Cholesteatoma Symptoms
Cholesteatoma typically presents with foul-smelling, purulent ear discharge (otorrhea) as the most consistent symptom, often accompanied by hearing loss, and is characteristically painless unless complications develop. 1, 2
Primary Clinical Presentation
The hallmark symptoms of cholesteatoma include:
- Chronic ear drainage (otorrhea): Foul-smelling, purulent discharge occurs in virtually all cases (100% in extensive disease), representing the most reliable presenting symptom 2
- Hearing loss: Conductive hearing loss is the predominant pattern, occurring in approximately 83% of patients, though sensorineural or mixed hearing loss may develop with advanced disease 2, 3
- Painless nature: Unlike acute otitis externa or media, cholesteatoma is characteristically painless unless complications arise 1
Secondary Symptoms Indicating Disease Progression
As cholesteatoma expands and erodes surrounding structures, additional symptoms emerge:
- Otalgia (ear pain): Develops in approximately 75% of cases with extensive disease, signaling complications or secondary infection 2
- Vertigo/dizziness: Occurs in about 58% of patients, indicating lateral semicircular canal erosion 2
- Temporal headache: Present in one-third of patients, potentially signaling intracranial extension 2
- Tinnitus and ear fullness: Common associated symptoms, though nonspecific 1
Signs of Serious Complications
Advanced cholesteatoma with intracranial or neurovascular involvement presents with:
- Facial nerve paralysis: Indicates facial canal dehiscence or erosion 3
- Altered mental status: Suggests intracranial extension with abscess formation or meningitis 3
- Severe headache with neurologic findings: May indicate tegmen erosion with cerebrospinal fluid leak, brain herniation, or intracranial abscess 2
Physical Examination Findings
On otoscopic examination, cholesteatoma demonstrates:
- Tympanic membrane abnormalities: Retraction pockets, perforation, or white debris visible behind an intact membrane 1
- Granulation tissue: Often present at sites of erosion 1
- Attic blockage and scutum erosion: Visible on careful examination 1
Critical pitfall: Cholesteatoma symptoms are nonspecific and diagnosis may be difficult on routine otoscopic examination alone, leading to delayed recognition 4. The combination of chronic foul-smelling otorrhea with hearing loss in the absence of significant pain should raise immediate suspicion for cholesteatoma rather than simple chronic otitis media.
Any patient with suspected cholesteatoma based on these symptoms and examination findings should be referred immediately to an otolaryngologist for definitive surgical management, as this is the only effective treatment. 1, 5