What is a cholesteatoma?
A cholesteatoma is a skin growth that occurs in an abnormal location, the middle
ear behind the eardrum. It is usually due to repeated infection, which causes
an ingrowth of the skin of the eardrum. Cholesteatomas often take the form of
a cyst or pouch that sheds layers of old skin that builds up inside the ear.
Over time, the cholesteatoma can increase in size and destroy the surrounding
delicate bones of the middle ear. Hearing loss, dizziness, and facial muscle
paralysis are rare but can result from continued cholesteatoma growth.
How does it occur?
A cholesteatoma usually occurs because of poor eustachian tube function as
well as infection in the middle ear. The eustachian tube conveys air from the
back of the nose into the middle ear to equalize ear pressure ("clear
the ears"). When the eustachian tubes work poorly perhaps due to allergy,
a cold or sinusitis, the air in the middle ear is absorbed by the body, and
a partial vacuum results 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 form of cholesteatoma
(one present at birth) 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.
What are the symptoms?
Initially, the ear may drain, sometimes with a foul odor. As the cholesteatoma
pouch or sac enlarges, it can cause a full feeling or pressure in the ear,
along with 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.
Is it dangerous?
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, brain abscess, meningitis, and
rarely death can occur.
What treatment can be provided?
An examination by an otolaryngologist-head and neck surgeon can confirm the
presence of a cholesteatoma. Initial treatment may consist of a careful cleaning
of the ear, antibiotics, and ear drops. 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,
x-rays of the mastoid (the skull bone next to the ear), and CAT scans (3-D
x-rays) of the mastoid may be necessary. These tests are performed to determine
the hearing level remaining in the ear and the extent of destruction the cholesteatoma
Surgery is performed under general anesthesia in most cases. 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;
and therefore, a second operation may be performed 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 residual cholesteatoma.
Admission to the hospital is usually done the morning of surgery, and if the
surgery is performed early in the morning, discharge maybe the same day. For
some patients, an overnight stay is necessary. In rare cases of serious infection,
prolonged hospitalization for antibiotic treatment may be necessary. Time off
from work is typically one to two weeks.
Follow-up office visits after surgical treatment are necessary and important,
because cholesteatoma sometimes recurs. In cases where an open mastoidectomy
cavity has been created, office visits every few months are needed in order
to clean out the mastoid cavity and prevent new infections. In some patients,
there must be lifelong periodic ear examinations.
Cholesteatoma is a serious but treatable ear condition which can only be diagnosed
by 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.
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