Cholesteatoma

Clinical Features
Diagnosis
Treatment

Symptoms
Sometimes: None (incidental finding)
Long history of repeated ear infections
Foul-smelling ear discharge
Some loss of hearing (which may not be noticed)
Ear infections following swimming, dunking the head in the bath, or ear
syringing
Serious complications:
Sudden onset of severe vertigo (lateral semicircular canal)
Severe deafness (inner ear)
Paralyzed face (facial nerve)
Severe headache, stiff neck, and photophobia (meningitis)

Signs
Attic crust: brown flake of dried skin in
upper part of TM
Extremely difficult and subtle sign to spot
Never trust an attic crust

Infected cholesteatoma Otitis externa

Discharge
Build up of debris
Swelling
Reddening
Narrowing of the ear canal

Diagnosis
Very difficult to diagnose in early stages
Sometimes discovered on operating table when doing grommet
insertion or myringoplasty
Most (but not all) cholesteatomas start in the attic
Audiometry: PTA (degree of hearing loss; conductive vs.
sensorineural)
Hearing tests before and after treatment to assess results
At best, we can prevent things from getting worse

CT scan:
Never better than the operating microscope
Is needed if we suspect complications (esp. meningitis)

Treatment
Medical:
Only to treat ear infection
Topical/Systemic antibiotics/antiinflammatories

Surgical:
Mastoidectomy

Highly schematic view of the medial wall of the right tympanic cavity,
lateral aspect. The tympanic plexus is shown on the promontory.

Aims of Mastoidectomy
To remove the disease
To prevent future complications
To get a dry ear, that doesnt keep getting infected
To preserve as far as possible what remains of
the normal structures of the ear
To get as good hearing as possible

Issues in Mastoidectomy
Most important aim: remove the disease
Removing disease vs. Preserving hearing mechanism
Complete removal vs. Incomplete removal
Radical: benefits vs. disadvantages
Most difficult areas:
Facial nerve
Stapes footplate
Lateral semicircular canal

Risk of damaging the very structures we are trying to save

Approaches to Mastoidectomy
Endaural / Canal wall down / Small cavity / Modified radical
mastoidectomy
Cavity is easier to clean
Less chance of cholesteatoma recurrence

Postaural / Canal wall up / Combined approach tympanoplasty

More normal-looking ear
Second look operation after ~ 1 yr

Tympanoplasty
Ossiculoplasty
KTP laser

Risks of Mastoidectomy
General risks of long surgery:
Heart & lung problems
DVT
Stroke

Specific risks of mastoid surgery:

The same structures that are at risk from the disease
are at risk from the operation to remove it:

Total and permanent deafness in the operated ear

Severe tinnitus
Balance disturbance and vertigo
Facial nerve paralysis
Meningitis and/or brain abscess

Follow-up
Residual cholesteatoma
Pearl

Recurrent cholesteatoma
Regular cleaning of ear
Neglected mastoid cavities are dangerous!

Hearing aids & BAHA

Cholesteatoma left ear. The disease has eroded the bone above
and behind the upper part of the eardrum, the attic.

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.

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 don't 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.

Artificial ear bone in place, left ear. Titanium metal prosthesis positioned
between stapes head and cartilage reinforced eardrum.
Key:
m = malleus head
i = incus body
c = cartilage slice reinforcing eardrum
s = stapes head
L = Lateral semicircular canal

BIPP allergy with red swelling and blistering of skin around ear dressing

Healing postauricular incision two weeks following mastoid surgery. Stitches

ready for removal.

A pearl of cholesteatoma. 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 hadn't 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 reconstruct the outer attic wall, left ear, five years
following mastoid surgery. To the non-specialist it looks just like the
cholesteatoma, but it isn't. This ear is safe and healthy.
Key:
m = malleus handle
C = cartilage graft