Cholesteatoma is a type of skin cyst or sac located in the middle ear. Typically, cholesteatoma is a complication of repeated ear infections and eustachian tube dysfunction. Infection weakens an area of the eardrum membrane. If the eustachian tube fails to pass air up into the middle ear, a vacuum develops and pulls the weakened area of the eardrum membrane into the middle ear. The inward progression of the weakened area becomes a sac, lined with skin, which is, by definition, a cholesteatoma. As shedding old skin accumulates in the sac, it enlarges.
Cholesteatomas are benign but are invasive and can erode the surrounding structures of the ear. The sac or cyst continues to grow and becomes chronically infected. This cyst can ultimately erode the mastoid bone and the bones of the middle ear causing hearing loss. Infected cholesteatomas can cause serious, even life threatening complications.
Cholesteatoma often causes foul smelling material to drain out of the affected ear. Hearing loss becomes noticeable in that ear. The ear may have a sense of fullness or pressure. If the cholesteatoma erodes into the inner ear, dizziness or facial weakness may occur. In severe situations, cholesteatomas can lead to brain infections and other serious complications.
With a microscope, the ear specialist may be able to see pockets in the eardrum filled with drainage. The cholesteatoma may or may not be visible when looking into the ear with an otoscope. A CAT scan sometimes provides additional information about the extent of the cholesteatoma. An audiogram or hearing test determines how the hearing has been affected.
Treatment for Cholesteatoma
The primary goal of cholesteatoma treatment is to stop the infection and drainage. The physician may clean the ear out and place the patient on oral antibiotics and eardrops. Almost always, a cholesteatoma requires surgery. The surgery is called a tympanoplasty with mastoidectomy (mastoidectomy types include canal wall up, canal wall down, atticotomy, partial, etc).
A clean, dry, and safe ear is a bit more important than improving hearing. Hearing preservation is a secondary goal and may not always be obtainable. Most patients are able to maintain or improve their hearing. In some cases, two surgeries may be necessary in order to be sure all of the cholesteatoma is gone. The purpose of the first surgery is to remove the cholesteatoma while the purpose of the second surgery is to check for recurrent or residual cholesteatoma, reconstruct the ear, and restore the patients hearing, if possible. The second surgery is usually done six to twelve months after the first surgery. An ear that becomes persistently infected during the waiting period may need early reassessment, medical treatment, and surgical intervention. Some operated ears need long term, periodic cleaning or even repeat surgery if the cholesteatoma recurs.
Care After Surgery
Surgery is almost always done as an outpatient. Most patients go home within four to six hours after surgery. A dressing placed at surgery should not be removed until two days after surgery. A family member may remove the head dressing. Typically, a cotton plug is left in the ear opening cotton and should be left in the ear. Do not clean the ear with a Q-tip. Place the eardrops prescribed at the pre-operative visit on top of the ear opening plug, four drops, three times a day. Place a dry cotton ball over the ear packing after using the eardrops. Keep water out of the ear - use a Vaseline - petroleum jelly - soaked cotton ball to plug the ear for bathing. Do not put the ear or head under water until the doctor says the ear is ready. Usually an incision behind the ear can be washed starting two days after surgery. Pat it dry and coat it with Polysporin, Bacitracin, Neosporin or similar antibiotic ointment after bathing (remember to keep water out of the ear with Vaseline soaked cotton, though.) If the incision becomes red, call the doctor.
No strenuous exercising, and no activities that require severe straining for the first six weeks after surgery. Plan to see the doctor about two weeks after surgery. Plan to return to work after a week if work does not require any heavy lifting or straining. If heavy lifting is necessary at work, stay out of work for at least two weeks. At the two-week post-operative visit, ask the doctor when to return to work. In order to prevent placing any strain on the surgical site, avoid blowing the nose vigorously. Open your mouth and do not pinch the nose for sneezing or coughing.
For any questions or concerns regarding your post-operative course please contact us. An answering service should pick the line up after office hours.
What to Expect After Surgery
Some pulsation, popping, clicking and other sounds may occur in the ear. Ear fullness and occasional sharp pain may appear. All of this will go away gradually after surgery. For more annoying pain, use pain medication but only as needed. Use Tylenol or equivalent for less serious pain and stronger pain medicine as prescribed. If the pain medicine fails to relieve pain, notify the doctor. At two to four months after surgery, the middle ear fluid reaction to surgery gradually clears. The hearing may fluctuate as the ear crackles and pops open. Sometimes, taste disturbance occurs, but usually clears within a few weeks to a few months. It can be permanent, especially if disease surrounds the taste nerve.
Patients sometimes experience dizziness and nausea after cholesteatoma surgery. Some mild unsteadiness and brief dizziness with head turning is not uncommon. If dizziness is marked, do not get up without assistance. If dizziness is present, carefully increase walking every day. Notify the doctor if your dizziness is either marked or worsens. If dizzy, do not drive until quick head turns can be made without disturbing ability to focus.
At the time of the post-op visit, ask the doctor when to resume driving. Some bloody drainage may persist for up to a week or so after surgery. Change the outer ear cotton at least every eight hours. You may initially need to change it more frequently. Notify the doctor immediately if the drainage becomes yellow in appearance, has a foul smell, or if bloody drainage seems excessive. Also notify the doctor if body temperature is greater than 101° F. A short course of antibiotics should be taken per prescription instructions. Always double check for allergies to any medications. Also, notify the doctor promptly for any reaction to the medications that are prescribed.