Cholesteatoma

A cholesteatoma is an enlarging sac of squamous epithelium containing keratin debris located in the middle ear or mastoid. It occurs most often in patients who have recurrent ear infections with purulent drainage (ie, chronic suppurative otitis media). Cholesteatoma is frequently detected during examination but needs to be confirmed by CT. For episodic purulent drainage, oral and ototopical antibiotic therapy is used. Surgery can stop infections and prevent complications.

Geriatric Essentials

• Left untreated, cholesteatomas can cause vertigo and sensorineural hearing loss.

Cholesteatomas usually result when the space medial to the pars flaccida (the thin, superior part of the tympanic membrane) is poorly ventilated, which leads to retraction of the tympanic membrane. The result is a sac in which keratin debris accumulates. Usually, tufts of keratin debris protrude from the area above the short process of the malleus. Occasionally, cholesteatomas originate from squamous epithelium that grows into the tympanic cavity through a marginal tympanic membrane perforation.

Symptoms and Signs

Most patients have recurrent ear infections with purulent drainage (ie, chronic suppurative otitis media). However, some patients have few symptoms. Sometimes, the only signs are conductive hearing loss (caused by progressive erosion of the ossicular chain) and a tympanic membrane that appears abnormal. Less commonly, progressive erosion of the semicircular canals causes vertigo and progressive erosion of the cochlea causes sensorineural hearing loss.

A cholesteatoma may erode through the tegmen, allowing an epidural abscess to form. If periphlebitis or thrombophlebitis develops, infection may spread to the brain parenchyma or dural venous sinuses.

Diagnosis

High-resolution CT of the temporal bone with specific bone-imaging settings can show the status of the middle ear, mastoid structures, tegmen, and otic capsule.

Treatment

For episodic purulent drainage, oral and ototopical antibiotic therapy is used as in chronic suppurative otitis media. Ototopical antibiotics (eg, ciprofloxacin [with or without a corticosteroid] or ofloxacin) are first-line choices. Patients who do not respond to this therapy may require systemic antibiotic therapy with amoxicillin 250 to 500 mg po q 8 h for 10 days or a 3rd-generation cephalosporin; antibiotic choice is subsequently modified by culture results and response to therapy. Surgery can stop infections and prevent complications; it is almost always recommended unless the patient is in poor health or the cholesteatoma sac can be cleaned of keratin debris in the physician's office.

This topic was last updated June 2006.