eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Cholesteatoma: Follow-up

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

Follow-up

Further Outpatient Care

  • Observe each patient with cholesteatoma for many years.
    • Recurrence can occur long after the initial surgical excision.
    • Include semiannual or annual evaluations in follow-up care, even in the otherwise asymptomatic patient.
  • Patients who have undergone open cavity procedures may require follow-up care as often as every 3 months for canal cleaning. In contrast, some patients require cleaning only once per year. How frequently these patients require cleaning to keep the canal free of desquamated epithelium and cerumen soon becomes apparent.
  • Patients who have had closed cavity operations generally require a second look procedure 6-9 months after the original operation.
  • Once the second look incisions are healed, regular follow-up care at 6- to 12-month intervals is necessary to ensure against persistent recurrence of cholesteatoma.

Complications

  • Various complications are possible from cholesteatoma and cholesteatoma surgery. The most feared complication is facial nerve paralysis. The incidence of permanent facial nerve injury following cholesteatoma surgery is not entirely certain but appears to be approximately 1% or less. Incidence is probably considerably less than 1% in the hands of experienced otologists who perform the operation regularly. Whether facial nerve monitoring helps reduce the risk of postoperative facial nerve injury is controversial.
  • A 1-2% chance of total neurosensory hearing loss is associated with cholesteatoma removal. A cholesteatoma that has produced a labyrinthine fistula or that lies directly over the footplate is more likely to produce permanent neurosensory loss.9
  • Many patients have alteration of taste on the anterior ipsilateral tongue for weeks after an otologic procedure. However, this condition usually resolves within a few months after surgery.
  • Long-term balance disturbance can occur because of labyrinthine or middle ear injury but is uncommon (occurring in <1% of patients).
  • In approximately 10-15% of patients, the graft fails, and a permanent TM perforation follows tympanomastoidectomy for removal of cholesteatoma. Such perforations frequently can be eliminated by surgical treatment.
  • Depending on the procedure, approximately 5-30% of operations are unsuccessful, and cholesteatoma persistence or recurrence manifests at some point in the postoperative period. Persistence may appear as early as 5-6 months postoperatively or may be delayed for many years. Consequently, close follow-up care is important.

Prognosis

  • Elimination of 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.

Miscellaneous

Medicolegal Pitfalls

  • The principal medicolegal pitfall is failure to diagnose. Failure to diagnose a cholesteatoma is one of the more common causes for claims against a pediatrician. Cholesteatomas grow slowly, and if significant hearing loss has occurred, supporting a claim that the cholesteatoma must have been present for a long period of time is easy. If the ear has been examined frequently in the recent past, parents often believe that the diagnosis should have been made earlier. This common situation can be avoided by maintaining excellent documentation of the otologic examination with a complete description of findings and by referral if in doubt.

Special Concerns

  • The routine use of facial nerve monitoring remains controversial.
    • A survey of practicing otologists performed in 1990 demonstrated that most experienced otologists do not believe that facial nerve monitoring is obligatory. Many experienced otologists use it only occasionally. Facial nerve monitoring requires experience and is unlikely to provide meaningful protection to an inexperienced operator.
    • Conversely, some surgeons believe that predicting in which individuals the facial nerve is at risk is impossible. Consequently, these surgeons believe monitoring should be performed in every patient. These surgeons view monitoring as a precaution, much like ECG monitoring, that potentially may be useful in any given situation.
    • A large percentage of surgeons do not use facial nerve monitoring for all patients. Instead, these surgeons monitor only selected individuals, including those undergoing revision operations, those who have had perioperative facial nerve weakness, and those whose imaging studies demonstrate facial nerve anomalies.
 


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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  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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