Cholesteatoma Surgery
Cholesteatoma surgery is a targeted ENT operation to remove an expanding keratin-filled sac (cholesteatoma) from the middle ear and mastoid that progressively erodes bone and adjacent structures.
Left untreated, cholesteatoma causes persistent ear discharge, conductive hearing loss and can extend to cause facial nerve damage, labyrinthine injury or intracranial infection.
Modern surgery aims for complete disease clearance, restoration of middle ear mechanics where possible, and meticulous follow-up to detect and manage recurrence.
Overview And Clinical Background
Pathology, natural history and surgical goals
A cholesteatoma is a collection of desquamated keratinising squamous epithelium that behaves like an expanding lesion within the middle ear or mastoid.
It commonly arises from tympanic membrane retraction pockets, chronic infection or congenital rests and drives local bone resorption through enzymatic activity and pressure effects.
The surgical priority is eradication of disease, safe preservation of hearing structures when feasible, and reconstruction of hearing mechanics in the same or staged procedures.
- Pathogenesis: Keratin-entrapment, chronic inflammation and enzymatic bone erosion lead to progressive expansion, often with a background of chronic otitis media.
- Variants include acquired retraction-pocket cholesteatoma, congenital cholesteatoma presenting as a retrotympanic mass, and secondary disease after tympanic membrane perforation.
- Surgical aim: Complete removal of cholesteatoma and infected mucosa, mastoid clearance if involved, and reconstruction of the tympanic membrane and ossicular chain when possible.
Symptoms, Signs And Presentation
Patients typically present with chronic, often foul-smelling otorrhoea, reduced hearing on the affected side, ear fullness, and sometimes dizziness or facial weakness if disease is advanced.
In children the presentation may be subtle and recurrent infection or delayed speech may be clues prompting specialist assessment.
- Common symptoms: Persistent ear discharge despite treatment, progressively worsening conductive hearing loss, and intermittent ear pain.
- Less common signs include vertigo, tinnitus, and frank facial nerve palsy in severe erosive disease.
- Red flag: Acute facial weakness, severe headache or signs of intracranial extension (fever, focal neurodeficit) require urgent imaging and referral.
Diagnosis Methods And Investigations
Clinical exam, audiology and cross-sectional imaging
Diagnosis relies on otoscopic and microscopic ear examination, audiometry to document conductive deficit, and CT imaging to map mastoid and ossicular involvement.
MRI with diffusion-weighted sequences is useful to detect residual/recurrent disease and to differentiate inflammatory granulation from cholesteatoma in complex cases.
- Otomicroscopy: Direct visualisation of a retraction pocket, white keratin debris, or a marginal perforation suggests cholesteatoma and guides urgency.
- Imaging: High-resolution CT temporal bone defines bony erosion, ossicular status and mastoid involvement; MRI-DWI complements CT when residual disease is suspected.
- Audiology and vestibular tests quantify hearing loss and balance impact for preoperative planning and counselling.
Treatment Options And Surgical Techniques
Surgery is the definitive treatment and is tailored to disease extent: canal wall up or canal wall down mastoidectomy, tympanoplasty with ossicular reconstruction, and staged operations where required to reduce recurrence risk.
Endoscopic-assisted ear surgery may improve visualisation of hidden pockets while microscopic mastoid techniques remain mainstays for extensive disease.
- Canal wall up vs down: Canal wall up preserves ear anatomy and allows reconstruction but may have higher surveillance needs; canal wall down offers wide disease clearance with a maintenance mastoid cavity.
- Tympanoplasty & ossiculoplasty: Reconstruction of the tympanic membrane and ossicular chain uses grafts or prostheses to restore conductive hearing when disease clearance permits.
- Adjuncts: endoscopic inspection, intraoperative cortical bone polishing, and planned staged second-look procedures reduce residual disease risk.
Recovery, Risks And Prognosis
Postoperative recovery includes short hospital stay, ear dressings, antibiotic cover and staged audiology follow-up.
Risks include residual or recurrent cholesteatoma, persistent hearing loss, taste disturbance, dizziness, facial nerve injury (rare) and wound complications.
With complete excision and appropriate follow-up, many patients achieve infection control and stable or improved hearing; surveillance for recurrence is essential for several years.
- Immediate care: Ear packing or dressings removed in clinic; analgesia, topical care and activity modification advised for 1–2 weeks.
- Complication vigilance: watch for worsening pain, fever, facial weakness or persistent discharge—these require prompt review.
- Prognosis: Durable disease control and good functional outcomes are achievable with experienced surgical teams and appropriate second-look strategies.
Why Choose Us
CureU Healthcare combines experienced otologic surgeons, advanced imaging, endoscopic and microscopic ear-surgery expertise, and integrated audiology rehabilitation.
We plan individualized surgical strategies, offer nerve-monitoring for complex cases and provide long-term surveillance to minimise recurrence while optimising hearing outcomes.
Conclusion
Cholesteatoma surgery removes destructive middle-ear disease to protect hearing and prevent serious complications.
Early specialist referral, meticulous surgical technique and structured follow-up deliver the best chance of disease eradication and functional recovery.
