Primary Treatment for Cholesteatoma
Surgery is the only definitive treatment for cholesteatoma and should be performed by an otolaryngologist to achieve complete disease eradication and prevent life-threatening complications. 1
Immediate Referral Required
- Any patient with suspected cholesteatoma requires immediate referral to an otolaryngologist for surgical management 2, 1
- Cholesteatoma is typically painless and presents with foul-smelling purulent ear discharge, hearing loss, and characteristic tympanic membrane abnormalities including retraction pockets, perforation, or visible white keratinous debris 1
- Do not mistake cholesteatoma for simple otitis externa or acute otitis media—the presence of tympanic membrane abnormalities (perforation, retraction pockets, granulation tissue) distinguishes cholesteatoma and mandates specialist referral 2
Surgical Approach Selection
The primary goal of surgery is complete eradication of cholesteatoma to achieve a dry, disease-free ear. 3, 4
Surgical technique depends on disease extent:
- Canal wall-up (CWU) tympanoplasty: Preserves normal ear canal anatomy and is preferred for limited disease, particularly mesotympanic cholesteatoma with intact ossicular chain 5, 6
- Canal wall-down (CWD) mastoidectomy: Provides superior visualization and access for extensive disease but creates an open mastoid cavity requiring lifelong care 5, 3
- Modified Bondy radical mastoidectomy: Indicated for cholesteatoma with intact ossicular chain, offering excellent disease control (no middle ear residual disease) while preserving hearing 6
Key surgical considerations:
- Complete cortical mastoidectomy with wide posterior tympanotomy is essential for adequate exposure 5
- Residual cholesteatoma rates are higher with CWU (5.7%) compared to modified Bondy technique (0% in middle ear space) 6
- Recurrence rates range from 8.57% for CWU to 10% for modified approaches at 2-8 year follow-up 6
Critical Pitfalls to Avoid
- Never attempt medical management alone—cholesteatoma requires surgical excision as it progressively erodes bone and can cause intracranial complications, facial nerve paralysis, and labyrinthine fistula 7, 4
- Delayed diagnosis is common due to nonspecific symptoms (nasal congestion, recurrent infections in sinonasal cholesteatoma), so maintain high clinical suspicion with any chronic ear discharge and tympanic membrane abnormality 7
- Endoscopic techniques are increasingly favored for their minimally invasive nature and improved visualization of hidden disease 3
Postoperative Surveillance
- Long-term follow-up is mandatory as recurrence can occur years after surgery (2-8 years reported) 6
- CT temporal bone without contrast provides excellent anatomic detail for detecting recurrent disease and bone erosions 2
- MRI with diffusion-weighted imaging helps differentiate recurrent cholesteatoma from granulation tissue or scar 2, 7