What is the treatment for cholesteatoma?

Treatment for Cholesteatoma

Surgical excision is the definitive treatment for cholesteatoma, with the specific surgical approach determined by the extent of disease, degree of bone destruction, and mastoid pneumatization. 1

Diagnosis and Evaluation

• Cholesteatoma typically presents with painless otorrhea and may be associated with tympanic membrane abnormalities including perforation, retraction pockets, and granulation tissue 2
• Any patient with suspected cholesteatoma should be referred to an otolaryngologist for definitive management 2
• Preoperative high-resolution CT (HRCT) scan of the temporal bone is essential for surgical planning and can help estimate the degree of ossicular erosion 2
• Non-echoplanar diffusion-weighted MRI sequences are optimal for detection of residual cholesteatoma in post-surgical surveillance 3

Surgical Management Options

Primary Surgical Approaches

There are three main surgical approaches for cholesteatoma management:

1. Canal Wall Up (CWU) Mastoidectomy:

   • Preserves the posterior ear canal wall
   • Better hearing outcomes but higher recurrence rates
   • More anatomically normal appearance 4

2. Canal Wall Down (CWD) Mastoidectomy:

   • Removes the posterior ear canal wall
   • Lower recurrence rates but may require more frequent cleaning
   • Creates a mastoid bowl that requires long-term maintenance 1, 4

3. Limited Approach (Third Option):

   • Includes atticotomy, atticoantrostomy, or limited mastoidectomy
   • Based on cholesteatoma size and location
   • Creates smaller, self-cleaning cavities with less anatomical disruption 4

Surgical Decision-Making Algorithm

The choice of surgical approach should be guided by:

• Extent of cholesteatoma
• Amount of preoperative destruction
• Size of mastoid pneumatization 1
• Patient factors (age, compliance with follow-up) 4

Post-Surgical Management

• 89% of operated ears require periodic follow-up (approximately every 5 months) for:
  • Cleansing of mastoid cavity
  • Maintaining middle ear aeration (possibly with ventilation tube insertion) 1
• CT temporal bone without IV contrast is recommended for postoperative surveillance to detect recurrence by evaluating for:
  • Abnormal, new, or enlarging lobulated material
  • Subtle osseous erosions 2
• MRI with diffusion-weighted imaging (DWI) is suitable for postsurgical assessment to differentiate between:
  • Keratinous debris (cholesteatoma)
  • Non-cholesteatoma findings such as granulation tissue or scar 2

Complications and Considerations

• Without timely detection and intervention, cholesteatomas can grow aggressively and invade intratemporal structures 5
• Potential complications include bone erosion, intracranial involvement, and orbital spread 6
• Recurrence remains a major concern even after appropriate surgical management 6, 1
• Currently, no viable nonsurgical therapies are available for cholesteatoma 5

Follow-up Protocol

• Regular otologic examination is essential to monitor for recurrence
• Imaging surveillance with non-echoplanar DWI MRI has reduced the need for routine "second-look" surgery 3
• Long-term follow-up is necessary as the underlying cause of cholesteatoma (negative middle ear pressure) often persists 1