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What is Cholesteatoma?

A cholesteatoma is a skin growth that occurs in an abnormal location, typically inside the middle ear, behind the eardrum. It is usually due to repeated infection, which causes an ingrowth of the skin of the eardrum. Cholesteatomas often take the form of a cyst or pouch that sheds layers of old skin that builds up inside the ear. Over time, the cholesteatoma can increase in size and destroy the surrounding, delicate bones of the middle ear. Hearing loss, dizziness and facial muscle paralysis are rare, but can result from continued cholesteatoma growth.

What causes cholesteatoma?

A cholesteatoma is usually a result of poor eustachian tube function or an infection in the middle ear. The eustachian tube conveys air from the back of the nose into the middle ear to equalize ear pressure (“clear the ears”). When the eustachian tubes aren’t functioning properly (perhaps due to allergy, a cold or sinusitis), the air in the middle ear is absorbed by the body, and a partial vacuum results in the ear. The vacuum pressure sucks in a pouch or sac by stretching the eardrum, especially areas weakened by previous infections. This sac often becomes a cholesteatoma. A rare congenital form of cholesteatoma (one present at birth) can occur in the middle ear and elsewhere (such as the nearby skull bones). However, the type of cholesteatoma associated with ear infections is most common.

What are the warning signs?

Initially, the ear may drain, sometimes with a foul odor. As the cholesteatoma pouch or sac enlarges, it can cause a full feeling or pressure in the ear, along with hearing loss. An ache behind or in the ear, especially at night, may cause significant discomfort. Dizziness or muscle weakness on one side of the face (the side of the infected ear) can also occur. Any of these symptoms are good reasons to seek medical evaluation.

Is it dangerous?

Cholesteatoma is a serious condition and should never be ignored. Left untreated, it can continue to grow and spread into surrounding areas, including the inner ear and brain. This can lead to deafness, brain abscess, meningitis, and even death.

How is cholesteatoma treated?

An examination by an otolaryngologist (head and neck surgeon) can confirm the presence of a cholesteatoma. Initial treatment may consist of a careful cleaning of the ear, antibiotics and ear drops. Therapy aims to stop drainage in the ear by controlling the infection. The growth traits of a cholesteatoma must also be evaluated.

Large or complicated cholesteatomas usually require surgical treatment to protect the patient from serious complications. Hearing and balance tests, x-rays of the mastoid (the skull bone next to the ear), and CAT scans (3-D x-rays) of the mastoid may be necessary. These tests are performed to determine the hearing level remaining in the ear and the extent of destruction caused by the cholesteatoma.

In most cases, a cholesteatoma will be removed during an operation performed under general anesthesia. The goals of surgery are not only removal of the cholesteatoma, but also to achieve an infection-free ear, and hearing preservation or restoration. (However, in cases of severe ear destruction, reconstruction may not be possible.) For some patients, facial nerve repair or procedures to control dizziness may also be required. Reconstruction of the middle ear is not always possible in one operation; therefore, a second operation may be performed 6 to 12 months later. The second operation will attempt to restore hearing and inspect the middle ear space and mastoid for residual cholesteatoma.

Admission to the hospital is usually done the morning of surgery. If the operation is performed early in the morning, discharge maybe the same day. For some patients, an overnight stay will be necessary. In rare cases of serious infection, prolonged hospitalization for antibiotic treatment may be warranted. Time off from work is typically 1 to 2 weeks.

Follow-up office visits after surgical treatment are important, because cholesteatoma sometimes recurs. In cases where an open mastoidectomy cavity has been created, office visits every few months are advisable to clean out the mastoid cavity and prevent new infections. Some patients may need periodic ear examinations throughout the rest of their lives.


Cholesteatoma is a serious, but treatable, ear condition which can only be diagnosed by medical examination. Persisting earache, ear drainage, ear pressure, hearing loss, dizziness, or facial muscle weakness signals the need for evaluation by an otolaryngologist.

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