eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Middle Ear & Mastoid

Middle Ear, Cholesteatoma: Workup

Author: Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, University of Texas School of Human Development
Contributor Information and Disclosures

Updated: Jun 29, 2009

Workup

Imaging Studies

  • CT scanning is the imaging modality of choice because CT scanning can detect subtle bony defects. However, CT scanning cannot always distinguish between granulation tissue and a cholesteatoma. Even technically excellent fine-cut CT scans cannot reliably determine the full extent of disease. The surgeon cannot always predict what is needed in the operating room based on findings from the preoperative evaluation. Both the operating surgeon and the patient must understand this limitation of the preoperative assessment and be prepared for intraoperative surprises.6,7,8 Gaurano (2004) has demonstrated that expansion of the mastoid antrum can be seen in 92% of middle ear cholesteatomas and, similarly, 92% had CT demonstrable erosion of the ossicles.The subtle bony defects that can be detected using CT a scan include the following:8
    • Scutal erosion
    • Labyrinthine fistula
    • Defects in the tegmen
    • Details of ossicular involvement
    • Details of ossicular erosion or discontinuity
    • Anomalies or invasion of the fallopian canal
  • MRI is used when very specific problems are expected to involve surrounding soft tissues. These problems including the following:8
    • Dural involvement or invasion
    • Subdural or epidural abscess
    • Herniated brain into the mastoid cavity
    • Inflammation of the membranous labyrinth or facial nerve
    • Sigmoid sinus thrombosis
  • A number of articles have recently appeared in the literature suggesting that diffusion weighted MRI may be able to distinguish between recurrent or persistent middle ear cholesteatoma and scar tissue or granulation tissue. If future studies verify both a high sensitivity and specificity, replacing routine second look procedures with high quality diffusion weighted MRI images may be possible.9,10
  • Some surgeons reserve preoperative imaging for only special cases and are quite comfortable performing surgery without it. These surgeons may request a preoperative CT scan in the following circumstances:
    • If the diagnosis is in doubt: The diagnosis may be in doubt in individuals with only small attic retractions observed during the physical examination. CT scanning may help distinguish between shallow retractions without soft tissue extension into the epitympanic space and an extensive soft tissue mass with bony erosion. 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 could represent tympanosclerosis, cartilage, or a recurrent cholesteatoma. CT scan findings frequently help resolve such questions. Diffusion weighted MRI may also be helpful in such circumstances.
    • If the patient is adamant about avoiding an operation: Poor surgical candidates or patients who wish to avoid an operation for other reasons can be better advised about the risks of nonsurgical management if a CT has been performed and findings are evaluated. The presence of extensive disease, labyrinthine fistula, encroachment on the fallopian canal, and involvement of the oval window niche increase the risk of expectant management.
    • Helping a patient or parents assess some of the risks of ossicular involvement is often useful: If ossicular involvement is apparent on preoperative CT scans, parents should be counseled that ossicular removal may be necessary and significant postoperative conductive hearing loss should be expected.
    • If the underlying anatomy is indeterminate and the extent of disease is unclear as the result of previous surgery
    • In patients with congenital anomalies (eg, atresia cases, individuals with craniofacial anomalies)
    • If complications are suspected.
    • If labyrinthine fistula or erosion of the fallopian canal is suspected: In this case, CT scanning remains the procedure of choice.
    • If intracranial invasion, dural inflammation, meningitis, abscess, or sigmoid sinus thrombosis is suspected, MRI is indicated.
  • Other surgeons believe any patient with a cholesteatoma who is scheduled for surgical intervention should have a preoperative CT scan. They believe that useful information is obtained in every circumstance and, consequently, that the expense and radiation exposure is always justified.

Other Tests

Incisional biopsies are unnecessary because the diagnosis can be made based on physical examination and radiography findings.

Diagnostic Procedures

Audiometry should be performed prior to surgery whenever possible. Occasionally, a serious complication may require urgent surgery, and, in such cases, audiometric testing can be foregone. Air conduction, bone conduction, speech reception threshold, and speech discrimination scores should all be determined within a few weeks of the proposed operative procedure. No other diagnostic tests are generally necessary.

Histologic Findings

The histology findings from 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.

More on Middle Ear, Cholesteatoma

Overview: Middle Ear, Cholesteatoma
Workup: Middle Ear, Cholesteatoma
Treatment: Middle Ear, Cholesteatoma
Follow-up: Middle Ear, Cholesteatoma
Multimedia: Middle Ear, Cholesteatoma
References
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References

  1. Ottaviani F, Neglia CB, Berti E. Cytokines and adhesion molecules in middle ear cholesteatoma. A role in epithelial growth?. Acta Otolaryngol. 1999;119(4):462-7. [Medline].

