Treatment options for cholesteatoma

How to manage a cholesteatoma?

Conservative management with repeated cleaning (debridement) on a set time course is reasonable for those with small cholesteatomas with minimal symptoms, particularly in those of advanced age and those with anaesthetic risks. Regular follow-up is very important to avoid complications noted above.

Surgery is the mainstay of management in cholesteatoma. Several types of mastoidectomy operations are designed according to the extent of the disease, the degree of hearing loss, and partly based on the patient's expectations. In our practice, we perform three types of mastoid operations depending on the extent of the disease relative to the individual’s anatomy. These procedures vary between one and three hours in length, usually under general anaesthesia. Longer surgeries may require overnight hospital stays. Same-day discharge is becoming the norm with mastoidectomy.

Canal wall down mastoidectomy »

Canal wall down mastoidectomy is the most common mastoidectomy in dealing with medium and large cholesteatomas. The objective is to remove all of the cholesteatoma and its surrounding bony structures to minimize recurrence of disease. In doing so, a mastoid cavity (bowl) is created inside the skull by removing the back part of the ear canal wall. This cavity ranges in size, and by virtue of its presence, demands a larger opening to the ear canal and regular cleaning — usually six to 12 months intervals. Water precaution is of utmost importance.

Canal wall down mastoidectomy — A mastoid bowl is created requiring periodic cleaning

Ear canal opening enlarged after mastoidectomy

Canal wall up mastoidectomy »

Canal wall up mastoidectomy procedure is reserved for those with a smaller cholesteatoma and a well-developed mastoid bone. The cholesteatoma is usually strategically located in a favorable spot whereby one would consider preserving the back wall of the ear canal. Consequently, there will not be a mastoid cavity requiring cleaning. This is of course the most significant advantage over canal wall down mastoidectomy. However, the risk of recurrence is much higher.

 

Canal wall up mastoidectomy (cavity is concealed and not exteriorized)

 

Endaural mastoidectomy (atticotomy) »

In both canal wall down mastoidectomy and canal wall up mastoidectomy, the procedures are performed through an incision behind the ear. This renders the ear numb for several months and causes the ear to project out a little during this period of time. If the cholesteatoma is sufficiently small while the mastoid bone is very dense in the presence of a large ear canal, an endaural approach can be performed through the ear canal with a very small scar at the upper part of the ear canal opening.

 

Atticotomy – can be performed through a small incision in the ear canal leaving a small cavity

 

Preoperative course

The risks of mastoid surgery relate to the extent of the cholesteatoma, the degree of bony invasion and the experience of the surgeon. Some of the problems are expected, such as:

• Pain, ear numbness, ear projection and scarring
  
  
• Taste disturbance
  Taste disturbance relates to the cutting of a taste nerve in the ear (chorda tympani) that detects taste sensation from the side of the tongue. Patients often complain about a numb feeling the tongue with a bland taste in the mouth. Often, an altered taste sensation described as metallic, bitter and sweet defines this complaint. It affects at least 30% of our patients after all types of ear surgery. It is usually temporary, lasting from days, to weeks, sometimes several months. In rare circumstances taste disturbance may persist. 
  
  
• Further hearing loss
  Further hearing loss is common after mastoid surgery, since bony support structures around the hearing bones (ossicles) are removed while reconstruction may or may not be performed. Additional mechanical hearing loss can also occur, sometimes requiring a second reconstructive operation at a later stage.
  
  
• Nausea
  Nausea is usually due to general anaesthesia, and is usually short-lived. 

Surgical risks

Generally, a mastoid operation performed by an experienced ear surgeon (otologist) is very safe. Serious risks described below are very rare:

• Facial Paralysis
  The facial nerve travels through the center of the mastoid bone. In a routine, uncomplicated mastoidectomy, the risk of injuring this nerve is very rare. When the facial nerve becomes enveloped by cholesteatoma, surgical decompression of the facial nerve may be necessary with much increased risk. Facial nerve monitoring has become routinely used to help safeguard the facial nerve in more complicated mastoid surgeries.
  
  
• Deafness
  
  
• Inner-ear injury
  
  
• Severe dizziness and balance disorder
  This usually occurs in the presence of an inner ear fistula-erosion of the semi-circular canal. Gradual improvement from habituation and compensation occurs over a few weeks.