1De la Cruz A, Fayad JN.

Detection and
management of childhood cholesteatoma.
Pediatr Ann. 1999 Jun. 28(6):370-3.
[Medline].

2Janet C, L CS, L JA, A GK, C PB.

Congenital cholesteatoma and cochlear
implantation: Implications for management.
Cochlear Implants Int. 2012 Mar 2.
[Medline].

3Lim HW, Yoon TH, Kang WS. Congenital

cholesteatoma: clinical features and growth
patterns. Am J Otolaryngol. 2012 Feb 21.
[Medline].

4Stapleton AL, Egloff AM, Yellon RF.

Congenital cholesteatoma: predictors for
residual disease and hearing outcomes. Arch
Otolaryngol Head Neck Surg. 2012 Mar.
138(3):280-5. [Medline].

5Joel Swartz, H. Harnsberger. Imaging of

the Temporal Bone. 3 Sub edition. New
York: George Thieme Verlag; Oct 1, 1997.

9Kemppainen HO, Puhakka HJ, Laippala

PJ, et al. Epidemiology and aetiology of
middle ear cholesteatoma. Acta Otolaryngol.
1999. 119(5):568-72. [Medline].

Practice Essentials
sect2: a1 para, childcount:0
A cholesteatoma consists of squamous epithelium that is
trapped within the skull base and that can erode and destroy
important structures within the temporal bone. Its potential
for causing central nervous system (CNS) complications
(eg, brain abscess, meningitis) makes it a potentially fatal
lesion. See the image below.
VideoWidgets::figure
capt_n_gallery_link_url::incaption: A large cholesteatoma. No
landmarks are visible, which typically is the case with advanced
cholesteatomas.
A large cholesteatoma. No landmarks are visible, which typically is the case
with advanced cholesteatomas.
View Media Gallery
para, childcount:0
Generally, the following 3 types of cholesteatoma are
identified:
itemizedlist
listitem
• para, childcount:0Congenital cholesteatoma
listitem
• para, childcount:0Primary acquired cholesteatoma
listitem
• para, childcount:0Secondary acquired cholesteatoma

Signs and symptoms

para, childcount:0
The hallmark symptom of a cholesteatoma is a painless
otorrhea, either unremitting or frequently recurrent. Other
symptoms include the following:
itemizedlist
listitem
• para, childcount:0Conductive hearing loss
listitem
• para, childcount:0Dizziness: Relatively uncommon
listitem
• para, childcount:0Drainage and granulation tissue in
the ear canal and middle ear: Unresponsive to antimicrobial
therapy
para, childcount:0
Occasionally, cholesteatoma initially presents with
symptoms of CNS complications, including the following:
itemizedlist
listitem
• para, childcount:0Sigmoid sinus thrombosis
listitem
• para, childcount:0Epidural abscess
listitem
• para, childcount:0Meningitis

eaid=56708714 eadv=17889674 ebuy=223784114

ecid=84683570954 pos=141 pvid=149260908800829401
para, childcount:1
Unlike other cholesteatomas, the congenital type is usually
identified behind an intact, normal-appearing tympanic
membrane. The child often has no history of recurrent
suppurative ear disease, previous otologic surgery, or
tympanic membrane perforation. reference_ids_tool_tip reference_ids [1, 2, 3, 4]
para, childcount:1
See Clinical Presentation for more detail.
Diagnosis
para, childcount:0
No laboratory tests or incisional biopsies are generally
necessary for the diagnosis of cholesteatomas, because the
diagnosis can be made based on physical examination and
radiologic findings.

para, childcount:0
Computed tomography (CT) scanning is the diagnostic
imaging modality of choice for these lesions, owing to its
ability to detect subtle bony defects.

para, childcount:0
Histologically, surgically removed cholesteatoma
specimens demonstrate typical squamous epithelium. The
histology is indistinguishable from that of sebaceous cysts
or keratomas removed from any other portion of the body.

para, childcount:0
Audiometry should be performed prior to surgery whenever
possible. Air and bone conduction, the speech reception
threshold, and speech discrimination scores should all be
determined within a few weeks of the proposed operative
procedure.

