From the Guidelines
Management of infected cholesteatoma requires prompt surgical intervention combined with appropriate antibiotic therapy. The definitive treatment is surgical removal of the cholesteatoma through tympanomastoidectomy, which may be canal wall up or canal wall down depending on the extent of disease 1. Prior to surgery, empiric antibiotic therapy should be initiated with coverage for common pathogens including Pseudomonas aeruginosa, Staphylococcus aureus, and anaerobes. A typical regimen includes ciprofloxacin 750mg orally twice daily for adults (or 20-30mg/kg/day divided twice daily for children) for 10-14 days. Alternatively, amoxicillin-clavulanate 875/125mg twice daily for adults can be used. For severe infections or complications, intravenous therapy with piperacillin-tazobactam 4.5g every 6 hours or ceftazidime 2g every 8 hours plus clindamycin 600-900mg every 8 hours may be necessary.
Some key points to consider in the management of infected cholesteatoma include:
- The use of topical antibiotic ear drops such as ciprofloxacin/dexamethasone (4 drops 2-3 times daily) to control otorrhea 1
- Careful aural toilet to remove debris and purulent discharge is essential before applying drops
- Surgery should not be delayed once the acute infection is controlled, as cholesteatoma is a progressive disease that can lead to serious complications including meningitis, brain abscess, facial paralysis, and labyrinthine fistula
- Following surgery, patients require long-term follow-up with regular otoscopic examinations and imaging studies to monitor for recurrence, which occurs in approximately 20-30% of cases.
It's worth noting that the benefits of topical antibiotics versus placebo in children is yet unclear, as highlighted in a review of the literature on treatments for CSOM and cholesteatoma in adults and children 1. However, surgical intervention remains the cornerstone of treatment for infected cholesteatoma, and antibiotic therapy should be tailored to the individual patient's needs and the severity of the infection.
From the Research
Management of Infected Cholesteatoma
- The management of infected cholesteatoma involves surgical intervention, with the primary aim of providing a disease-free dry ear 2.
- Antibiotic treatment is often used in conjunction with surgery, with protocols including topical gentamicin and dexamethasone, and oral clindamycin 3.
- The use of oral ciprofloxacin has been protocolized for adults with refractory suppuration, and topical ciprofloxacin has been used preoperatively to decrease postoperative infections in patients with preoperative otorrhea 3.
- High hydrostatic pressure treatment has been explored as a method for inactivating microbial pathogens, including biofilms, on ossicles prior to reimplantation 4.
- Surgical techniques for managing infected cholesteatoma include canal wall up (CWU) or canal wall down (CWD) mastoidectomy, with or without reconstruction of the middle ear cleft 5.
- Recent advances in management have also included the use of transcanal endoscopy and laser-assisted cholesteatoma surgery, although these approaches have their own limitations and challenges 5.
Surgical Approaches
- CWU and CWD mastoidectomy are two common surgical approaches for managing infected cholesteatoma 5.
- Various "synthesis" techniques have been developed, combining the merits of CWU and CWD 5.
- The choice of surgical method depends on the individual case, and flexibility in selection is essential for optimizing outcomes 5.
Antibiotic Treatment
- Antibiotic treatment is an important aspect of managing infected cholesteatoma, with the goal of reducing the risk of postoperative infection 3.
- The use of antibiotic treatment protocols, such as those including topical gentamicin and dexamethasone, and oral clindamycin, has been shown to be effective in reducing postoperative infections 3.
- The selection of antibiotic treatment should be based on the individual case, taking into account factors such as the presence of preoperative otorrhea and the risk of refractory suppuration 3.