Can Cholesteatoma Cause Dizziness?
Yes, cholesteatoma can definitely cause dizziness and vertigo through erosion of the otic capsule and destruction of the lateral semicircular canal, creating a labyrinthine fistula. 1, 2
Mechanism of Vestibular Symptoms
Cholesteatoma is a destructive lesion that gradually expands and erodes adjacent bony structures in the temporal bone. 2 The primary mechanism by which it causes dizziness involves:
- Labyrinthine fistula formation: Erosion of the lateral semicircular canal is the most common pathway, creating direct communication between the middle ear and inner ear vestibular system 3, 2
- Labyrinthitis: This is the most common extracranial complication of cholesteatoma, and patients with otitis media who complain of dizziness should raise immediate clinical suspicion for potential labyrinthitis 1
- Direct vestibular dysfunction: Bone resorption can result in destruction of the otic capsule with consecutive vestibular dysfunction 2
Clinical Presentation
When cholesteatoma causes dizziness, patients typically present with:
- Vertigo (true spinning sensation) rather than vague lightheadedness 3, 4
- Pressure-induced symptoms: Pressure over the mastoid process may elicit vertigo and nystagmus (positive fistula test) 4
- Associated otologic symptoms: Foul-smelling purulent ear discharge (100% of extensive cases), hearing loss (83%), and otalgia (75%) 5
- Chronic ear disease history: Most patients have longstanding middle ear inflammation 3
Prevalence and Clinical Significance
Among patients with extensive cholesteatoma presenting with complications:
- 58% reported vertigo at the time of presentation 5
- Labyrinthitis is the highest incidence extracranial complication of cholesteatoma 1
- The destructive nature means symptoms often indicate advanced disease requiring urgent intervention 1, 2
Diagnostic Approach
CT temporal bone without contrast is the appropriate imaging modality to differentiate cholesteatoma from simple otitis media and identify bony erosion. 6
Key diagnostic features include:
- Otoscopic examination: Look for retrotympanic mass, perforation, retraction pockets, and granulation tissue 6
- Fistula testing: Apply pressure to the mastoid or tragus to elicit vertigo/nystagmus 4
- CT findings: Identify tegmen erosion (67% of extensive cases), lateral semicircular canal fistula, and extent of disease 5
Critical Management Considerations
Surgery is the only definitive treatment for cholesteatoma, and the presence of vestibular symptoms indicates more extensive disease requiring urgent intervention. 2, 5
- Early surgical intervention is critical when dizziness is present, as it indicates otic capsule involvement 1, 2
- Canal wall-down mastoidectomy is typically required for extensive disease with complications 3, 5
- Vertigo typically resolves within days after successful cholesteatoma removal 3
- Multidisciplinary approach: Neurosurgical consultation may be needed if intracranial extension is present 1, 5
Common Pitfalls to Avoid
- Do not dismiss dizziness in chronic ear disease: Any patient with otitis media complaining of dizziness should be evaluated urgently for cholesteatoma with labyrinthine involvement 1
- Do not confuse with other causes of vertigo: Unlike benign paroxysmal positional vertigo (seconds duration, positional) or Ménière's disease (episodic with fluctuating hearing), cholesteatoma-related dizziness is typically persistent and associated with chronic ear discharge 6, 7
- Do not delay imaging: CT temporal bone should be obtained promptly when cholesteatoma is suspected with vestibular symptoms 6
- Recognize that cholesteatoma is typically painless unless complications develop, distinguishing it from acute otitis externa 6