para, childcount:1
Magnetic resonance imaging (MRI) is used when very
specific problems, such as the following, are suspected
reference_ids_tool_tip reference_ids [5]
:
itemizedlist
listitem
• para, childcount:0Dural involvement or invasion
listitem
• para, childcount:0Subdural or epidural abscess
listitem
• para, childcount:0Brain herniation into the mastoid
cavity
listitem
• para, childcount:0Inflammation of the membranous
labyrinth or facial nerve
listitem
• para, childcount:0Sigmoid sinus thrombosis
listitem
• para, childcount:0Meningitis

para, childcount:1
See Workup for more detail.

Management
para, childcount:0
Virtually all cholesteatomas should be excised. The only
absolute contraindications to the surgical removal of
cholesteatomas are medical in nature.

para, childcount:1
Canal wall-down tympanomastoidectomy

para, childcount:0
In the canal wall–down (open) procedure, the posterior
canal wall is removed. A large meatoplasty is created to
allow adequate air circulation into the cavity that arises
from the operation. Canal wall–down operations have the
highest probability of permanently ridding patients of
cholesteatomas.

para, childcount:1
Canal wall-up tympanomastoidectomy

para, childcount:0
In the canal wall–up (closed) procedure, the canal wall is
preserved. Canal wall–up procedures have the advantage of
maintaining a normal appearance, but the risk of persistent
or recurrent cholesteatomas is higher than in the canal
wall–down operation.

Background
sect2: a4 para, childcount:2
A cholesteatoma consists of squamous epithelium that is
trapped within the skull base that can erode and destroy
important structures within the temporal bone. Its potential
for causing central nervous system (CNS) complications
(eg, brain abscess, meningitis) makes it a potentially fatal
lesion (see the images below). (See Etiology and
Pathophysiology and Prognosis.)

VideoWidgets::figure
capt_n_gallery_link_url::incaption: Epitympanic (attic)
cholesteatoma. This is a typical primary acquired cholesteatoma in
its earliest stages.
Epitympanic (attic) cholesteatoma. This is a typical primary acquired
cholesteatoma in its earliest stages.
View Media Gallery

VideoWidgets::figure
capt_n_gallery_link_url::incaption: A congenital cholesteatoma. A
white mass can be seen behind an intact drum.
A congenital cholesteatoma. A white mass can be seen behind an intact
drum.
View Media Gallery

para, childcount:0
Throughout the early half of the 20th century,
cholesteatomas were managed by exteriorization. The
mastoid air cells were exenterated, the posterior wall of the
external auditory canal was removed, and the opening into
the resulting cavity was enlarged to ensure adequate air
exchange and to make visual inspection simple.

para, childcount:2
During the 1950s and 1960s, the House Otologic Group
developed a new approach. The group attempted to leave
the basic underlying anatomic structure of the ear and
temporal bone intact, principally by preserving the canal
wall. These aggressive attempts to conserve the normal
anatomy of the ear created great controversy. Surgeons
tended to align themselves with either the old "canal wall–
down" (ie, open cavity) procedure reference_ids_tool_tip reference_ids [6] or
with the new "canal wall–up" (ie, closed cavity) method.
reference_ids_tool_tip reference_ids [7]

para, childcount:0
Most otologic surgeons have now migrated to an
intermediate position, with the majority of those in the
United States now performing both techniques and basing
the selection of the open or closed cavity procedure on the
individual circumstances of each patient. (See Workup and
Treatment.)

Etiology and Pathophysiology

sect2: a5 para, childcount:0
A cholesteatoma consists of squamous epithelium that is
trapped in the skull base. Squamous epithelium trapped
within the temporal bone (ie, middle ear or mastoid) can
expand only at the expense of the bone that surrounds and
contains it. Consequently, a growing cholesteatoma can
erode and destroy important structures within the temporal
bone.

para, childcount:0
Cholesteatomas cause bony erosion by either of the
following mechanisms:
itemizedlist
listitem
• para, childcount:0Pressure effects produce bony
remodeling, as occurs normally throughout the entire
skeleton when pressure is applied consistently over time
listitem
• para, childcount:0Enzymatic activity at the margin of
the cholesteatoma enhances osteoclastic activity, which
greatly increases the speed of bone erosion; osteolytic
enzymes appear to increase when a cholesteatoma becomes
infected

para, childcount:0
Occasionally, a cholesteatoma escapes the confines of the
temporal bone and skull base. Extratemporal complications
can occur in the neck, CNS, or both. When a cholesteatoma
within the cranium grows large enough to produce mass
effect, brain dysfunction can develop.

para, childcount:0
Generally, the following 3 types of cholesteatoma are
identified: congenital, primary acquired, and secondary
acquired.