  2. De la Cruz A, Fayad JN. Detection and management of childhood cholesteatoma. Pediatr Ann. Jun 1999;28(6):370-3. [Medline].

  3. Kemppainen HO, Puhakka HJ, Laippala PJ, et al. Epidemiology and aetiology of middle ear cholesteatoma. Acta Otolaryngol. 1999;119(5):568-72. [Medline].

  4. Golz A, Goldenberg D, Netzer A, et al. Cholesteatomas associated with ventilation tube insertion. Arch Otolaryngol Head Neck Surg. Jul 1999;125(7):754-7. [Medline].

  5. Thompson JW. Cholesteatomas. Pediatr Rev. Apr 1999;20(4):134-6. [Medline].

  6. Tierney PA, Pracy P, Blaney SP, Bowdler DA. An assessment of the value of the preoperative computed tomography scans prior to otoendoscopic 'second look' in intact canal wall mastoid surgery. Clin Otolaryngol Allied Sci. Aug 1999;24(4):274-6. [Medline].

  7. Gaurano JL, Joharjy IA. Middle ear cholesteatoma: characteristic CT findings in 64 patients. Ann Saudi Med. Nov-Dec 2004;24(6):442-7. [Medline].

  8. Joel Swartz, H. Harnsberger. Imaging of the Temporal Bone. 3 Sub edition. New York: George Thieme Verlag; Oct 1, 1997.

  9. Vercruysse JP, De Foer B, Pouillon M, et al. The value of diffusion-weighted MR imaging in the diagnosis of primary acquired and residual cholesteatoma: a surgical verified study of 100 patients. Eur Radiol. Mar 3 2006;[Medline].

  10. Dubrulle F, Souillard R, Chechin D, et al. Diffusion-weighted MR imaging sequence in the detection of postoperative recurrent cholesteatoma. Radiology. Feb 2006;238(2):604-10.

  11. Roland PS, Meyerhoff WL. Open-cavity tympanomastoidectomy. Otolaryngol Clin North Am. Jun 1999;32(3):525-46. [Medline].

  12. Graham MD, Delap TG, Goldsmith MM. Closed tympanomastoidectomy. Otolaryngol Clin North Am. Jun 1999;32(3):547-54. [Medline].

  13. Roth TN, Haeusler R. Inside-out technique cholesteatoma surgery: a retrospective long-term analysis of 604 operated ears between 1992 and 2006. Otol Neurotol. Jan 2009;30(1):59-63. [Medline].

  14. Sanna M, Facharzt AA, Russo A, Lauda L, Pasanisi E, Bacciu A. Modified Bondy's technique: refinements of the surgical technique and long-term results. Otol Neurotol. Jan 2009;30(1):64-9. [Medline].

  15. Busaba NY. Clinical presentation and management of labyrinthine fistula caused by chronic otitis media. Ann Otol Rhinol Laryngol. May 1999;108(5):435-9. [Medline].

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Further Reading

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Keywords

keratoma, cholesteatoma, middle ear cholesteatoma, canal-wall-down otologic surgery, canal-wall-up otologic surgery, canal-wall-down technique, canal-wall-up technique, ear lesion, ear mass, congenitally acquired cholesteatoma, primarily acquired cholesteatoma, secondarily acquired cholesteatoma, congenital cholesteatoma, primary cholesteatoma, secondary cholesteatoma, chronic middle ear fluid, conductive hearing loss, tympanic membrane retraction, tympanic membrane trauma, tympanic membrane injury, acute otitis media, AOM, OM, acute OM, tympanic membrane perforation, painless otorrhea, otorrhea, hearing loss, deafness

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Contributor Information and Disclosures

Author

Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, University of Texas School of Human Development
Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Consulting

Medical Editor

Jack A Shohet, MD, Associate Clinical Professor, Department of Otolaryngology-Head and Neck Surgery, University of California Irvine; Otolaryngologist, Shohet Ear Associates Medical Group, Inc
Jack A Shohet, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Neurotology Society, American Tinnitus Association, and California Medical Association
Disclosure: Envoy Medical Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gerard J Gianoli, MD, Clinical Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine; Vice President, The Ear and Balance Institute; Chief Executive Officer, Ponchartrain Surgery Center
Gerard J Gianoli, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Neurotology Society, American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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