What is the management of cholesteatoma?

Management of Cholesteatoma

The definitive management of cholesteatoma requires surgical intervention by an otolaryngologist, with the specific surgical approach determined by the extent and location of disease. 1, 2

Diagnosis and Evaluation

• Cholesteatoma typically presents with painless otorrhea and tympanic membrane abnormalities including perforation, retraction pockets, and granulation tissue 1
• Any patient with suspected cholesteatoma should be promptly referred to an otolaryngologist for definitive management 3, 1
• Preoperative imaging is essential for surgical planning:
  • High-resolution CT temporal bone without IV contrast is recommended to assess the extent of disease, bony erosion, and anatomical variations 3, 1
  • MRI with diffusion-weighted imaging (DWI) helps differentiate cholesteatoma from other soft tissue pathologies like granulation tissue or scar 3, 1

Surgical Management

• Surgery is the only curative treatment for cholesteatoma, with the approach determined by disease extent 2, 4:

  • Limited disease: Transcanal approach with atticotomy for small cholesteatomas confined to the attic region 4
  • Moderate disease: Combined approach tympanoplasty (canal wall up) for circumscribed cholesteatomas 4
  • Extensive disease: Canal wall down mastoidectomy for large cholesteatomas with significant spread 4, 5

• Surgical goals include:

  • Complete removal of cholesteatoma matrix 2
  • Control of infection 2
  • Repair of tympanic membrane perforation 2
  • Preservation or improvement of hearing when possible 2

• For tympanic membrane reconstruction, cartilage shows better structural outcomes compared to temporalis muscle fascia (92.4% vs 84.3% graft integration rates) 2

Postoperative Management and Surveillance

• Regular follow-up is essential to monitor for recurrence 1
• Postoperative imaging surveillance:
  • CT temporal bone without IV contrast is recommended to detect recurrence by evaluating for abnormal tissue and subtle bone erosions 3, 1
  • MRI with diffusion-weighted imaging (DWI) is valuable for differentiating recurrent cholesteatoma from postoperative changes like granulation tissue or scar 3, 1

Management of Complications

• Extensive cholesteatomas may require additional interventions for complications:
  • Intracranial extension may require neurosurgical consultation 5
  • Sigmoid sinus thrombosis may require anticoagulation 2, 5
  • Facial nerve involvement may necessitate facial nerve decompression 5

Special Considerations

• Patients with diabetes or immunocompromised states require special attention due to increased risk of complications 3, 2

• The choice of surgical approach should consider:

  • Patient factors (age, comorbidities, compliance with follow-up) 2
  • Disease extent and location 4
  • Surgeon's experience 4

• Recurrence remains a major concern, particularly with extensive disease, necessitating long-term surveillance 3, 5