A cholesteatoma is a skin growth that occurs in the middle ear behind the eardrum. This condition usually results from poor eustachian tube function concurrent with middle ear infection (otitis media), but can also be present at birth. The condition is treatable, but can only be diagnosed by examination. Over time, untreated cholesteatoma can lead to bone erosion and spread of the ear infection to localized areas such as the inner ear and brain.

Cholesteatoma

An abnormal skin growth in the middle ear behind the eardrum is called cholesteatoma. Repeated infections and/or a tear or pulling inward of the eardrum can allow skin into the middle ear. Cholesteatomas often develop as cysts or pouches that shed layers of old skin, which build up inside the middle ear. Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear leading to hearing loss that surgery can often improve. Permanent hearing loss, dizziness, and facial muscle paralysis are rare, but can result from continued cholesteatoma growth. If untreated for years, deafness, brain abscess, meningitis, and death can occur in rare circumstances.

Symptoms

Initially, the ear may drain fluid with a foul odor. As the cholesteatoma pouch or sac enlarges, it can cause a feeling of fullness 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.

Cholesteatoma is a serious but treatable ear condition, which can be diagnosed only by medical examination. Bone erosion can cause the infection to spread into the surrounding areas, including the inner ear and brain.

Causes

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 allergies, a cold, or sinusitis, the air in the middle ear is absorbed by the body, creating a partial vacuum in the ear. The vacuum pressure sucks in a pouch or sac by stretching the eardrum, especially areas weakened by previous infections. This can develop into a sac and become 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.

Evaluation

An examination by an otologist or otolaryngologist can confirm the presence of a cholesteatoma. Initial evaluation may consist of a careful cleaning of the ear, antibiotics, and eardrops. Hearing tests and CT scans (3-D x-rays) of the mastoid may be necessary. These tests are performed to determine the hearing level in the ear and the extent of destruction the cholesteatoma has caused.

Treatment

Definitive treatment for cholesteatoma usually involves surgery. Surgery on the ear is performed to protect the patient from serious complications. Surgery is almost always performed under general anesthesia in an outpatient setting. For some patients, an overnight stay is necessary. In rare cases of serious infection, prolonged hospitalization for antibiotic treatment may be necessary.

The primary purpose of surgery is to remove the cholesteatoma to eliminate the infection and create a dry ear. A second surgery is sometimes necessary 6-12 months later to both ensure that the cholesteatoma is gone and attempt reconstruction of the damaged middle ear bones in an effort to improve hearing. In cases of severe ear destruction, reconstruction may not be possible.

Time off from work is typically one to two weeks. After surgery, follow-up office visits are necessary to evaluate results and to check for recurrence. Occasionally a larger opening to the ear is required with removal of the back ear canal.  This is called a “canal wall down” procedure and requires more frequent visits in follow-up. Some patients will need lifelong periodic ear examinations.