From the Guidelines
A cholesteatoma is a serious condition that requires prompt medical attention to prevent complications such as permanent hearing loss, meningitis, brain abscess, or facial paralysis. Cholesteatomas are abnormal skin growths that develop in the middle ear behind the eardrum, typically beginning as a cyst that gradually increases in size and destroys surrounding structures, including the small bones of hearing (ossicles), facial nerve, and even the inner ear or brain in severe cases 1.
Causes and Symptoms
Cholesteatomas often result from chronic ear infections, eustachian tube dysfunction, or congenital defects. Symptoms include persistent foul-smelling drainage from the ear, hearing loss, dizziness, ear pressure, and occasionally facial weakness.
Diagnosis and Treatment
Diagnosis involves physical examination with an otoscope and imaging studies like CT scans. Treatment is primarily surgical removal (mastoidectomy or tympanoplasty) as cholesteatomas don't respond to medications alone. Antibiotics may be prescribed before surgery to control infection, but they cannot eliminate the cholesteatoma itself.
Importance of Follow-up
If left untreated, cholesteatomas can cause serious complications. Regular follow-up is essential after treatment as recurrence rates can be significant, ranging from 5-20% depending on the extent of disease and surgical approach 1. Early detection and intervention are crucial to prevent these complications, and surveillance at 3 to 6 months can help identify structural changes in the tympanic membrane that may require intervention 1.
Key Considerations
It is essential to consider the potential risks and benefits of treatment, including the cost of examination and the potential for significant hearing loss or other complications if left untreated 1. The role of patient preferences is also important, and shared decision-making regarding the surveillance interval can help ensure that the patient's needs and concerns are addressed 1.
From the Research
Definition and Overview of Cholesteatoma
- Cholesteatoma is considered a benign, expanding, and destructive epithelial lesion of the temporal bone that is the result of a multifactorial process 2.
- It is a serious and challenging entity to manage, whether found within the pediatric or adult population, and can lead to significant complications if undetected and left untreated 2.
Classification and Staging
- The European Academy of Otology and Neurotology in collaboration with the Japanese Otological Society (EAONO/JOS) recently produced a joint consensus document outlining the definitions, classification, and staging of middle ear cholesteatoma 2.
- The goals of this document were to provide terminologies in the description of cholesteatoma, classify cholesteatoma into distinct categories to facilitate the comparison of surgical outcomes, and to provide a staging system that reflects the severity, difficulty of complete removal, and restoration of normal function 2.
Surgical Management
- Surgery remains the mainstay of cholesteatoma management, and the available surgical approaches have expanded to include traditional procedures, endoscopic procedures, canal wall reconstruction procedures, mastoid obliteration, and retrograde mastoidotomy 3.
- The selection of management technique will depend on disease characteristics, patient factors, and surgeon preference 3.
- Endoscopic ear surgery is increasingly accepted as a primary modality for cholesteatoma surgery, offering enhanced visualization of the middle ear and equivalent outcomes regarding residual and recurrent disease, similar rates of complications, decreased pain, and shorter healing time 4.
Complications
- Complications of cholesteatoma result from characteristic inflammatory and resorptive processes that erode the structures of the middle and inner ear with potential to spread locally 5.
- Common intratemporal complications include hearing loss, facial nerve palsy, labyrinthine fistula, and dysgeusia, while extratemporal complications may be life-threatening and include cerebrospinal fluid leak and encephalocele, meningitis, epidural and intraparenchymal abscesses, subdural empyema, and otic hydrocephalus 5.
Treatment Outcomes
- A contemporary, pragmatic approach to managing cholesteatoma in the only hearing ear has been described, with a focus on intact canal wall procedures and ossicular chain reconstruction 6.
- This approach appears safe when performed by an experienced surgeon, and reliable long-term patient follow-up is maintained, with 79% of patients maintaining stable or improved pure tone thresholds at a mean follow-up of 48 months 6.