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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.
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.
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.
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.
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.
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.
© 2004 AAO-HNS/AAO-HNSF
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