Cholesteatoma

A cholesteatoma is a build-up of skin in a place where skin has no business being: behind the eardrum, in the middle ear and the mastoid bone. The name is misleading, because the growth has nothing to do with cholesterol and nothing to do with cancer. Inside it is ordinary keratinising skin that sheds into itself and grows year after year like a dense ball of flakes. It is not a tumour, but it behaves persistently: as it expands it eats away the bone around it, and that bone is precisely what separates the ear from the facial nerve, the balance organ and the coverings of the brain. This is why a cholesteatoma is not treated with drops or courses of tablets but with surgery, and the earlier it is found, the less has to be rebuilt afterwards.

Where skin in the middle ear comes from

The usual culprit is the Eustachian tube, the narrow channel between the ear and the back of the nose that equalises pressure. If it works badly for years, negative pressure builds behind the eardrum and the membrane is drawn inwards into a pocket. Shed flakes have nowhere to go from that pocket, they pile up, the pocket swells — and an acquired cholesteatoma is born. Hence the link with chronic nasal congestion, allergy, a deviated septum, or enlarged adenoids in children.

The second route is a lasting hole in the eardrum after prolonged discharging middle ear infection or an injury: skin from the outer surface grows inwards through the edge of the hole. The same can happen after ear surgery and after fractures of the temporal bone.

A separate story is the congenital form: a white pearl is found behind a completely intact eardrum in a child whose ear has never hurt. It is uncommon and is usually picked up by chance during an examination or a hearing check before school.

The signs that give it away

A cholesteatoma nearly always affects one ear and grows slowly, so the signs accumulate over months and years. The following should raise suspicion:

• discharge from the ear with an unpleasant, rotten smell — not heavy, but stubborn, settling and then returning;
• drops and antibiotics that help only briefly, with everything repeating a fortnight later;
• hearing in that ear slowly getting worse, along with a blocked feeling;
• noise or ringing in the ear, sometimes a dull ache or a sense of pressure;
• ear infections coming back several times a year, always on the same side.

Pain is not typical of a cholesteatoma, and that is the trap: the ear does not hurt, so it seems harmless, while the growth quietly continues. Far more reliable warnings are the smell and the fact that everything is happening on one side only.

What is risked by waiting

As it enlarges, a cholesteatoma presses on the tiny bones of hearing and dissolves them. Hearing lost that way does not come back on its own: even a successful operation does not always restore it fully, because sometimes there is nothing left to restore. Next the bone thins towards the inner ear, bringing attacks of vertigo, and towards the canal of the facial nerve, which weakens movement in that half of the face.

The worst happens when infection travels deeper into the skull. This is rare, but it is exactly why the appointment should not be put off: a cholesteatoma can lead to meningitis, a brain abscess, clotting in a venous sinus, or pus in the inner ear with permanent deafness.

Call the emergency services if, alongside a troublesome ear, there is severe headache with a high temperature, a stiff neck, vomiting, discomfort in bright light, confusion or a fit. See a doctor within days if hearing drops suddenly, if dizziness makes it hard to stand, if the face becomes lopsided, or if the ear starts discharging after an injury or an operation.

How it is found and why surgery is unavoidable

It starts with an examination of the ear under magnification: the doctor sees a retracted pocket, crusts, or a whitish mass behind the drum. Hearing and the movement of the eardrum are then tested, and to see how far things have gone a computed tomography scan of the temporal bones is arranged — it shows whether the hearing bones and the wall of the facial nerve canal have been eroded. Magnetic resonance imaging with a particular sequence helps to tell remaining cholesteatoma apart from scarring and fluid, which matters most when there has already been an operation.

Drops and antibiotics are needed, but they only calm the inflammation and dry the ear before the procedure. The cholesteatoma itself does not shrink or dissolve with medication: it has to be removed in full. How extensive the surgery is depends on what is found — sometimes it can be reached through the ear canal, more often the mastoid has to be opened up. The hearing bones can be replaced with a prosthesis, either at the same time or as a second stage once the ear has settled. A year or eighteen months later a review or a repeat scan is often arranged: in some people the growth comes back, and catching it early is far better.

Recovery and looking after the ear

After the operation the ear is packed for a few weeks, hearing is muffled and it is too early to judge it. Full recovery usually takes six to eight weeks, and returning to work can happen sooner, depending on how extensive the surgery was. A few simple rules are worth keeping to during that period.

• Keep water out of the ear: in the shower plug it with cotton wool smeared in petroleum jelly, and stay out of pools and the sea for about six weeks.
• Do not blow your nose forcefully, because air is driven up the tube against a healing eardrum; dab the nose instead and check the timing with your surgeon.
• Sneeze with your mouth open.
• Ask separately about flying and diving: the timing is individual and depends on what was done.
• Go back to the doctor if you develop a fever, more pain, heavy discharge, dizziness or weakness of the face.

Follow-up after a cholesteatoma is long, sometimes several years. This is not excessive caution: recurrences do happen, and spotted early they need far smaller surgery.

Online consultation

In a consultation the doctor will work out whether your symptoms fit a cholesteatoma or are better explained by an outer ear infection or wax, explain how an ordinary recurrent ear infection differs from one that calls for a scan, and help you avoid losing months to endless courses of drops. If scans and a hearing test have already been done, they can be gone through with you and you will be told which findings genuinely need a surgeon.

The format is convenient after surgery too: questions about when you can wash your hair, fly or swim, what the discharge letter means and why hearing has not come back yet are usually easier to raise with a doctor online than to save up for the next face-to-face appointment. Examining the ear under a microscope and removing the growth, however, can only be done in person — the job of the consultation is to establish whether you need that, and how soon.

This material is for information only and does not replace medical advice.