Congenital cholesteatoma
para, childcount:1
Congenital cholesteatomas arise as a consequence of
squamous epithelium trapped within the temporal bone
during embryogenesis. The typical congenital
cholesteatoma is found in the anterior mesotympanum or in
the perieustachian tube area. They are identified most
commonly in early childhood (6 mo to 5 y). reference_ids_tool_tip
reference_ids [8]
para, childcount:0
As they expand, congenital cholesteatomas can obstruct the
Eustachian tube and produce chronic middle ear fluid and
conductive hearing loss. They can also expand posteriorly
to encase the ossicular chain and, by this mechanism,
produce conductive hearing loss.

para, childcount:1
Unlike other cholesteatomas, the congenital type is usually
identified behind an intact, normal-appearing tympanic
membrane. The child often has no history of recurrent
suppurative ear disease, previous otologic surgery, or
tympanic membrane perforation. reference_ids_tool_tip reference_ids [1, 2, 3, 4]

Primary acquired cholesteatoma

para, childcount:0
A primary acquired cholesteatoma results from tympanic
membrane retraction. The classic case develops from
progressively deeper medial retraction of the pars flaccida
into the epitympanum (attic). As this process continues, the
lateral wall of the epitympanum (the scutum) is slowly
eroded, producing a defect in the lateral wall of the
epitympanum that slowly expands.

eaid=56708714 eadv=17889674 ebuy=223784114

ecid=84683571794 pos=141 pvid=149260914914232365
para, childcount:1
The tympanic membrane continues retracting medially until
it passes over the heads of the ossicles and into the
posterior epitympanum. Ossicular destruction is common.
If the cholesteatoma pokes posteriorly into the aditus ad
antrum and the mastoid itself, erosion of the tegmen
mastoideum, with exposure of the dura and/or erosion of
the lateral semicircular canal with deafness and vertigo,
may result. reference_ids_tool_tip reference_ids [9]

para, childcount:0
A second type of primary acquired cholesteatoma arises
when the posterior quadrant of the tympanic membrane is
retracted into the posterior middle ear. The drum initially
adheres to the long process of the incus. As retraction
continues medially and posteriorly, squamous epithelium
envelops the superstructure of the stapes and retracts into
the sinus tympani.

para, childcount:0
Primary cholesteatomas arising from the posterior tympanic
membrane are likely to produce facial nerve exposure (and
occasionally paralysis) and destruction of the stapedial
superstructure. Surgical removal from the sinus tympani
may be extremely challenging.

Secondary acquired cholesteatoma

para, childcount:2
Secondary acquired cholesteatomas result directly from an
injury to the tympanic membrane. This injury can be a
perforation caused by acute otitis media or trauma, or it
may be due to surgical manipulation of the drum.
para, childcount:1
A procedure as simple as the insertion of tympanostomy
tubes could implant squamous epithelium into the middle
ear, ultimately producing a cholesteatoma. Posterior
marginal perforations are the most likely to result in
cholesteatoma formation. Although central perforations are
considered unlikely to produce cholesteatomas, they do so
occasionally. Any deep retraction pocket can lead to
cholesteatoma formation if the retraction pocket becomes
deep enough to trap desquamated epithelium. reference_ids_tool_tip
reference_ids [10, 11]

Epidemiology
sect2: a6 para, childcount:0
The incidence of cholesteatomas in the United States is
unknown, but they are a relatively common reason for
otologic surgery (approximately weekly in tertiary otologic
practices). Death from intracranial complications of
cholesteatoma is now uncommon, with the change being
attributable to earlier recognition, timely surgical
intervention, and supportive antibiotic therapy.
Cholesteatomas remain a relatively common cause of
permanent, moderate conductive hearing loss in children
and adults.

