Print

CHOLESTEATOMA - A SERIOUS CONDITION

WHAT IS A CHOLESTEATOMA?

A cholesteatoma is a skin growth that occurs in an abnormal location inside the middle ear behind the eardrum. Ear canal skin "sheds" just like the skin in any other part of the body Cholesteatomas often take the form of a cyst or pouch lined by ear canal skin. This collects the layers of shed old skin and builds up inside the ear. Over time the cholesteatoma can increase in size or become infected 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 CHOLESTEATOMA 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, or most commonly due to unknown factors, 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 OF CHOLESTEATOMA?

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.) The ear may drain, sometimes with a foul odour. 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 CHOLESTEATOMA 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, but rarely, death can occur.

WHAT TREATMENT CAN BE PROVIDED?

An examination by an otolaryngologist - head and neck (Ear Nose and Throat) 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.

An audiogram (hearing test) and a CT scan 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 anaesthesia. 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, or persisting Eustachian tube dysfunction,reconstruction may not be possible.

WHAT IS A MASTOIDECTOMY?

This is when the cholesteatoma is removed from the middle ear and mastoid air cell system. The mastoid is a bone which forms part of the ear, and is composed often of bone like honeycomb. The cholesteatoma finds its way into this bone readily, and thus the bone of the mastoid, which sits immediately behind the ear, must be removed. Some of the hearing bones (ossicles) need to be removed to enable safe clearance of the cholesteatoma. Often they can be replaced at the time, or at a second operation after 9-12 months. This means the hearing may not be able to be restored or may only be restored after a second procedure.

ARE THERE COMPLICATIONS?

Complications are very uncommon in experienced hands.

• Anaesthetic risks: These are very rare, but are best discussed on an individual basis.
• Surgical risks include:
• Further hearing deterioration or loss- sometimes accompanied by tinnitus (ringing in the ear)
• Temporary (or rarely permanent) loss of taste in the front of the tongue (on the same side as the operation) secondary to excision of the "chorda tympani" nerve which runs through the ear.
• Damage to the nerve which supplies the facial muscles ("the facial nerve".)
• Cholesteatoma or ear discharge may recur
• Wound infection
• Bleeding from the wound

WHAT MAY I EXPECT AFTER THE OPERATION?

The hair immediately behind the ear is shaved. There is a cut (and subsequently a scar) behind the ear. Usually there will be dissolving stitches buried under the skin. There will be tape over the wound for 3 weeks. The "ear hole" will be slightly larger than before. This usually "oozes" a mixture of blood and iodine from the dressing inside the ear for several weeks during the healing process. A regular change of cotton wool is advised to soak this up. The ear canal is much larger (termed a mastoid cavity), and takes some 12 weeks to heal on the inside. There will be a head bandage on overnight. Most people are able to return home the next day. Regular visits are necessary to ensure complete healing. Long term follow-up (possibly life-long) visits, on a less frequent basis may also be required.

Swimming and water exposure should be OK once the ear is healed, but on occasions water exposure may still have to be restricted. The ear wound heals fairly rapidly, but some people find the area of the wound may be fairly numb or tender for some months afterwards.

Exercise and sport should be avoided for 2 weeks post operatively but walking is quite safe.

Reconstruction of the middle ear is not always possible in one operation; and therefore, a second operation may be performed nine to twelve months later. At the second operation an attempt to restore hearing may be made, and at the same time an inspection is made of the middle ear space and mastoid for residual cholesteatoma.

Admission to the hospital is usually done the morning of surgery, An overnight stay is usually 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 visits after surgical treatment are necessary and important because cholesteatoma sometimes recurs. In cases where an open mastoidectomy cavity has been created, visits to the specialist every few months are needed in order to clean out the mastoid cavity and prevent new infections. In most patients there must be lifelong periodic ear examinations,usually. On a 6 to 12 monthly basis.

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 specialist evaluation.