It is the growth of skin tissue in the middle ear cavity and bones. It begins with the ingrowth of the skin epithelium due to the collapse of the eardrum or recurrent middle ear infections. Cholesteatomas form cysts or sacs. The skin folds inside them and expands like a snowball. Over time, cholesteatomas can grow and damage the very delicate ossicles around them. Hearing loss and facial nerve paralysis may develop due to continued growth.
It mostly occurs due to the "eustachian tube" not functioning properly and frequently recurring inflammations. The Eustachian tube provides ventilation of the middle ear. If this tube cannot function properly due to reasons such as allergies, colds, sinusitis, negative pressure occurs in the middle ear. This negative pressure pulls the eardrum, which is already thinned due to inflammation, inward. Usually, cholesteatoma begins within this formed sac. There is another rare familial form of cholesteatoma, which can be seen in the middle ear or other cranial bones. However, cholesteatoma associated with ear infections is the most common type.
Patients apply with complaints of recurrent and persistent inflammatory ear discharge and hearing loss. However, some patients with cholesteatoma may not experience ear discharge for a long time. In rare cases, vertigo (dizziness) or imbalance may occur as a result of the inflammatory process in the middle ear or due to direct labyrinth erosion by cholesteatoma. Irritation of the facial nerve can lead to partial or complete facial nerve paralysis.
As cholesteatomas grow in their location, they make room for themselves by melting the surrounding bone structures. Through bone melting, the infection in the middle ear can reach the inner ear and head (brain membranes, brain). If appropriate treatment is not given, it can lead to deafness, dizziness and balance disorders, meningitis and brain abscess, and rarely death.
There may be ear discharge at first. The discharge is sometimes foul-smelling. When cholesteatoma grows, it causes melting of the auditory ossicles in the middle ear, hearing loss develops and gradually increases. There may also be a feeling of pressure and fullness in the ear. As the cholesteatoma grows, dizziness may occur when the infection reaches the inner ear, headache when it reaches the head, and facial paralysis may occur when it melts the bone canal of the facial nerve and puts pressure on the facial nerve. If any of these symptoms occur, the patient should be examined by an Ear, Nose and Throat specialist.
What is the importance of chronic middle ear infections or cholesteatoma?
Significant complications may occur when the infection in the middle ear reaches neighboring important structures;
Hearing loss: It is the result of infection or cholesteatoma in the middle ear that destroys the auditory ossicles. Tinnitus is often an accompanying symptom. If it occurs after damage to the inner ear, it will not recover despite treatments.
Dizziness and balance problems: It is the result of the infection reaching the inner ear. It occurs due to erosion in the semicircular canals where the balance organ is located (canal fistula) or toxic effects.
Facial paralysis (facial paralysis): It occurs after the destruction of the bone canal of the facial nerve in the middle ear or mastoid bone (the bone behind the ear).
Meningitis and spread to the brain: They occur when the infection spreads from the middle ear and mastoid bone to the adjacent skull. These are important complications such as epidural abscess, brain abscess and meningitis. Sometimes thrombophlebitis (blockage and inflammation of the vein with clot) - lateral sinus thrombophlebitis - may occur in the large veins in the head.
Chronic otitis media with cholesteatoma is detected during an examination by an Ear, Nose and Throat specialist. Treatment aims to stop ear discharge and control infection. Cholesteatomas usually require surgical treatment to protect the patient from serious complications. To determine the hearing level, evaluate the balance organ and investigate the prevalence of cholesteatoma, audiogram (hearing test), balance tests and computerized tomography of the mastoid bone (the bone behind the ear in which the middle ear and its surroundings are nestled) may be required.
The treatment of chronic otitis with cholesteatoma is surgery. The main purpose of surgical treatment is to completely clear the infection and cholesteatoma and obtain a discharge-free, dry ear. Preserving or restoring hearing is the secondary goal of treatment. If the cholesteatoma is very widespread and has caused significant damage to the ear and its surroundings, hearing reconstruction may not be possible. Cholesteatoma may cause erosion in the semicircular bone canals where the balance organ is located, resulting in dizziness. In this case, the erosion that occurs will also need to be repaired.
If facial nerve paralysis occurs, repair of the nerve will also be required. Reconstruction of the middle ear and restoration of hearing may not always be possible in a single session. For this purpose, a second surgery is performed 6-12 months later to remove cholesteatoma residues in the middle ear and mastoid and to attempt to restore hearing. The surgery is mostly performed with general anesthesia. Patients who undergo surgery due to serious infection or complications stay in the hospital longer for post-operative antibiotic treatment.
There is always a risk of recurrence of cholesteatoma no matter what surgical technique is used. Therefore, patients need to be followed up on an outpatient basis after surgery. Patients with an open mastoidectomy cavity should be checked every few months to clean the cavity and prevent recurrence of infection. Some patients may require lifelong regular follow-up. In those who underwent closed technique surgery (the external ear canal was preserved, the middle ear and mastoid cavity were cleared of cholesteatoma, the middle ear was reconstructed as much as possible and a new eardrum was made. Special MRI scans are useful in follow-up.
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