Prognosis
sect2: a7 para, childcount:0
Eliminating a cholesteatoma is almost always possible;
however, multiple operations may be required. Because
surgery is generally successful, complications from
uncontrolled cholesteatoma growth are now relatively
uncommon.

para, childcount:1
Canal wall–down (open cavity) tympanomastoidectomy
offers a very low rate of recurrence or persistence of
cholesteatomas. Reoperation for cholesteatomas occurs in
5% of patients or less. This compares quite favorably to the
20-40% recurrence rates associated with closed-cavity
techniques (canal wall–up). reference_ids_tool_tip reference_ids [6]

para, childcount:0
Nonetheless, because the ossicular chain and/or tympanic
membrane cannot always be completely restored to normal,
cholesteatomas remain a relatively common cause of
permanent, moderate conductive hearing loss.

para, childcount:1
A study by Rosito et al linked cholesteatoma with
sensorineural hearing loss. In an analysis of 115 patients
with middle ear cholesteatoma on one side, greater bone-
conduction thresholds were found in the affected ear than
in the contralateral ear at various frequencies. It was also
found that the larger the air-bone gap in the affected ear,
the greater the damage to the inner ear. reference_ids_tool_tip reference_ids
[12]

Mortality
para, childcount:0
Death from intracranial complications of cholesteatoma is
now uncommon, with the change being attributable to
earlier recognition, timely surgical intervention, and
supportive antibiotic therapy.

Diagnostic Considerations
para, childcount:0
The diagnosis may be in doubt in individuals with only
small epitympanic retractions observed during the physical
examination. Computed tomography (CT) scanning may
help to distinguish between shallow retractions without soft
tissue extension into the epitympanic space and an
extensive soft tissue mass with bony erosion.

para, childcount:0
CT scanning can be helpful in individuals who have
already had tympanomastoid surgery. In this group of
patients, a white mass behind the tympanic membrane
(shown below) may represent tympanosclerosis, cartilage,
or a recurrent cholesteatoma. CT scan findings frequently
help to resolve such questions. Diffusion-weighted
magnetic resonance imaging (MRI) may also be helpful in
such circumstances.

VideoWidgets::figure
capt_n_gallery_link_url::incaption: A large cholesteatoma. No
landmarks are visible, which typically is the case with advanced
cholesteatomas.
A large cholesteatoma. No landmarks are visible, which typically is the case
with advanced cholesteatomas.
View Media Gallery

para, childcount:1
Middle ear osteoma and chronic suppurative otitis media
are other differentials in the diagnosis of cholesteatoma.

Approach Considerations
sect2: d1 para, childcount:0
Virtually all cholesteatomas should be excised. The only
absolute contraindications to the surgical removal of
cholesteatomas are medical in nature. Some individuals
have health problems of such gravity as to make the risk of
surgical intervention unacceptably high.
para, childcount:0
Absence of hearing in the contralateral ear is a relative
contraindication to surgery. Since, however, the
cholesteatoma frequently presents a greater risk to residual
hearing than surgery does, surgical removal usually
remains the management option of choice in these
situations.
para, childcount:0
Depending on the procedure, approximately 5-40% of
cholesteatoma operations are unsuccessful, with
cholesteatoma persistence or recurrence manifesting at
some point in the postoperative period. Persistence may
appear as early as 5-6 months postoperatively, or it may be
delayed for many years. Consequently, close follow-up
care is important.
para, childcount:1
The applicability of using small otoendoscopes as part of
the surgical management of cholesteatomas is being
explored. A study by Hunter et al in pediatric patients with
cholesteatoma, comparing total endoscopic ear surgery
with microscopic surgery and combined endoscopic-
microscopic procedures, found that results were similar
between the endoscopic and microscopic techniques with
regard to hearing outcomes, complication rates, and
recurrence and residual disease rates. reference_ids_tool_tip reference_ids [25]

Nonsurgical care
para, childcount:0
Medical therapy is not a viable treatment for
cholesteatomas. Patients who refuse surgery or whose
medical condition makes a general anesthetic too hazardous
should have their ears cleaned regularly. Regular cleaning
can help to control infection and may slow growth of the
cholesteatoma, although it does not stop further expansion
or eliminate risk. The mainstay of microbial therapy should
be topical, but systemic therapy is occasionally a helpful
adjunct.
Consultations
para, childcount:0
Consultation with an otolaryngologist is mandatory. Rarely,
advice from a neurosurgeon is required to help manage an
intracranial consultation.

