Cholesteatoma
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.
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