Cholesteatoma Causes Symptoms and Treatment

Cholesteatoma is a common yet often little-known problem, and it is considered one of the most serious conditions affecting the middle ear if not detected early. It is an abnormal accumulation of skin inside the ear that gradually grows, causing hearing loss, chronic discharge, and potentially serious complications if treatment is delayed.

The causes of cholesteatoma in children and adults

• Its symptoms and how to accurately diagnose it

• Treatment methods, including medication and surgery

• Tips for prevention and recovery after surgery

By following these steps and maintaining regular medical follow-up, you can protect yourself or your child from complications and ensure the best chance of restoring hearing and maintaining ear health.

What is Cholesteatoma?

Cholesteatoma is an abnormal growth of skin inside the middle ear. Despite its name, it is not related to blood cholesterol, but it is dangerous because it can cause hearing loss, chronic ear discharge, and serious complications if treatment is delayed.

Is Cholesteatoma Congenital or Acquired?

• Congenital cholesteatoma: Present from birth, rare, and often discovered by chance in children.

• Acquired cholesteatoma: More common, usually develops due to chronic ear problems, eardrum damage, or a perforation in the eardrum.

Tip: Early detection reduces risks and increases the chances of preserving hearing.

Can Cholesteatoma Recur After Surgery?
Yes, cholesteatoma can come back even after surgical removal. The risk of recurrence is higher in children than adults, so regular follow-up is essential to prevent complications.

Does Cholesteatoma Affect Vision?
In very rare cases, the growth can press on nerves near the ear, potentially affecting vision or the visual field.

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Stages of Cholesteatoma

Stage 1: Formation Stage

• The eardrum starts to retract.

• Skin accumulates inside the retraction.

• Often no obvious symptoms, maybe a slight feeling of blockage.

Stage 2: Growth Stage

• The cholesteatoma gradually enlarges.

• Symptoms appear, such as: repeated discharge, foul odor, mild hearing loss.

Stage 3: Erosion Stage

• The cholesteatoma begins eroding the bones of the middle ear.

• More obvious symptoms: erosion of the ossicles, significant hearing loss, pain, tinnitus.

• Immediate treatment is essential.

Stage 4: Complication Stage ⚠️

• The most dangerous stage.

• The cholesteatoma may extend to the inner ear or facial nerve.

• Possible complications: dizziness, balance loss, facial nerve paralysis, severe brain infections (rare).

Note for children: Cholesteatoma develops faster in children, and symptoms may appear late, so regular monitoring is very important.

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Types of Cholesteatoma

1️⃣ Congenital Cholesteatoma

• Present from birth, mostly in children.

• No prior infections.

• Grows slowly but can cause problems if untreated.

2️⃣ Acquired Cholesteatoma

Primary:

• Caused by weakness or dysfunction of the Eustachian tube.

• Leads to eardrum retraction and skin accumulation inside the ear.

Secondary:

• Resulting from:

  • Chronic ear infections

  • Eardrum perforation

  • Previous ear surgeries

• Skin abnormally enters the middle ear.

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Main Causes of Cholesteatoma

1️⃣ Repeated chronic middle ear infections

• Affect the eardrum and cause skin to move abnormally into the middle ear.

2️⃣ Weakness or blockage of the Eustachian tube

• The Eustachian tube ventilates the middle ear.

• Weakness or blockage causes negative pressure, retracting the eardrum and allowing skin to accumulate.

3️⃣ Eardrum perforation

• May result from: chronic infection, injury, or previous surgery.

• Skin enters the middle ear and starts to accumulate.

4️⃣ Chronic sinus infections or allergies

• Affect the Eustachian tube and increase the risk of eardrum retraction.

5️⃣ Childhood ear infections

• Children are more susceptible due to weaker immunity and shorter Eustachian tube.

• The problem may appear years later.

6️⃣ Congenital causes

• Rare, caused by misplaced skin cells from birth, without prior infections.

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Symptoms of Cholesteatoma

1️⃣ Ear discharge

• Persistent pus or foul-smelling discharge, often continues despite temporary treatment.

