By:  James Prueter, DO

A cholesteatoma is an accumulation of exfoliated keratin (skin) in the middle ear or other aerated areas of the temporal bone. These growths can be categorized as either congenital (very rare) or acquired. The categorization is based off multiple factors including appearance, growth patterns and disease extension. Given enough time, these cholesteatomas can grow large enough to cause damage to the bones in the middle ear. With continued growth, other symptoms such as dizziness and facial paralysis can occur, but these are rare. Cholesteatomas can also become infected and can be difficult to treat.

How Do Cholesteatomas Develop?

Although there are multiple theories as to the etiology of cholesteatomas, the most accepted theory is that these growths develop because of tympanic membrane retraction or perforation. According to this theory, as the tympanic membrane retracts, due to infection or poor Eustachian tube function, the cholesteatoma can be pulled into the middle ear space, causing damage. In fact, one of the most common issues these growths cause is hearing loss due to damage of the middle ear bones. Cholesteatomas can also cause more intense inflammatory reactions and cause erosion of the temporal bone.

How Are Cholesteatomas Diagnosed?

Typically, the first sign that a patient has a cholesteatoma is foul smelling otorrhea (ear drainage). Hearing loss is also common, as mentioned above. The otolaryngologist will perform a detailed physical exam of the head and neck. Cholesteatomas can be visually diagnosed by otoscopic or microscopic exam.

Further evaluation of these growths can be performed via computed tomography (CT) scans or magnetic resonance imaging (MRI). These scans are usually ordered to evaluate the depth and extent of disease.  These imaging modalities give the head and neck surgeon more information that they can use to plan for successful removal of the growth.

Hearing tests may be performed before and after treatment to determine a baseline and to monitor for any impact on hearing post-treatment.

How Are Cholesteatomas Treated?

Cholesteatomas usually need surgical intervention to hinder serious complications. This is when the physician would order CT or MRI scan to get a clearer picture of the growth and its impact on the surrounding structures.

If surgery is deemed necessary, it is performed under general anesthesia. The goal of the operation is to remove the growth and provide a clean, dry and safe middle ear environment. If hearing loss has occurred due to the cholesteatoma, it is not definite that the patient’s hearing will be restored during the primary surgery. A “second look”  operation would occur about 6 months later. The second surgery would ensure no recurrence of disease and reconstruct the hearing bones to improve hearing. The surgery to remove the growth is usually an outpatient procedure, and the patient will get to go home the same day.

Following up with the otolaryngologist is necessary due to the reoccurrence rate of cholesteatomas (about 30% of cholesteatomas can reoccur).

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