Where to refer a patient diagnosed with cholesteatoma for treatment?

Referral Destination for Cholesteatoma

Any patient with suspected cholesteatoma should be referred immediately to an otolaryngologist (ENT specialist) for definitive surgical management, as surgery is the only effective treatment. 1, 2

Why Immediate ENT Referral is Critical

• Surgical excision is the only curative treatment for cholesteatoma—there are no effective nonsurgical options currently available 3
• Cholesteatoma causes progressive bone erosion through enzymatic activity and pressure effects, leading to ossicular destruction, scutum erosion, lateral semicircular canal erosion, facial canal dehiscence, and tegmen erosion 3
• Delayed diagnosis increases the risk of serious complications including intracranial involvement and orbital spread 4

Clinical Features That Warrant Urgent Referral

• Foul-smelling, purulent ear discharge with hearing loss that is characteristically painless unless complications develop 1
• Tympanic membrane abnormalities on examination including retraction pockets, perforation, or white keratinous debris visible behind an intact membrane 1, 2
• Granulation tissue at sites of erosion, attic blockage, or scutum erosion visible on careful otoscopic examination 1

Pre-Referral Imaging Considerations

• Do not delay referral to obtain imaging—the otolaryngologist will determine appropriate preoperative imaging 2
• If imaging is obtained, high-resolution CT temporal bone without IV contrast is the cornerstone modality for presurgical planning, providing excellent anatomic detail of bony structures and extent of disease 2
• MRI with diffusion-weighted imaging (DWI) may be used by the specialist to differentiate cholesteatoma from other soft tissue pathology and scar tissue 2

Common Pitfalls to Avoid

• Do not confuse cholesteatoma with simple acute otitis media or ventilation tube-associated otorrhea—cholesteatoma requires surgical management and is characterized by white keratinous debris 1
• Do not mistake external auditory canal cholesteatoma for acute otitis externa—cholesteatoma is characteristically painless, unlike otitis externa which is painful 1
• Do not attempt prolonged medical management with antibiotics alone, as this will not resolve the underlying disease and allows progressive bone destruction 3