Cholesteatoma

Question 1

Define cholesteatoma.

Answer 1

Mass of stratified keratinising squamous epithelium within the middle ear or mastoid. Benign but may enlarge and cause local destruction.

Question 2

How common is cholesteatoma?

Answer 2

M:F 3:2
Most common aged 10-20yrs
~10 per 100,000 in adults and children
In children it affects the eustachian tube more than in adults - more aggressive in children

Question 3

What is the pathophysiology of cholesteatomas?

Answer 3

Pars tensa is retracted +/- associated atrophy of the pars tensa
The trapped epithelium proliferates to form a cholesteatoma or squamous epithelium can migrate through a defect in the TM or get implanted after surgery

Congenital occurs when there is no precious insult to the TM.

Question 4

Otoscopy:

Question 5

What is the management of cholesteatomas?

Answer 5

Suction
Atticotomy - limited mastoidectomy
Mastoidectomy

Question 6

What are the risk factors for cholesteatoma?

Answer 6

• Congenital abnormalities - cleft palate (x100), craniofacial abnormality
• Chromosomal disorders (e.g. Turner’s, Down’s) - secondary to poor eustachian tube function
• Middle ear disease
• Prior otological surgery
• Traumatic blast injury to the ear

Question 7

What are the clinical features of cholesteatoma?

Answer 7

Foul-smelling, non-resolving ear discharge - resistant to antibiotic therapy
Hearing loss +/- tinnitus
‘Attic crust’ on otoscopy

+/- vertigo
+/- otalgia - uncommon unless severe
+/- facial nerve palsy - causing altered taste
+/- cerebellopontine angle syndrome

Question 8

Which of the mentioned clinical features is shown here?

Answer 8

Attic crust on otoscopy - i.e. in the upper part of the middle ear

Question 9

What does vertigo in cholesteatoma indicate?

Answer 9

Erosion of the semicircular canal

Question 10

How do you diagnose cholesteatoma?

Answer 10

Pure tone audiogram - may have conductive hearing loss
CT/MRI petrous temporal bones - opacification shown below, may be needed before surgery to establish extent
**Fistula test **- pressure applied on the tragus or air pushed into ear; positive test if vertigo or nystagmus. Indicates semicircular canal fistula.
+/- Culture ear discharge - if no initial response to abx

Question 11

What is the management of cholesteatoma?

Answer 11

Refer to ENT semi-urgently - urgent if there are complications like CNVII palsy
Topical antibiotics e.g. topical mitomycin - prior to surgery
Surgery - canal wall up mastoidectomy or canal wall down mastoidectomy; definitive treatment to get rid of discharge and to improve hearing.
Post-op dexamethasone/midazolam- controls nausea

Question 12

What are the complications of cholesteatoma?

Answer 12

• Recurrence
• Hearing loss
• Labyrinthine fistula
• Facial palsy
• Meningitis
• Brain abscess
• Sigmoid sinus thrombosis
• Mastoiditis
• Petrous apicitis
• Epidural abscess

Question 13

What is the prognosis with cholesteatoma?

Answer 13

Tendency to recur despite treatment even with surgery
Topical mitomycin better than chemical cautery (acetic acid) in achieving a dry cavity