2️⃣ Hearing loss

• Gradual, due to:

  • Erosion of ossicles

  • Ear blockage from accumulated skin

• Can lead to significant hearing loss if untreated.

3️⃣ Ear pain or pressure

• A feeling of heaviness or continuous ache.

• Sometimes mild but bothersome, worsens with infection.

4️⃣ Tinnitus

• Ringing or buzzing in the ear, caused by nerve involvement and hearing issues.

5️⃣ Dizziness and imbalance

• If the cholesteatoma reaches the inner ear:

  • Dizziness

  • Unsteady walking

6️⃣ Frequent headaches

• Especially in advanced cases, due to inflammation spreading to surrounding tissues.

7️⃣ Facial muscle weakness or numbness (rare)

• If the cholesteatoma presses on the facial nerve:

  • Weakness on one side of the face

  • Difficulty smiling or closing the eye
    ⚠️ This is a serious symptom requiring immediate intervention.

8️⃣ Symptoms in children

• Delayed speech

• Difficulty paying attention

• Frequent ear pulling or crying

• Chronic ear discharge

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Warning Signs – See a Doctor Immediately

• Chronic ear discharge with a foul odor

• Worsening hearing loss

• Severe dizziness

• Persistent ear pain or facial numbness

Diagnosis of Cholesteatoma

Accurate diagnosis of cholesteatoma requires several careful steps to determine the size of the growth and its impact on the ear and hearing:

1️⃣ Clinical Ear Examination

• The first and most important step.

• The doctor uses an otoscope to observe:

  • Chronic ear discharge

  • Retraction or pocket in the eardrum

  • A white or yellow mass inside the ear

2️⃣ Hearing Test (Audiometry)

• Determines the degree and type of hearing loss (conductive or sensorineural).

• Important for assessment before and after treatment.

3️⃣ CT Scan of the Ear

• Shows:

  • Size of the cholesteatoma

  • Bone erosion

  • Involvement of the mastoid

• Essential for surgical planning.

4️⃣ MRI (Magnetic Resonance Imaging)

• Used in specific cases to:

  • Confirm the spread of the cholesteatoma

  • Follow-up after surgery

  • Differentiate cholesteatoma from inflammation

5️⃣ Ear Discharge Culture (if needed)

• Used when there is significant pus to identify the bacteria and choose the appropriate antibiotic.

6️⃣ Pediatric Diagnosis

• More challenging due to:

  • Hearing impairment

  • Speech delays

  • Recurrent ear discharge

• Requires careful, long-term follow-up to ensure early detection.

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Treatment of Cholesteatoma by Type

1️⃣ Congenital Cholesteatoma

• Primary treatment: Surgery to completely remove the growth, usually without significant hearing damage.

• Success rate: Very high, with continuous follow-up to ensure it does not recur.

• Medications: Only used if there is a secondary infection; they do not treat the cholesteatoma itself.

2️⃣ Primary Acquired Cholesteatoma

• Cause: Eardrum retraction due to Eustachian tube dysfunction.

• Surgery includes:

  • Complete removal of the cholesteatoma

  • Repair of the eardrum

  • Reconstruction of the ossicles if needed

• Pre-surgery care:

  • Ear cleaning

  • Treating infections

  • Using antibiotics if necessary

3️⃣ Secondary Acquired Cholesteatoma

• Cause: Eardrum perforation or chronic infection.

• Surgery includes:

  • Removal of the cholesteatoma

  • Closure of the eardrum perforation

  • Cleaning the middle ear and mastoid

• Surgery is often more extensive due to spread of the cholesteatoma and bone erosion.

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Medication for Cholesteatoma

❌ No medication can permanently remove cholesteatoma.
✔️ Medications are supportive, temporary, and used to relieve symptoms and prepare for surgery.

