What is a cholesteatoma?
A cholesteatoma is a skin growth that occurs in an abnormal location,
the middle ear behind the eardrum. It is usually due to repeated
infection, which causes an ingrowth of the skin of the eardrum.
Cholesteatomas often take the form of a cyst or pouch that sheds layers of
old skin that builds up inside the ear. Over time, the cholesteatoma can
increase in size and destroy the surrounding delicate bones of the middle
ear. Hearing loss, dizziness, and facial muscle paralysis are rare but can
result from continued cholesteatoma growth.
How
does it occur?
A cholesteatoma usually occurs because of poor eustachian tube function
as well as infection in the middle ear. The eustachian tube conveys air
from the back of the nose into the middle ear to equalize ear pressure
("clear the ears"). When the eustachian tubes work poorly perhaps due to
allergy, a cold or sinusitis, the air in the middle ear is absorbed by the
body, and a partial vacuum results in the ear. The vacuum pressure sucks
in a pouch or sac by stretching the eardrum, especially areas weakened by
previous infections. This sac often becomes a cholesteatoma. A rare
congenital form of cholesteatoma (one present at birth) can occur in the
middle ear and elsewhere, such as in the nearby skull bones. However, the
type of cholesteatoma associated with ear infections is most common.
What are the symptoms?
Initially, the ear may drain, sometimes with a foul odor. As the
cholesteatoma pouch or sac enlarges, it can cause a full feeling or
pressure in the ear, along with hearing loss. (An ache
behind or in the ear, especially at night, may cause significant
discomfort.) Dizziness, or muscle weakness on one side of the face (the
side of the infected ear) can also occur. Any, or all, of these symptoms
are good reasons to seek medical evaluation.
Is it dangerous?
Ear cholesteatomas can be dangerous and should never be ignored. Bone
erosion can cause the infection to spread into the surrounding areas,
including the inner ear and brain. If untreated, deafness, brain abscess,
meningitis, and rarely death can occur.
What treatment can be
provided?
An examination by an otolaryngologist-head and neck surgeon can confirm
the presence of a cholesteatoma. Initial treatment may consist of a
careful cleaning of the ear, antibiotics, and ear drops. Therapy aims to
stop drainage in the ear by controlling the infection. The extent or
growth characteristics of a cholesteatoma must also be evaluated.
Large or complicated cholesteatomas usually require surgical treatment
to protect the patient from serious complications. Hearing and balance
tests, x-rays of the mastoid (the skull bone next to the ear), and CAT
scans (3-D x-rays) of the mastoid may be necessary. These tests are
performed to determine the hearing level remaining in the ear and the
extent of destruction the cholesteatoma has caused.
Surgery is performed under general anesthesia in most cases. The
primary purpose of the surgery is to remove the cholesteatoma and
infection and achieve an infection-free, dry ear. Hearing preservation or
restoration is the second goal of surgery. In cases of severe ear
destruction, reconstruction may not be possible. Facial nerve repair or
procedures to control dizziness are rarely required. Reconstruction of the
middle ear is not always possible in one operation; and therefore, a
second operation may be performed six to twelve months later. The second
operation will attempt to restore hearing and, at the same time, inspect
the middle ear space and mastoid for residual cholesteatoma.
Admission to the hospital is usually done the morning of surgery, and
if the surgery is performed early in the morning, discharge maybe the same
day. For some patients, an overnight stay is necessary. In rare cases of
serious infection, prolonged hospitalization for antibiotic treatment may
be necessary. Time off from work is typically one to two weeks.
Follow-up office visits after surgical treatment are necessary and
important, because cholesteatoma sometimes recurs. In cases where an open
mastoidectomy cavity has been created, office visits every few months are
needed in order to clean out the mastoid cavity and prevent new
infections. In some patients, there must be lifelong periodic ear
examinations.
Summary
Cholesteatoma is a serious but treatable ear condition which can only
be diagnosed by medical examination. Persisting earache, ear drainage, ear
pressure, hearing loss, dizziness, or facial muscle weakness signals the
need for evaluation by an otolaryngologist-head and neck surgeon.