eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Cholesteatoma: Differential Diagnoses & 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, School of Human Development.
Contributor Information and Disclosures

Updated: Mar 7, 2008

Differential Diagnoses

Other Problems to Be Considered

Tympanosclerosis
Middle ear osteoma
Chronic suppurative otitis media

Workup

Laboratory Studies

  • No laboratory diagnostic tests are generally necessary.

Imaging Studies

  • Some surgeons believe that any patient with a cholesteatoma scheduled for surgical intervention should have a preoperative CT scan. These surgeons believe that useful information is obtained in every circumstance and, consequently, that the expense and radiation exposure is always justified. The imaging modality of choice is a CT scan without intravenous contrast. CT scans can reveal the following subtle bony defects:
    • Scutal erosion
    • Labyrinthine fistula
    • Defects in the tegmen
    • Details of ossicular involvement
    • Details of ossicular erosion or discontinuity
    • Anomalies, erosion, or invasion of the facial nerve canal
  • CT scanning cannot always distinguish between granulation tissue and cholesteatoma.
    • Even technically excellent, fine-cut CT scans cannot always determine the full extent of disease.
    • The surgeon, therefore, cannot always predict which operative course is required.
    • Both the operating surgeon and the patient must understand these limitations of the preoperative assessment and must prepare for intraoperative surprises.
  • Other surgeons reserve preoperative imaging for only special cases and are comfortable performing surgery without preoperative imaging. These surgeons are likely to request a preoperative CT scan in the following circumstances:
    • Doubtful diagnosis
      • The diagnosis may be in doubt among individuals with only small attic retractions upon physical examination.
      • CT scanning may 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 already have had tympanomastoid surgery. In this group of patients, a white mass behind the TM can represent tympanosclerosis, cartilage deliberately placed at a previous operation, or recurrent cholesteatoma. CT scanning frequently helps determine which.
    • Patient who adamantly wishes to avoid surgery
      • Poor surgical candidates or patients who, for other reasons, wish to avoid an operation, can be better advised regarding the risks of nonsurgical management on the basis of CT scanning.
      • Information from a CT scan may help a surgeon advise the patient and parents and/or caregivers that 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.
    • If ossicular involvement is apparent on preoperative CT scans, then parents can be counseled that ossicular removal may be necessary and that a significant postoperative conductive hearing loss should be expected.
    • Indeterminate underlying anatomy and unclear extent of disease as the result of previous surgery
    • Reasonable expectation of congenital anomalies (eg, atresia, craniofacial anomalies)
    • Suspected complications
  • MRI is useful when the following very specific problems involving surrounding soft tissues are expected:
    • Dural involvement invasion and/or inflammation
    • Subdural or epidural abscess
    • The presence of herniated brain into the mastoid cavity
    • Inflammation of the membranous labyrinth or facial nerve
    • Intracranial invasion
    • Sigmoid sinus thrombosis
    • Meningitis

Other Tests

  • Audiometry
    • In most circumstances, perform audiometry prior to surgery and include air and bone conduction and speech discrimination testing.
    • Infrequently, a serious complication of cholesteatoma requires urgent surgery; in these patients, audiometric testing can be omitted.

Histologic Findings

The histology of surgically removed cholesteatoma specimens demonstrates typical squamous epithelium. The histology is indistinguishable from sebaceous cysts or keratomas removed from any other portion of the body.

More on Cholesteatoma

Overview: Cholesteatoma
Differential Diagnoses & Workup: Cholesteatoma
Treatment & Medication: Cholesteatoma
Follow-up: Cholesteatoma
Multimedia: Cholesteatoma
References
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References

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

  3. Manolidis S, Kutz JW Jr. Diagnosis and management of lateral sinus thrombosis. Otol Neurotol. Sep 2005;26(5):1045-51. [Medline].

  4. Kazahaya K, Potsic WP. Congenital cholesteatoma. Curr Opin Otolaryngol Head Neck Surg. Oct 2004;12(5):398-403. [Medline].

  5. Potsic WP, Korman SB, Samadi DS, Wetmore RF. Congenital cholesteatoma: 20 years' experience at The Children's Hospital of Philadelphia. Otolaryngol Head Neck Surg. Apr 2002;126(4):409-14. [Medline].

  6. Dawes PJ, Leaper M. Paediatric small cavity mastoid surgery: second look tympanotomy. Int J Pediatr Otorhinolaryngol. Feb 2004;68(2):143-8. [Medline].

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  8. Dornhoffer JL, Colvin GB, North P. Evidence of residual disease in ossicles of patients undergoing cholesteatoma removal. Acta Otolaryngol. Jan 1999;119(1):89-92. [Medline].

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  10. Anderson J, Caye-Thomasen P, Tos M. A comparison of cartilage palisades and fascia in tympanoplasty after surgery for sinus or tensa retraction cholesteatoma in children. Otol Neurotol. Nov 2004;25(6):856-63. [Medline].

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  16. 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].

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  19. 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].

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Further Reading

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Keywords

cholesteatoma, keratoma, middle ear cholesteatoma, primary cholesteatoma, primary acquired cholesteatoma, secondary cholesteatoma, secondary acquired cholesteatoma, otorrhea, tympanic membrane perforation, TM perforation, temporal bone, squamous epithelium, congenital cholesteatoma, scutal erosion, labyrinthine fistula

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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, 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 Speaking and teaching; Insight vision Consulting fee Consulting

Medical Editor

Orval Brown, MD, Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas
Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

John E McClay, MD, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's Medical Center, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Maureen Strafford, MD is a member of the following medical societies: American Medical Women's Association, American Pain Society, American Society of Anesthesiologists, International Anesthesia Research Society, Society for Education in Anesthesia, Society for Pediatric Anesthesia, and Society of Cardiovascular Anesthesiologists
Disclosure: Nothing to disclose.

 
 
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