment Recurrent ear discharge despite treatment Foul smelling ear discharge Cholesteatoma is usually diagnosed on careful inspection of the eardrum. This may be obvious or it may be subtle. It often requires the ear to be competely clean, which may require specialist skills and equipment. On rare occasions, scans are required to diagnose or confirm the presence of cholesteatoma top
What structures are in the temporal bone? Most of the temporal bone is occupied by the air spaces of the middle ear. This air space is neede to allow the ear drum to vibrate and transmit sound. The ear canal, ear drum and hearing bones are also housed within the temporal bone. Their role is also to transmit sound through to the inner ear. The inner ear, which has two parts, the cochlea (for hearing) and the vestibule (for balance) lies deep within the temporal bone. Nerves from the brain to the face and neck run through the temporal bone. Major bood vessels to and from the brain also run through the temporal bone. top
What is the treatment for cholesteatoma? Cholesteatoma is an abnormal physical structure. It cannot be removed with medicines. As it is progressive, it requires removal, which means surgery. All cholesteatoma should be surgically removed if the patient is fit enough for anaesthetic. top
What are the aims of cholesteatoma surgery? Cholesteatoma surgery has two conflicting aims. Getting the balance between these is very difficult. This is the reason why you should consider carefully who performs your cholesteatoma surgery. The conflicting aims of cholesteatoma surgery are: To completely remove (and prevent the recurrence) of cholesteatoma. To maintain or restore the normal function of the structures of the temporal bone. The conflict arises because: The former is facilitated by wide removal of all the structures of the temporal bone. The latter is facilitated by preservation of the structures of the temporal bone. There are many techniques currently used to try to achieve these aims. Older techniques tend to be heavily biased towards achieving the first aim at the cost of the second. This is the reason why you should consider carefully who performs your cholesteatoma surgery. top
Is it possible to measure how well cholesteatoma surgery is performed? Mr Hamilton has proposed that four outcomes should be recorded to measure the effectiveness of cholesteatoma surgery. 1. Complete removal of cholesteatoma 2. No new growth of cholesteatoma 3. Dry ear, even when washing or swimming 4. Socially useful hearing The first two assess whether the disease has been completely removed. The latter pair assess whether the ear is functioning normally. Each is a simple yes/no answer. top
How effective is conventional surgery at removing cholesteatoma? Take a look at how well cholesteatoma is completely removed in one operation: Famous and dedicated surgeons who have audited and published their work often have residual cholesteatoma rates of 15-30 per cent. Is this necessarily a measure of individual failure? If even the most skilled surgeons leave this amount of disease, the problem resides more with the limitations imposed by the surgical instruments than with the dexterity of the surgeons: Conventional instruments are not up to the task of completely clearing all cholesteatoma. top
What advances may improve the situation? Lasers vaporise disease and therefore are: simple to use cause no movement stop bleeding Some lasers can be transmitted along fibres. These can guide the laser energy around corners. In cholesteatoma surgery, this means that the laser can be guided around the many obstacles in the temporal bone. Some surgeons feel that endoscopes may help by improving inspection and image capture of cholesteatoma in regions of complex anatomy. However, the benefit of endoscopy in cholesteatoma surgery is limited as: endoscopes are not actually used for removing disease; the surgeon holding an endoscope has only one free hand to perform surgery; endoscopes are difficult to use with bleeding tissues. problems encountered during cholesteatoma surgery conventional steel instruments fibre-guided laser cochlea damaged by movement of hearing bones movement needed to remove disease no movement involved in disease many obstacles can work around corners with angled instruments can be guided around corners by optical fibre or off mirror inflamed tissues full of blood vessels dissection worsens bleeding laser stops bleeding complex anatomy requires dexterity especially around corners point and shoot Compare how well suited to the problems posed by cholesteatoma are conventional instruments, endoscopes and the fibre- guided laser top
How much does the laser improve the removal of cholesteatoma? Mr Hamilton compared the complete clearance of cholesteatoma in two hospitals, one with a laser and one without. He did this by checking whether there was any residual cholesteatoma at a second operation. The flow chart shows how patients were involved in the study:
top
Does the laser improve hearing results after cholesteatoma? The laser does not require movement to remove cholesteatoma. This means that an entirely new approach can be adopted to the treatment of firmly adherent cholesteatoma on the hearing bones. Previously it was necessary to remove the hearing bones with the cholesteatoma, in order to protect the delicate inner ear from damage. Now the laser can remove firmly adherent cholesteatoma from the hearing bones without movement and thereby without placing the inner ear at risk top
How is cholesteatoma removed from the hearing bones? Cholesteatoma can be lasered from the ossicles themselves without movement. The ossicles also present a barrier to removal of cholesteatoma. A special view, the "orthogonal" view, has been developed to get to the cholesteatoma on the other side of the ossicles: this enables a direct view of the deep side of the ossicles, the facial nerve and the gap in between which Mr Hamilton has termed the epitympanic gutter. This view protects the facial nerve and the hearing bones as the cholesteatoma is removed.
top
How is cholesteatoma removed from the epitympanic gutter? The area is approached using the orthogonal view. The facial nerve is identified and protected. The laser used on the ossicular side only, to protect the cochlea. Steel instruments only are used on the facial nerve side, to protect the nerve. top
How much does the laser improve hearing after cholesteatoma surgery? Mr Hamilton compared the hearing of two groups of patients after cholesteatoma surgery. One group had conventional treatment of the hearing bones, with reconstruction after removal of bones to facilitate surgery. The other group had new, laser-assisted "functional" surgery, in which cholesteatoma was removed from and around the hearing bones, which were left in place. Analysis of the results showed that the risk of poor hearing in the conventional group was approximately 3 times higher than the risk of poor hearing in the laser group. top
Summary Lasers are better suited to the removal of cholesteatoma than conventional instruments. Over the last decade Mr Hamilton has provided evidence that: Cholesteatoma is removed more effectively when a laser is used Lasers provide an opportunity to preserve hearing more effectively than any other technique To achieve these outcomes has required the development of a new approach to cholesteatoma surgery. This has required new technical terms and ultimately a new operation, Functional Orthogonal Cholesteatoma Surgery.