eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Cholesteatoma: Treatment & Medication

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

Treatment

Medical Care

Medical therapy is not a viable treatment for cholesteatoma. Patients who refuse surgery or those with a medical condition that makes a general anesthetic too hazardous should have the ear cleaned regularly, usually over 2-3 months. Regular cleaning can help control infection and may slow growth, but it does not stop further expansion or eliminate risk. The mainstay of antimicrobial therapy should be topical, but systemic therapy is occasionally a helpful adjunct.

Surgical Care

Surgical therapy consists of removal of the cholesteatoma. As mentioned in History, 2 types of operations are commonly used for the management of cholesteatoma. The open cavity (ie, canal wall down) technique was used exclusively until the House Otologic Group introduced the closed cavity (ie, canal wall up) technique. Various factors are considered in determining which procedure is best in a given circumstance.

Sometimes, this decision cannot be made until the operation has begun and a clear vision of the extent of disease has been obtained. Open cavity operations have the highest probability of permanently ridding the patient of cholesteatoma. Closed cavity procedures have the advantage of maintaining a normal appearance but have a higher risk of persistent or recurrent cholesteatoma. The risk of persistence is sufficient to cause most surgeons to advise an obligatory "second look" tympanomastoidectomy 6-12 months following the initial operation.6 During the second look, traces of residual disease frequently can be removed prior to the development of either complications or massive recurrence.

  • In some circumstances, the surgeon is fairly sure preoperatively which operation (closed or open cavity) to perform, especially in the following situations:7
    • If the patient has had several episodes of the cholesteatoma and wishes to avoid future operations, the open cavity technique is most applicable.
    • For patients who are unwilling or unable to return for a second look procedure, an open cavity operation is safer.
    • A large meatoplasty is simply unacceptable under any circumstance for some patients. These patients can be treated with a closed technique if they understand that disease recurrence is more likely and that they may require multiple serial surgical procedures.
  • Some congenital anomalies are known to be associated with a lifelong history of eustachian tube dysfunction. In some individuals, previous surgical procedures have irreversibly injured the eustachian tube. In such individuals, an open cavity operation often is best.
  • Frequently reserving management decisions regarding the canal wall until the operation has begun and a better understanding of the extent of disease has been obtained is best. Some intraoperative findings favor an open technique:
    • Sinus tympani is involved.
    • Medial end of the canal wall is involved, with the cholesteatoma wedged laterally between the heads of the ossicles in the epitympanum and medial canal wall.
    • Ostitis 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.
    • Although small defects in the canal wall are readily repaired, larger defects are harder to repair; usually, simply converting the operation to an open cavity technique is best.
    • Labyrinthine fistula is present. 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, which simply results in cholesteatoma recurrence. If the cholesteatoma matrix is removed from the fistula, some surgeons are comfortable leaving the canal wall up.
  • In the United States, most surgical procedures for cholesteatoma now are 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 canal alone.
  • Regardless of which technique is used, all air cells should be removed. If ossicles are involved, they must be removed to avoid recurrence.8 The ossicular chain can be reconstructed either at the end of the primary procedure or as part of a secondary operation.
  • The TM is usually reconstructed. If a closed cavity technique is used, replace missing bone with a cartilage graft. If an open cavity procedure is selected, create a large meatoplasty to allow adequate air circulation into the cavity that remains consequent to removal of the posterior canal wall.
  • Consult a surgical atlas for a step-by-step description of the various surgical procedures.

Consultations

  • Consultation with an otolaryngologist is mandatory.
  • Rarely, advice from a neurosurgeon is required to help manage an intracranial consultation.

Medication

Drug therapy is not currently a component of the standard of care for this condition. When the cholesteatoma becomes infected, infection can be extremely difficult to eradicate. Because the cholesteatoma has no blood supply, systemic antibiotics cannot be delivered to the center of the cholesteatoma. Topical antibiotics can often surround a cholesteatoma, penetrating a few millimeters toward its center and suppressing infection; however, a large infected cholesteatoma resists any type of antimicrobial therapy. Consequently, otorrhea either persists or recurs despite frequent aggressive treatment with antibiotics.

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].

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

  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].

  9. 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].

  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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  12. Chadha NK, Jardine A, Owens D, et al. A multivariate analysis of the factors predicting hearing outcome after surgery for cholesteatoma in children. J Laryngol Otol. Nov 2006;120(11):908-13. [Medline].

  13. 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].

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

  15. Migirov L, Duvdevani S, Kronenberg J. Otogenic intracranial complications: a review of 28 cases. Acta Otolaryngol. Aug 2005;125(8):819-22. [Medline].

  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].

  17. Semaan MT, Megerian CA. The pathophysiology of cholesteatoma. Otolaryngol Clin North Am. Dec 2006;39(6):1143-59. [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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