‘Cholesteatoma’ is a term to describe a problem where infected dead skin builds up in the ear.
Cholesteatoma most commonly forms from tympanic membrane retraction. When a retraction becomes very severe, sometimes the dead skin that the ear drum produces can not be cleared by the natural processes that usually ensure the ear is kept clean (it is because of these natural processes that it is not necessary to do anything to clean your ears). This gets much worse when the dead skin becomes infected, as firstly the amount of dead skin the ear drum produces becomes much more, and secondly swelling of the surrounding tissues makes it even more difficult for the dead skin to be cleared (see diagram below):
Cholesteatoma most commonly forms from tympanic membrane retraction. When a retraction becomes very severe, sometimes the dead skin that the ear drum produces can not be cleared by the natural processes that usually ensure the ear is kept clean (it is because of these natural processes that it is not necessary to do anything to clean your ears). This gets much worse when the dead skin becomes infected, as firstly the amount of dead skin the ear drum produces becomes much more, and secondly swelling of the surrounding tissues makes it even more difficult for the dead skin to be cleared (see diagram below):
When this problem has started, it is very difficult for the ear to make the problem better. The collection of dead skin continues growing, and the enzymes it produces wear away nearby parts of the body. The parts of the body most at risk are the ‘ossicles’ hearing bones, meaning loss of hearing is another sign there may be a cholesteatoma. Other structures nearby include the hearing organ and balance organ, the nerve that moves the face, and the inside of the head. I’m very severe cases, cholesteatoma can lead to infections similar to meningitis.
The priorities in treating this condition are as follows:
- Treating any complications that may have occurred, and avoiding any new complications.
- Removing the condition to prevent it from getting worse.
- Stopping the recurrent infections.
- Stopping the condition forming again.
- Maintaining or improving the hearing.
- Avoiding the need for any long term ‘ear care’.
- Avoiding the need to have any more operations than are necessary.
Over recent years, there have been a number of developments in cholesteatoma management that has allowed progress in these areas. The use of specialised scans (diffusion weighted MRI) have prevented unnecessary operations (1), ‘obliteration’ techniques have been developed to try and stop the condition re-forming (2), and the laser can be used to increase the chance that all the condition is removed whilst being as gentle as possible to the hearing organ (3).
However, each case of cholesteatoma is different, and there are still compromises to be made between making hearing as good as possible, and the chance of the condition returning. Also, we would generally always choose to have another operation rather than run an incessant risk of having a long-term complication.
Cholesteatoma surgery usually, but not always, involves a cut behind the ear. This tends to scar very well. The surgery is most commonly done as a daycase procedure, but can mean spending one night in hospital.
References:
1. Non-echoplanar diffusion weighted imaging in the detection of post-operative middle ear cholesteatoma: navigating beyond the pitfalls to find the pearl. Lingam RK, Nash R, Majithia A, Kalan A, Singh A. Insights Imaging. 2016 Oct;7(5):669-78.
2. Single-Stage Mastoid Obliteration in Cholesteatoma Surgery and Recurrent and Residual Disease Rates: A Systematic Review. van der Toom HFE, van der Schroeff MP, Pauw RJ. JAMA Otolaryngol Head Neck Surg. 2018 May 1;144(5):440-446.
3. Recommendations for Potassium-Titanyl-Phosphate Laser in the Treatment of Cholesteatoma. le Nobel GJ, James AL. J Int Adv Otol. 2016 Dec;12(3):332-336.
