Cholesteatoma

Question 1

What is a Cholesteatoma?

Answer 1

Cholesteatoma is a non-cancerous growth that develops in the middle ear behind the eardrum

Question 2

Why does a Cholesteatoma form?

Answer 2

It typically results from poor Eustachian tube function concurrent with infection in the middle ear, leading to skin growth within the ear canal. Often, it manifests as a cystic structure filled with keratin debris

Question 3

Who is cholesteatoma most common in?

Answer 3

It is most common in patients aged 10-20 years. Being born with a cleft palate increases the risk of cholesteatoma around 100 fold.

Question 4

What is a primary acquired cholesteatoma?

Answer 4

PAC is theorised to occur due to chronic eustachian tube dysfunction leading to negative middle ear pressure, retractions pockets formation, and subsequent invagination of squamous epithelium into the middle ear space.

Question 5

What are 3 risk factors for cholesteatoma?

Answer 5

1. Chronic otitis media with effusion
2. Eustachian tube dysfunction
3. Immunodeficiency

Question 6

What is a secondary acquired cholesteatoma?

Answer 6

SAC occurs when squamous epithelium is introduced into the middle ear through a perforation in the tympanic membrane.

Question 7

How do secondary acquired cholesteatomas occur?

Answer 7

1. Otologic surgery: Procedures such as tympanoplasty or mastoidectomy can inadvertently introduce skin into the middle ear.
2. Trauma: Penetrating injuries to the eardrum can implant squamous epithelium into the middle ear.

Question 8

Name 3 complications of cholesteatomas?

Answer 8

1. Ossicular chain erosion
2. Labyrinthine fistula
3. Intracranial extension

Question 9

What are the 5 main features of cholesteatomas?

Answer 9

1. Foul-smelling, non-resolving discharge
2. Hearing loss
3. Vertigo
4. Facial nerve palsy
5. Cerebellopontine angle syndrome

Question 10

What is seen on otoscopy in cholesteatoma?

Answer 10

‘attic crust’ - seen in the uppermost part of the ear drum

Question 11

What are 2 first-line investigations for cholesteatomas?

Answer 11

1. Otoscopy
2. Audiometry

Question 12

What are 2 further investigations for cholesteatomas?

Answer 12

1. CT scan
2. MRI

Question 13

Name 3 differential diagnosis’ for cholesteatomas?

Answer 13

1. Chronic Otitis media with effusion.
2. Acute otitis media
3. Otosclerosis

Question 14

How can you differentiate between cholesteatomas and chronic otitis media with effusions?

Answer 14

Unlike cholesteatoma, COME usually presents bilaterally and is common in children.
Clinically, patients may report hearing loss or aural fullness but lack the recurrent otorrhoea seen in cholesteatoma. Otoscopic examination often reveals a retracted or bulging tympanic membrane with an amber or blue hue due to the presence of serous fluid.

Question 15

How can you differentiate between cholesteatomas and acute otitis media?

Answer 15

While both AOM and cholesteatoma can cause hearing loss and otorrhoea, AOM differs by its acute presentation and systemic symptoms.
Otoscopy will commonly show a bulging red tympanic membrane, distinct from the retraction pocket seen in cholesteatoma. The presence of middle ear effusion confirmed by pneumatic otoscopy or tympanometry also favours AOM over cholesteatoma.

Question 16

How can you differentiate between cholesteatomas and otosclerosis?

Answer 16

Unlike cholesteatoma, otosclerosis does not involve skin debris or recurrent infection. It often presents bilaterally and is more common in women.
Clinically, patients may report progressive hearing loss without otorrhoea. On examination, the tympanic membrane is typically normal with a characteristic ‘flamingo pink’ hue seen only in active disease. The Rinne test will be negative on the affected side, while Weber’s test lateralises to the same ear.

Question 17

How is cholesteatomas managed?

Answer 17

patients are referred to ENT for consideration of surgical removal