Surgical Management of Cholesteatoma
The primary treatment for cholesteatoma is complete surgical excision, with the specific surgical approach determined by the extent and location of the disease. 1
Understanding Cholesteatoma
Cholesteatoma is a benign but destructive lesion characterized by abnormal growth of keratinizing squamous epithelium in the middle ear. It typically presents with:
- Foul-smelling purulent ear discharge (most common symptom)
- Progressive hearing loss
- Otalgia (ear pain)
- Vertigo in some cases
- Potential complications including bone erosion and intracranial involvement 2
Surgical Approaches
The choice of surgical technique depends on several factors:
1. Canal Wall Down (CWD) Mastoidectomy
- Involves removal of the posterior ear canal wall
- Provides excellent exposure for complete disease removal
- Creates a cavity that requires lifelong maintenance
- Preferred for extensive cholesteatomas with complications
- Higher rate of disease clearance but may impact hearing function 2, 3
2. Canal Wall Up (CWU) Mastoidectomy
- Preserves the posterior ear canal wall
- Better hearing outcomes and fewer cavity problems
- Higher risk of residual/recurrent disease
- Requires more frequent follow-up imaging
- Suitable for limited disease in patients with good eustachian tube function 3
3. Combined/Modified Approaches
- Atticotomy/limited mastoidectomy ("third way")
- Open mastoidectomy with reconstruction of the posterior wall
- Combines advantages of both main techniques
- Creates smaller, self-cleaning cavities with better hearing preservation 3, 4
Surgical Decision-Making Algorithm
Limited cholesteatoma confined to attic/epitympanum:
- Atticotomy or limited mastoidectomy
- Reconstruction of ossicular chain if eroded
Moderate extension with good eustachian tube function:
- Canal wall up mastoidectomy
- Second-look surgery may be required in 6-12 months
Extensive cholesteatoma with complications:
- Canal wall down mastoidectomy
- Consider reconstruction of posterior wall if feasible
Cases with intracranial complications:
- Canal wall down with neurosurgical consultation
- Address complications (abscess drainage, sinus thrombosis management) 2
Outcomes and Follow-up
- Surgical success rates of 90-95% can be achieved with appropriate technique selection 4
- Residual cholesteatoma rates vary (6-30%) depending on technique
- Hearing preservation is possible with ossicular chain reconstruction
- Regular follow-up is essential, particularly with canal wall up procedures
Important Considerations
- Complete disease removal is the primary goal to prevent recurrence
- Hearing preservation is a secondary but important consideration
- Anatomical reconstruction should be attempted when feasible
- Surgeon experience significantly impacts outcomes
- Regular postoperative follow-up is crucial for early detection of recurrence
Pitfalls to Avoid
- Incomplete removal of disease leading to recurrence
- Inappropriate technique selection for extent of disease
- Inadequate follow-up, particularly after canal wall up procedures
- Failure to address complications (intracranial, labyrinthine)
The surgical management of cholesteatoma requires expertise and careful preoperative planning. While complete disease removal remains the primary goal, modern techniques allow for better hearing preservation and quality of life outcomes when properly selected and executed.