Mastoidectomy
sect2: d9 para, childcount:1
Surgical therapy consists of removing the cholesteatoma. In
certain circumstances, the surgeon can make the decision to
use a canal wall–up (closed) or canal wall–down (open)
technique preoperatively.

para, childcount:1
Canal wall–down operations have the highest probability of
permanently ridding the patient of a cholesteatoma. Canal
wall–up procedures have the advantage of maintaining a
normal appearance, but because the risk of persistent or
recurrent cholesteatomas is higher with this operation, most
surgeons advise an obligatory second-look
tympanomastoidectomy 6 months to 1 year after the initial
procedure. reference_ids_tool_tip reference_ids [26, 27]

para, childcount:1
At the time of the second look, small amounts of residual
disease can frequently be removed prior to the development
of either complications or massive recurrence. (Increasing
evidence suggests that diffusion-weighted MRI may be
able to accurately detect cholesteatoma recurrence and, in
some cases, replace a second-look procedure. reference_ids_tool_tip
reference_ids [28]
)

para, childcount:1
If the patient has had several episodes of recurrence of the
cholesteatoma and wishes to avoid future operations, the
canal wall–down technique is most applicable. In addition,
it is safer for patients who are unwilling or unable to return
for a second-look procedure. reference_ids_tool_tip reference_ids [6, 7, 29]

para, childcount:0
Some congenital anomalies are known to be associated
with a lifelong history of eustachian tube dysfunction, and
in some individuals, previous surgical procedures have
irreversibly injured the eustachian tube. These again are
patients in whom an open-cavity operation often is best.

para, childcount:1
Osborn et al reported the results from 420 children who
underwent 700 operations and concluded that most children
with cholesteatoma can be managed with an intact–canal
wall technique. reference_ids_tool_tip reference_ids [30]

para, childcount:0
Sometimes, the decision as to which procedure to use is not
possible until the operation has begun and a clear
understanding of the extent of the disease has been
obtained.
para, childcount:0
No operation can be successful unless the goals of the
procedure are kept clearly in mind. These goals include the
following:
itemizedlist
listitem
• para, childcount:0To make the ear safe by eliminating
the cholesteatoma and chronic infection
listitem
• para, childcount:0To make the ear problem-free for all
the usual activities of daily living, including swimming
listitem
• para, childcount:0To conserve residual hearing
listitem
• para, childcount:0To improve hearing when possible
listitem
• para, childcount:0To provide an acceptable cosmetic
appearance

eaid=56708714 eadv=17889674 ebuy=223784114

ecid=84683571794 pos=141 pvid=149260929160961586
Preoperative details
para, childcount:0
A careful discussion of the advantages and disadvantages
of canal wall–up and canal wall–down (open) procedures is
useful. If a canal wall–down procedure is considered
preoperatively, showing the patient a picture of a well-
crafted meatoplasty, as shown below, can help the patient
form a clear understanding of the expected postoperative
appearance.

para, childcount:0
Advantages and disadvantages of the canal wall–up
procedure include the following:
itemizedlist
listitem
• para, childcount:0Normal appearance
listitem
• para, childcount:0Hearing aids easy to fit
listitem
• para, childcount:0No routine cleaning required
listitem
• para, childcount:0High tolerance for water exposure
listitem
• para, childcount:0Usually a staged procedure
listitem
• para, childcount:0Relatively high rate of recurrent or
persistent cholesteatomas

para, childcount:0
Advantages and disadvantages of the canal wall–down
procedure include the following:
itemizedlist
listitem
• para, childcount:0Enlarged meatus
listitem
• para, childcount:0Hearing aids difficult to fit
listitem
• para, childcount:0Annual or semiannual canal
cleaning needed
listitem
• para, childcount:0Occasional problem with water
exposure: Dizziness may develop after exposure to water or
cold air.
listitem
• para, childcount:0Usually a single procedure
listitem
• para, childcount:0Low rate of persistent or recurrent
cholesteatomas

