Cholesteatoma Treatment
Surgical excision is the definitive treatment for cholesteatoma, with the specific surgical approach determined by the extent and location of disease. 1
Referral and Initial Management
- Any patient with suspected cholesteatoma requires immediate referral to an otolaryngologist for definitive management, as this is not a condition for conservative observation 1
- Preoperative high-resolution CT (HRCT) of the temporal bone is essential for surgical planning, helping to identify ossicular erosion, tegmen erosion, and other anatomic complications 1
- MRI with diffusion-weighted imaging (DWI) should be obtained to differentiate cholesteatoma from granulation tissue or other soft tissue pathology, providing superior tissue characterization that CT cannot offer 1
Surgical Approach Selection
The surgical technique depends on disease extent and location:
For Early/Limited Disease:
- Transcanal endoscopic or microscopic techniques can be used for small attic cholesteatomas or retraction pockets, particularly in children with anterior and inferior pars tensa lesions 2, 3
- In highly selected pediatric cases with early acquired cholesteatoma (anterior/inferior pars tensa retractions without ossicular erosion), mechanical reduction with tympanostomy tube placement may be attempted, though this is only appropriate for minimal disease 3
For Extensive Disease:
- Canal wall down mastoidectomy is the procedure of choice for extensive cholesteatomas, particularly those with tegmen erosion, sigmoid sinus involvement, or other major complications 4
- Combined approach tympanoplasty is used for circumscribed cholesteatomas that extend both lateral and medial to the ossicles 5
- Classical radical mastoidectomy should be performed for marginal perforations with large cholesteatomas situated medial to the ossicular chain, especially in patients where follow-up may be unreliable 5
Critical Surgical Considerations
Common pitfalls to avoid:
- Tegmen plate erosion occurs in approximately 67% of extensive cases, requiring careful preoperative planning and potential neurosurgical consultation 4
- Sigmoid sinus involvement (25% of extensive cases) and jugular bulb invasion (8% of cases) necessitate vascular expertise and may require blind sac closure 4
- Endoscopic techniques are increasingly favored for their minimally invasive nature and improved visualization, though recurrence remains a concern requiring long-term surveillance 6, 2
Postoperative Management
- CT temporal bone without IV contrast is the primary surveillance modality for detecting recurrent disease by identifying new or enlarging lobulated material 1
- MRI with DWI is essential for differentiating recurrent cholesteatoma from postoperative granulation tissue and scar, which CT cannot reliably distinguish 1
- Intravenous antibiotics are routinely administered postoperatively, with steroids added when indicated for inflammation control 4
The key prognostic factors affecting surgical success include: patient age, specific location of disease, extent of ossicular chain involvement, and the presence of complications such as intracranial extension or vascular involvement 4, 3