Otology A16



Cholesteatoma lies on the spectrum of conditions under the chronic suppurative otitis media (CSOM) umbrella. It can be congenital or acquired, the latter of which can be further divided into primary or secondary (i.e. caused by perforation or surgical manipulation). 

The pathology involves progressive tympanic membrane retraction with accumulation of keratinised squamous epithelium in the pocket due to compromised migration; these cells release enzymes that erode the bony wall and ossicles, thus contributing to the name cholesteatoma in the absence of actual tumour. 

Features include: 

  • Offensive discharge for more than 6 weeks
  • Conductive hearing loss
  • Aural fullness
  • Tinnitus
  • Episodic vertigo

Otoscopy usually reveals a retraction pocket in the pars flaccida with or without granulation tissue and keratin debris.

Before any intervention it is essential to investigate with a CT scan of the temporal bone along with pure tone audiometry to assess the degree of hearing loss, and possibly a bacteria swab for culture. 

Subsequent management usually involves surgical intervention: options include either tympanomastoidectomy or tympanoplasty, the choice of which may have to be decided during the operation. 

The recurrence rate, dependent on a variety of factors including type of operation, ranges from 5 to 30%; any cholesteatoma left in situ will re-grow, so it is important to remove it all. Diffusion weighted MRI (or less commonly second-look surgery) is carried out to check for residual cholesteatoma.

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