What is the treatment for ear canal cholesteatoma?

Treatment of Ear Canal Cholesteatoma

Surgical excision is the only effective treatment for ear canal cholesteatoma, as there are no effective nonsurgical options currently available. 1

Immediate Referral and Surgical Planning

• Any patient with suspected ear canal cholesteatoma requires immediate referral to an otolaryngologist for definitive surgical management 2
• Preoperative high-resolution CT (HRCT) of the temporal bone without IV contrast is essential for surgical planning, providing excellent anatomic detail of bony structures and determining disease extent 3
• MRI with non-echoplanar diffusion-weighted imaging (DWI) in the coronal plane should be obtained to differentiate cholesteatoma from other soft tissue pathology and inflamed granulation tissue 3

Surgical Approach Selection

The surgical technique for ear canal cholesteatoma depends on the stage and extent of disease:

For Early, Limited Disease

• Transcanal excision can be performed for small, circumscribed lesions lateral to the ossicles 4
• The goal is to evert the cholesteatomatous pocket into the meatus intact, followed by reconstruction of the outer attic wall 4

For Advanced Disease

• Combined approach tympanoplasty is indicated for circumscribed cholesteatoma both lateral and medial to the ossicles 4
• Classical radical mastoidectomy is the method of choice for marginal perforations with large cholesteatomas situated medial to the ossicular chain 4
• Modified radical mastoidectomy creating the smallest possible mastoid cavity should be performed in poorly pneumatized ears (85% of cases), aiming for a dry ear in approximately 90% of cases 5

Surgical Goals and Outcomes

The primary aim of surgery is to provide a disease-free, dry ear, with secondary goals of functional hearing improvement. 6

• Surgical intervention produces excellent hearing outcomes, with air conduction improving from 49.5 dB HL to 23.2 dB HL (p<0.001) 2
• Complete excision is critical, as residual disease leads to recurrence 5
• The intact wall technique has approximately 50% failure rate due to retraction pocket formation or residual disease, regardless of surgeon skill 5

Postoperative Surveillance

• CT temporal bone without IV contrast is the primary modality for detecting recurrent cholesteatoma, identifying abnormal, new, or enlarging lobulated material 3
• MRI with DWI and delayed postcontrast T1-weighted imaging differentiates recurrent cholesteatoma from postoperative granulation tissue and scar 3
• Regular otolaryngologic follow-up is mandatory given the risk of recurrence 5

Critical Pitfalls to Avoid

• Do not attempt nonsurgical management, as cholesteatoma causes progressive bone erosion through enzymatic activity and pressure effects, leading to ossicular erosion, lateral semicircular canal erosion, facial canal dehiscence, and tegmen erosion 1
• Do not confuse ear canal cholesteatoma with simple acute otitis externa; cholesteatoma is characteristically painless, unlike acute otitis externa 2
• Avoid relying on CT alone for tissue characterization due to poor specificity; MRI with DWI is essential for differentiating cholesteatoma from scar tissue 3