Intraoperative details
para, childcount:1
Often, the best plan is to reserve the decision about how to
manage the canal wall until the operation has begun and a
better understanding of the extent of disease has emerged.
Some intraoperative findings that favor a canal wall–down,
or open, technique, include the following reference_ids_tool_tip reference_ids
[6]
:
itemizedlist
listitem
• para, childcount:0Involvement of the sinus tympani
listitem
• para, childcount:0Involvement of the medial end of
the canal wall, with the cholesteatoma wedged laterally
between the heads of the ossicles in the epitympanum and
medial canal wall
listitem
• para, childcount:0Ostitis or irremovable cholesteatoma
in the area around the opening to the eustachian tube or in
the most inferior portions of the middle ear space (often
calls for a true radical mastoidectomy)
listitem
• para, childcount:0Large defects in the canal wall:
Frequently, the best plan is to convert the operation to an
open-cavity procedure (in contrast, small defects in the
canal wall are readily repaired)
listitem
• para, childcount:0Labyrinthine fistula: If the
cholesteatoma matrix is left over the fistula so as not to
expose it, then the canal must be removed; otherwise,
epithelium is trapped within the mastoid cavity, resulting in
cholesteatoma recurrence; if the cholesteatoma matrix is
removed from the fistula, some surgeons are comfortable
leaving the canal wall up

para, childcount:0
Most surgical procedures for cholesteatomas in the United
States are now performed through an incision behind the
ear combined with an incision in the external auditory
canal, but the procedure can be performed through an
extended incision starting in the ear canal.

para, childcount:1
Regardless of which technique is used, all of the mastoid’s
air cells should be removed. If ossicles are involved, they
must be removed to avoid recurrence. reference_ids_tool_tip reference_ids [28]
Reconstruct the ossicular chain either at the end of the
primary procedure or as part of a secondary operation.

para, childcount:0
The tympanic membrane is usually reconstructed. If a canal
wall–up technique is used, missing bone is replaced with a
cartilage graft. If a canal wall–down procedure is selected,
a large meatoplasty is created to allow adequate air
circulation into the cavity that arises as a consequence of
removing the posterior canal wall. (See the image below.)

VideoWidgets::figure

capt_n_gallery_link_url::incaption: The photo exhibits a large

meatoplasty performed as part of an open cavity (canal wall–
down) mastoidectomy. A similar meatoplasty usually is necessary
if a clean, dry, problem-free cavity is to be maintained.
The photo exhibits a large meatoplasty performed as part of an open cavity
(canal wall–down) mastoidectomy. A similar meatoplasty usually is
necessary if a clean, dry, problem-free cavity is to be maintained.
View Media Gallery

VideoWidgets::figure

capt_n_gallery_link_url::incaption: A typical audiogram

demonstrating bilateral conductive hearing loss, which may be
observed in an individual with a cholesteatoma.
A typical audiogram demonstrating bilateral conductive hearing loss, which
may be observed in an individual with a cholesteatoma.
View Media Gallery

para, childcount:1
Essential features of a canal wall–up procedure include the
following reference_ids_tool_tip reference_ids [7] :
itemizedlist
listitem
• para, childcount:0Removal of all infected air cells
listitem
• para, childcount:0A functioning eustachian tube
listitem
• para, childcount:0A well-maintained middle ear space
listitem
• para, childcount:0Adequate communication between
the mastoid and the middle ear space through the aditus ad
antrum or a generous facial recess
listitem
• para, childcount:0Elimination of any bony
epitympanic defect with a cartilage or bone graft

