What is Cholesteatoma ?
Definition of Cholesteatoma
Cholesteatoma is a condition wherein there is a benign growth of skin in the middle or petrous apex. This growth is considered abnormal. The petrous apex is at the deeper area of the inner ear. A squamous epithelial cell is the usual cell that is trapped either at the entire ear canal or at the eardrum.
There are 2 causes of cholesteatoma:
- Congenital cholesteatomal– this is a less common cause. Usually, the abnormal growth is located at the back of the eardrum. The problem is identified when the child is at 6 months to 5 years old. As the squamous cell expands, it can obstruct the Eustachian tube, it produces chronic middle ear fluid and some conductive hearing loss.
- Acquired- this is the more common cause which is due to the tear or retraction of the eardrum. This happens when there is a deep medial retraction of the pars flaccida into the epitympanum. The wall of the epitympanum will erode slowly expands making the tympanic membrane retract.
The patient with cholesteatoma will show recurrent ear discharge. The formation of this benign growth is aided by the disturbed tubal function with reduced ventilation of the middle ear. There is also bone destruction to the 3 small bones- malleus, incus and stapes or the ossicles. If the problem is left untreated, there will be nerve deterioration, deafness, imbalance and even vertigo. The enzyme-activated cell groups can destruct the bone structures and it will also open the brain which will be a cause for infection and other serious complications.
The condition can affect the facial nerves because the erosion can extend to the brain passing through the inner and middle ear and passes through the tip of the mastoid bone. Simple ear infection due to swimming should not be taken for granted since this can aggravate acquired cholesteatoma.
There are several factors why cholesteatoma occurs. For one, the connective tissues can induce bone desorption during chronic otitis media. The exacerbation of skin and its produce can influence the destruction of the connective tissue. This is because the exacerabation has the ability to change the pressure during the experiment in an animal model.
Picture 1 : Cholesteatoma (Middle ear space filled with Cholesteatoma, and middle ear bones eroded)
image source : hearingaidscentral.com
Picture 2 : Cholesteatoma and Malleus
image source : chicagoear.com
Cholesteatoma in Children
This condition can threaten the child’s hearing because it can destroy the essential parts of the inner ear such as the Eustachian tube, the ossicles and even extend up to the brain. According to statistics, about three-fourth of children who are affected with the disease are boys and the diagnosis was done at about 5 years. This study was published in the April 2002 at the Archives of Otolaryngology- Head and Neck Surgery. The consequence such as hearing loss was rated slight to moderate.
The worst case scenario if left untreated is the bones will decay and eventually damage the middle ear and loss of hearing will happen. In rare instances, it can cause dizziness and facial paralysis.
To prevent cholesteatoma in children, it is best to treat eat infection especially in the inner area. It is best to complete the entire treatment even if the symptoms already disappear.
Painless otorrhea or the discharge in the ear. It can happen either unremittingly or frequently. This is the hallmark symptom of choleteatoma.
- Hearing loss is also common. This is because the benign growth fills the middle ear space.
- Dizziness also happens but very uncommon. The ear is also responsible for balance and when the person feels dizzy, this can mean a further problem or serious complications.
- During the physical examination, tympanic membrane perforation accounts for about 90 percent of the case.
- Aside from drainage, the ear canal is also filled with mucopus and granulation tissue.
If the opening or the sac is small, there is no severe infection and the hearing is remains at a level where the patient can still here, keratin cleansing can be done under microscopic examination at a given time. The cleaning should be scheduled every now and then.
If the sac is big and hearing is compromised, surgery will be done by an EENT. The goal of the surgery is to remove the cholesteatoma. The surgeon can choose between 2 procedures either canal-wall-up or close or canal-wall-down or open. The goal of the surgeon is to either;
- make the ear safe by removing the cholesteatoma and the infection
- Make the ear with fewer problems to do the usual activities such as swimming.
- To retain the residual hearing left or improve the hearing as much as possible
- To improve the cosmetic appearance.
Preparations are done when surgery will be done. The patient will be explained about the advantages and disadvantages of open or closed procedure. In the canal-wall-up or closed procedure, there will be normal appearance, hearing aid will easily fit into the ear, there is no routine cleaning needed but recurrent cholesteatoma is high.
On the other hand, a canal-wall-down procedure or open procedure, it can enlarge the meatus and hearing aid is difficult to fit and canal cleaning will be needed yearly or quarterly. One good thing about this is that there is a low rate of recurring cholesteatoma.
During the operation, there will be an incision at the back of the ear and air cells will be removed in the mastoid area through elevation of the tympanic membrane. The ossicles- the 3 small bones such as the meleus, incus and stapes will then be reconstructed as well as the tympanic membrane.
Follow Up and Long Term Care
After the surgery, the patient should have regular trips to the hospital or the doctor’s clinic to check on the ear. Usually, a dressing will be placed right after the surgery so the surgeon will check the dressing and remove it.
After weeks and months, the cavity or sac should be problem-free. A few cleaning techniques will be taught such as regular instillations of hydrogen peroxide or a mixture of alcohol and white vinegar. It can be administered daily or weekly.