Cholesteatoma

What a cholesteatoma is

Despite its name, a cholesteatoma contains no cholesterol and is not a tumor. It is a sac lined by skin (keratinizing squamous epithelium) that keeps shedding dead skin cells into its center. Because the debris cannot escape, the sac expands. It also releases enzymes that dissolve bone.

As it grows it can erode:

• the tiny hearing bones (ossicles), causing conductive hearing loss
• the bone over the balance canals, causing vertigo
• the bony canal of the facial nerve, causing facial weakness
• the thin bone separating the ear from the brain, leading to meningitis or brain abscess

Types and causes

Acquired cholesteatoma

This is the most common type, mostly in older children and adults.

• Retraction pocket: when the Eustachian tube works poorly, negative pressure in the middle ear sucks part of the eardrum inward, forming a pocket. Skin builds up in the pocket and cannot clear.
• Ingrowth through a perforation: skin grows through a hole in the eardrum, often after chronic infection; see eardrum perforation.
• After ear surgery or trauma.

Risk factors include repeated ear infections, long-term glue ear, cleft palate and Down syndrome.

Congenital cholesteatoma

A small pearl of skin cells trapped behind an intact eardrum from birth. It is usually discovered in young children as a white mass behind the eardrum, often without previous infections.

Symptoms

• Ear discharge: persistent or recurrent, often smelly, from one ear. It may improve with antibiotic drops but keeps coming back.
• Hearing loss: gradual, in the affected ear
• A feeling of fullness or pressure
• Mild ear ache (often painless)
• Tinnitus
• Later signs: dizziness or vertigo, facial weakness, headache

Symptoms often develop slowly over months to years.

Complications

Serious complications are uncommon with timely treatment but can be life-threatening.

Diagnosis

• Otoscopy and microscopy: an ENT surgeon cleans the ear and looks at the eardrum. A retraction pocket filled with white debris, crusting in the attic area above the eardrum, or a white mass behind the eardrum suggests cholesteatoma.
• Hearing tests (audiometry): measure the type and degree of hearing loss.
• CT scan of the temporal bone: shows extent and bone erosion and helps plan surgery.
• MRI with diffusion-weighted imaging: distinguishes cholesteatoma from scar tissue or fluid, and is often used to check for recurrence without a second operation.

Treatment

Surgery

Surgery is the only definitive treatment. Aims, in order: remove the disease completely, create a dry and safe ear, preserve or restore hearing.

• Canal wall up mastoidectomy (with tympanoplasty): removes disease while keeping the ear canal wall. Hearing and appearance are more natural, but a planned "second look" operation or MRI is often needed to check for residual disease.
• Canal wall down mastoidectomy: removes the back wall of the ear canal, creating an open cavity that is easier to inspect and has lower recurrence, but needs regular cleaning and water precautions.
• Ossicular reconstruction: rebuilding the hearing bones with prostheses, at the same time or later.
• Endoscopic ear surgery: increasingly used to see hidden areas through the ear canal.

Before surgery

Cleaning the ear (microsuction) and antibiotic ear drops can control infection and discharge, but do not cure the cholesteatoma.

After surgery

• keep the ear dry as instructed until healed
• regular follow-up for years, sometimes with MRI scans
• hearing aids if hearing remains reduced

Outlook

With complete removal, most people have a dry, safe ear. Cholesteatoma recurs or persists in a meaningful minority, especially in children, which is why long-term follow-up is essential. Hearing outcomes vary with how much damage was present before surgery.

Frequently asked questions

What are the symptoms of cholesteatoma?

The main symptoms are a persistent or recurring foul-smelling discharge from one ear and gradual hearing loss on that side. Some people feel fullness or mild pain. Later signs include dizziness, ringing in the ear and facial weakness.

What causes a cholesteatoma?

Most cholesteatomas develop when poor Eustachian tube function or repeated ear infections pull a pocket of eardrum inward, trapping skin cells. Some grow through a perforated eardrum. A less common congenital type is present from birth.

Is cholesteatoma cancer?

No. Cholesteatoma is not cancer and does not spread to other parts of the body. However, it slowly grows and erodes bone, so it can damage hearing, balance and the facial nerve, or cause serious infections if untreated.

Can cholesteatoma be treated without surgery?

Ear cleaning and antibiotic drops can control discharge and infection, but they do not remove the cholesteatoma. Surgery is needed to prevent further damage. Very rarely, in people too unwell for surgery, regular cleaning is used to manage a small cholesteatoma.

Can cholesteatoma come back after surgery?

Yes. Cholesteatoma can recur, especially in children and after canal wall up operations. Regular follow-up with ear examinations and MRI scans, or a planned second operation, helps detect any regrowth early.