para, childcount:0
Essential features of a canal wall–down procedure include
the following:
itemizedlist
listitem
• para, childcount:0Removal of all air cells, including
those within the retrofacial, retrolabyrinthine, and
subarcuate air cell tracts
listitem
• para, childcount:0Removal of the lateral and posterior
walls of the epitympanum so that the tegmen mastoideum
and tegmen tympani become a smooth, featureless plane
listitem
• para, childcount:0Amputation of the mastoid tip
(usually advisable)
listitem
• para, childcount:0Saucerization of the lateral margins
of the cavity
listitem
• para, childcount:0Lowering of the posterior bony
external auditory wall to the level of the facial nerve
listitem
• para, childcount:0Exteriorization of the anterior
epitympanic recess by removing the cog
listitem
• para, childcount:0Enlargement of the meatus (to at
least twice its normal size) by removing conchal cartilage
listitem
• para, childcount:0Lowering of the medial end of the
external auditory canal toward the floor of the
hypotympanum

para, childcount:0
Some surgeons prefer a subcortical technique that starts by
removing bone medially through the ear canal. The
epitympanum is progressively enlarged, and the posterior
canal wall is removed from the inside out. Bone removal is
limited to that necessary to remove all of the
cholesteatoma.

para, childcount:1
Such a subcortical, or inside-out, mastoidectomy combines
some of the advantages of canal wall–up and canal wall–
down techniques but commits the surgeon to a canal wall–
down operation if the cholesteatoma has extensive mastoid
involvement. reference_ids_tool_tip reference_ids [31, 32]

Canal wall-reconstruction tympanomastoidectomy

para, childcount:1
In a retrospective case review of 273 patients (mean age
35) with chronic otitis media with cholesteatoma, Walker et
al found that an alternative surgical procedure, canal wall–
reconstruction (CWR) tympanomastoidectomy with
mastoid obliteration, produced good long-term results. The
investigators, who examined the surgical outcomes on 285
ears (average follow-up 4.29 years), determined the rate of
failed procedures—those requiring conversion to open
cavity or subtotal petrosectomy—to be only 2.6%.
reference_ids_tool_tip reference_ids [33]

para, childcount:0
The investigators concluded that use of CWR
tympanomastoidectomy avoids the long-term drawbacks of
canal wall–down mastoidectomy while offering surgeons
excellent exposure of the middle ear and mastoid.

Management of the complications of cholesteatoma

para, childcount:1
Labyrinthine fistula

para, childcount:0
Sometimes, the existence of a labyrinthine fistula is
suggested on preoperative CT scans; at other times, the
presence of a fistula is a complete surprise. Initially, the
desquamated epithelium should be removed, carefully
leaving the matrix over the horizontal canal. Blunt probes
are used to locate the fistula by palpation. If the fistula
appears to be superficial, the matrix is gently removed at
the end of the case and the defect is covered with fascia.

para, childcount:0
However, if the fistula is large and it appears that the
cholesteatoma matrix is attached firmly to the membranous
labyrinth itself, leaving the matrix in position should be
considered. Debate continues as to whether hearing loss is
more likely if the matrix is removed.

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If the membranous labyrinth is opened at any point during
the procedure, broad-spectrum IV antibiotics and steroids
should both be administered immediately. Bacterial
labyrinthitis and inflammation pose the biggest risk to
hearing. reference_ids_tool_tip reference_ids [34] Fistulas involving the oval
window area should be treated according to the same
principles. Violation of the vestibule itself is much more
likely to produce hearing loss than violation of one of the
semicircular canals.

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Occasionally, a canal fistula is created during the surgical
procedure. If such a fistula involves one of the semicircular
canals, then it should be sealed with soft tissue (preferably
fascia) and IV antibiotics and steroids administered. These
patients are quite likely to have significant balance
disturbance in the immediate postoperative period, but a
significant number recover with little or no hearing loss if
appropriate antibiotic therapy and steroids are provided in
the postoperative period.

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Brain herniation

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Brain herniation through the tegmen of the middle fossa
has a characteristic glistening, shiny appearance. The
presence of clear fluid associated with such a lesion should
raise suspicion of a brain hernia and cerebrospinal fluid
leak. MRI and CT scanning can often help to clarify the
diagnosis preoperatively.

