Cholesteatoma Surgery


It is the growth of skin tissue in the middle ear cavity and bones. It starts with the inward growth of the skin epithelium due to the collapse of the eardrum or recurrent middle ear infections. Cholesteatomas form cysts or sacs. the skin of the skin folds in them and expands like a snowball. Over time, cholesteatomas can grow and damage the very delicate ossicles around them. Hearing loss, facial nerve palsy may develop due to continued growth.

How Does a Cholesteatoma Occur?

It is mostly caused by the failure of the “eustachian tube” to do its job and frequently recurring inflammations. The Eustachian tube provides ventilation of the middle ear. If this tube cannot work properly due to reasons such as allergy, cold, and sinusitis, negative pressure occurs in the middle ear. This negative pressure pulls the eardrum, which has already thinned due to inflammation, inward. Usually, cholesteatoma starts in this formed sac. There is another rare familial form of cholesteatoma, which can occur in the middle ear as well as in other skull bones. However, cholesteatoma associated with ear infections is the most common type.

What Are the Symptoms of Cholesteatoma?

Patients apply with the complaints of recurrent and persistent inflamed ear discharge and hearing loss. However, in some patients with cholesteatoma, ear discharge may not occur for a long time. In rare cases, vertigo (dizziness) or imbalance may occur as a result of the inflammatory process in the middle ear or due to direct labyrinth erosion by the cholesteatoma. Irritation of the facial nerve can lead to partial or complete facial nerve palsy.
Is it dangerous? What can happen if not treated?
While cholesteatomas grow where they are, they dissolve the surrounding bone structures and make room for themselves. The infection in the middle ear can reach the inner ear and head (brain membranes, brain) through the dissolution of the bone. Without appropriate treatment, it can lead to deafness, dizziness and balance disorder, meningitis and brain abscess, and rarely death.

What are the symptoms?

Ear discharge may occur initially. The discharge is sometimes foul-smelling. When cholesteatoma enlarges, it causes melting of the auditory ossicles in the middle ear, hearing loss develops and gradually increases. There may also be a feeling of pressure and fullness in the ear. With the growth of cholesteatoma, dizziness may occur when the infection reaches the inner ear, headache when it reaches the head, and facial paralysis when it melts the bone canal of the facial nerve and puts pressure on the facial nerve. When any of these symptoms are observed, the patient should be examined by an otolaryngologist.

What is the significance of chronic middle ear infections or cholesteatoma?

Significant complications may occur when the infection in the middle ear reaches the neighboring important structures, which are;

Loss of hearing: It is the result of an infection or cholesteatoma in the middle ear that destroys the auditory ossicles. Often tinnitus is also an accompanying symptom. If it occurs after damage to the inner ear, it does not improve despite the treatments.

Dizziness and balance problems: It is the result of the infection reaching the inner ear. It is caused by erosion (canal fistula) or toxic effects in the semicircular canals where the balance organ is nested.

Facial paralysis (facial paralysis):It occurs after destruction of the bony canal of the facial nerve in the middle ear or mastoid bone (the bone behind the ear).

Meningitis and spread to the brain: They occur when the infection passes from the middle ear and mastoid bone into the head in close proximity. These are important complications such as epidural abscess, brain abscess and meningitis. Sometimes thrombophlebitis (occlusion and inflammation of the vein with a clot) -lateral sinus thrombophlebitis- may occur in the large veins of the head.

Can it be treated?

Chronic otitis media with cholesteatoma is detected in the examination performed by an otolaryngologist. Treatment aims to stop the ear discharge and control the infection. cholesteatomas often require surgical treatment to protect the patient from serious complications. Audiogram (hearing test), balance tests, and computed tomography of the mastoid bone (the bone behind the ear in which the middle ear and its surroundings are nested) may be required to detect the level of hearing, evaluate the balance organ, and investigate the extent of the cholesteatoma.

Do you need surgery?

The treatment of chronic otitis media with cholesteatoma is surgery. The main purpose of surgical treatment is to completely clear the infection and cholesteatoma and to obtain a dry ear without discharge. Hearing preservation or restoration is the secondary goal of treatment. If the cholesteatoma is very extensive and has caused significant damage to the ear and its surroundings, reconstruction of the hearing may not be possible. The cholesteatoma can lead to erosion in the semicircular bony canals where the balance organ is housed, resulting in dizziness. In this case, the erosion will also need to be repaired.

If facial nerve palsy has occurred, the nerve will also need to be repaired. Middle ear reconstruction and hearing correction may not always be possible in a single session. For this purpose, with a second operation performed 6-12 months later, cholesteatoma residues in the middle ear and mastoid are cleaned, and hearing is tried to be corrected. The surgery is mostly performed with general anesthesia. Patients who have undergone surgery due to serious infection or complications stay in the hospital longer for post-operative antibiotic treatment.

Does cholesteatoma recur?

There is always a risk of recurrence of cholesteatoma no matter which surgical technique is applied. Therefore, patients should be followed up on an outpatient basis after surgery. Patients with an open mastoidectomy cavity should be checked every few months to clear the cavity and prevent recurrence of infection. Some patients may require lifelong regular follow-up. In those who underwent closed technique surgery (external ear canal was preserved, middle ear and mastoid space were cleaned of cholesteatoma, and the middle ear was reconstructed as much as possible and a new eardrum was made. Special MRI scans are useful in follow-up.

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