When medications are used:

• Control infection

• Reduce discharge and pus

• Prepare the ear for surgery

• Relieve symptoms after surgery

Types of medications:
1️⃣ Ear drops:

• Contain antibiotics and sometimes corticosteroids

• Reduce pus and inflammation

• ⚠️ Only use under doctor supervision

2️⃣ Oral antibiotics:

• Used for severe infection or spreading infection

• Treat secondary infection, not the cholesteatoma itself

3️⃣ Pain relievers:

• For earache and headaches

• Only temporary relief

4️⃣ Allergy medications and nasal sprays:

• Improve Eustachian tube function

• Reduce pressure in the ear

Why medications alone are insufficient:

• Cholesteatoma is accumulated skin that does not dissolve or disappear.

• It grows over time and erodes bones.

• Using only medications = temporary improvement, stronger recurrence, higher risk of hearing loss and neurological complications.

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Surgical Treatment of Cholesteatoma

Main goal: Complete removal of the cholesteatoma, prevent recurrence, and preserve hearing as much as possible.

1️⃣ Tympanoplasty (Simple Middle Ear Surgery)

• Suitable for small, limited cholesteatomas

• Removes cholesteatoma, repairs eardrum, improves hearing

2️⃣ Canal Wall Up Mastoidectomy

• Removes cholesteatoma and cleans the mastoid

• Preserves the posterior canal wall

• Ossicles reconstruction if possible

• Suitable for early or moderate cases, and children

• ❌ Higher recurrence risk, requires careful follow-up

3️⃣ Canal Wall Down Mastoidectomy

• Removes cholesteatoma completely and posterior canal wall

• Creates a permanent cavity for easier cleaning

• Suitable for advanced cases, severe bone erosion, or recurrent cholesteatoma

• ✅ Lower recurrence, safer

• ❌ Requires regular cleaning; hearing may not improve significantly

4️⃣ Ossiculoplasty (Ossicle Reconstruction)

• Improves hearing during initial surgery or later

• Uses prosthetic ossicles or patient's own bones

5️⃣ Two-Stage Surgery

• Stage 1: Removal and thorough cleaning

• Stage 2 (6–12 months later): Confirm no recurrence and reconstruct hearing

• Suitable for children and complex cases

6️⃣ Endoscopic Ear Surgery

• Minimally invasive using a small endoscope through the ear canal

• ✅ Less invasive, less pain, faster recovery

• ❌ Limited use, depends on surgeon expertise

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Prevention of Cholesteatoma

1️⃣ Treat ear infections promptly
2️⃣ Maintain Eustachian tube health (avoid chronic colds and uncontrolled allergies)
3️⃣ Protect ears from water and trauma, especially with eardrum perforation
4️⃣ Regular check-ups for children
5️⃣ Avoid passive smoking
6️⃣ Periodic ear examinations, especially with family history or chronic ear problems

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Recovery After Cholesteatoma Surgery

1️⃣ First day post-surgery:

• Under close medical observation

• Mild pain managed with analgesics

• Keep head elevated to reduce swelling and ear pressure

2️⃣ First 2 weeks:

• Avoid water in the ear (showering, swimming)

• Use prescribed ear drops or antibiotics

• Monitor for bleeding or discharge

• Light movement allowed, rest recommended

3️⃣ 2 weeks to 1 month:

• Remove any ear packing or dressing if present

• Follow-up check for ear healing

• Hearing test to assess improvement

• Strict adherence to medications

4️⃣ 1 to 3 months:

• Most cholesteatoma removed completely

• Gradual hearing improvement depending on ossicles and bone condition

• Some cases may require secondary ossicle reconstruction

5️⃣ 3–6 months:

• Final ear check to ensure no recurrence

• Follow-up imaging if needed

• Patient learns safe ear cleaning techniques

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Important Tips During Recovery

• Avoid strenuous activities or contact sports

• Do not blow your nose forcefully

• Maintain ear hygiene as instructed

• Report immediately if:

  • Foul discharge

  • Severe pain

  • Dizziness or facial weakness

Full Recovery Time:

• Basic recovery: ~6–8 weeks

• Final hearing improvement: may take several months depending on the case