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Options for managing a brain hernia fall into 2 basic
categories: reconstruction of the mastoid cavity and
obliteration of the mastoid cavity. If reconstruction is
chosen, glialized brain can be removed simply by sharply
excising it; any viable brain can be pushed back up into the
middle cranial fossa. If the defect is large, intradural and
extradural repair of the dural defect should be considered.

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The alternative involves obliterating the middle ear,
external auditory canal, and mastoid by removing the
posterior canal wall, obliterating the eustachian tube, filling
the defect with abdominal fat, and over sewing the external
canal. This is an especially appealing option if hearing is
very poor in the afflicted ear. If all of the squamous
epithelium has been removed, obliteration ensures a safe,
well-healed, problem-free ear, although maximal
conductive hearing loss is unavoidable.

Postoperative details
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Regular office visits are necessary following surgery. Some
surgeons prefer to see the patient on the following day and
remove the dressing themselves. Others prefer to wait 7-10
days; these surgeons allow the patient to remove the
dressing at home after 12-48 hours. If nonabsorbable
sutures or staples are used, they must be removed at 7-10
days.

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If suture or staple removal is unnecessary, some surgeons
delay the first postoperative visit for as long as 2-3 weeks.
Open cavities heal slowly, and 12-24 weeks are often
required for full epithelialization.

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Postoperative management

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Postoperative treatment regimens for canal wall–down
procedures vary considerably. The wick in the external
auditory canal (EAC) is removed at the first postoperative
visit, 7-10 days after surgery. Antibiotic otic drops are
prescribed twice daily for 10 days.

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The author prefers to fill cavities from the canal wall–down
surgery with antibiotic ointment at the first postoperative
visit.

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Open cavities require variable amounts of cleaning over the
first 4-8 postoperative weeks. The first cavity cleaning
occurs at the postoperative visit 2-3 weeks after the
procedure, and such cleaning can be accomplished
regularly in an office setting every 2-3 weeks, depending
on how quickly the cavity epithelializes.

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Often, the patient is asked to fill the cavity with peroxide
daily, starting 1-2 weeks postoperatively, or to irrigate the
cavity with an alcohol-vinegar solution. This limits the
amount of superficial infection.

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Control of granulation tissue

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Frequently, granulation tissue forms in the open cavity as it
heals. Granulation tissue may be helpful because it can
contract the size of the cavity, resulting in a much smaller
postoperative cavity than would be the case if the initial
defect epithelialized. On the other hand, granulation tissue
can obliterate medial portions of the cavity, including the
newly grafted drum, and compromise the hearing outcome.
Exuberant granulation tissues can significantly delay
epithelialization.

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Steroid creams, steroid-containing drops, and regular
applications of gentian violet can be used to help control
the development and extent of granulation tissue.

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Silver nitrate cautery effectively eliminates or reduces
granulation tissue. However, silver nitrate produces a
chemical burn, the depth of which is difficult to control, so
extra caution must be used around delicate or sensitive
structures such as the horizontal semicircular and facial
nerve in order to avoid injury.

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Infection control

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Often, a superficial infection develops that can be
effectively controlled using topical antibiotic drops. The
causative organisms are predominantly gram negative, with
Pseudomonas species as the single most common
pathogens, but gram-positive organisms, including
Streptococcus and Staphylococcus species, account for 20-
30% of recovered organisms.

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Aminoglycoside and fluoroquinolone topical preparations
provide appropriate antibacterial spectra for these
organisms. The complete absence of potential ototoxicity
among the fluoroquinolones makes them appealing. If a
nonsteroidal otic preparation is desired, either ciprofloxacin
or ofloxacin solution is an excellent choice.

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If granulation tissue is present, steroid-containing drops
may be preferred. In such cases,
ciprofloxacin/dexamethasone (Ciprodex) is an excellent
choice. Antibacterial creams containing fluoroquinolones
can also be used. Occasionally, if granulation tissue appears
to be overwhelming, steroid creams alone are useful.
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If a superficial fungal infection or candidiasis develops,
nystatin-triamcinolone (Mycolog) or clotrimazole
(Mycelex) cream is usually sufficient to eradicate it.