How does cholesteatoma form?
The skin of the external auditory canal and the outer layer of the eardrum are constantly renewed, and dead scales are removed. If, due to persistent vacuum in the middle ear, the membrane retracts and forms a pocket, the scales stop coming out and accumulate inside. Over time, the accumulation increases, becomes infected and begins to put pressure on the bone. Less commonly, cholesteatoma grows through the marginal opening in the membrane or occurs in children as a congenital inclusion of the epithelium behind the entire membrane.
- Acquired retraction - from a retracted membrane pocket
- Acquired through marginal perforation in chronic otitis media
- Congenital - a white formation behind an intact membrane in a child
- Postoperative and post-traumatic forms
Causes and risk factors
The key condition is long-term disruption of middle ear ventilation. The auditory tube does not open normally, negative pressure is maintained in the tympanic cavity, and the membrane is retracted. This is caused by frequent otitis media in childhood, adenoids, chronic allergic rhinitis, deviated nasal septum, and cleft palate. A separate contribution is made by previous ear injuries and operations, after which the epithelium can get into the middle ear.
- Chronic suppurative otitis media
- Exudative otitis and persistent dysfunction of the auditory tube
- Adenoids and chronic nasal diseases
- Cleft palate and other developmental anomalies
- Previous surgeries and ear injuries
- Smoking, including passive smoking in children
Symptoms and complications
Cholesteatoma grows slowly, so a person often considers his complaints as “habitual otitis media” for years. The classic combination is scanty but persistent discharge from the ear with a pungent putrid odor and gradually increasing hearing loss. Pain does not always occur. An alarming turn is the appearance of dizziness, unsteadiness, weakness of facial muscles: this indicates that the destruction has reached the inner ear or facial nerve. A breakthrough of infection into the cranial cavity results in meningitis and abscess.
- Constant or recurring discharge with an unpleasant odor
- Hearing loss in one ear
- Noise in the ear and feeling of fullness
- Dizziness when sneezing and pressing on the tragus
- Paresis of facial muscles
- Inflammation of the mastoid process, intracranial complications
Diagnostics
The basis is to examine the ear under a microscope or endoscope: the doctor sees perforation in the upper parts of the membrane, a deep retracted pocket or whitish masses. A computed tomography scan of the temporal bones is required: it shows the extent of bone destruction, the condition of the auditory ossicles, the facial nerve canal and the semicircular canals. MRI in a special mode helps to distinguish cholesteatoma from scars and fluid, especially when monitoring after surgery. Hearing is assessed by audiometry, and the discharge is sent for culture.
- Otomicroscopy and endoscopy of the ear
- CT (MSCT) of the temporal bones
- MRI for unclear picture and after surgery
- Pure-tone audiometry
- Culture of discharge with sensitivity determination
- Examination by a neurologist in case of complications
Treatment
Drops and antibiotics only temporarily reduce inflammation, but do not eliminate the accumulation of epithelium itself, so the only radical method is surgery. Its purpose is primarily sanitizing: to completely remove cholesteatoma and prevent intracranial complications. Hearing restoration is solved by the same or the second stage - plastic surgery of the eardrum and prosthetics of the auditory ossicles. The volume of intervention depends on the prevalence of the process. After surgery, regular monitoring is needed because cholesteatoma can grow back.
- Sanitation surgery on the middle ear with removal of cholesteatoma
- Tympanoplasty to restore sound conduction
- Second stage after 6–12 months with an extensive process
- Treatment of diseases of the nose and nasopharynx to normalize the functioning of the auditory tube
- Keep the ear dry and do not swim without protection until it heals.
- Routine examinations and follow-up studies after surgery
