Cholesteatoma

CHOLESTEATOMA What it is, causes, how it is managed and if you have any
26 YEARS OLD TRUCK DRIVER WHO IS IN YOUR GP CLINIC questions don’t hesitate to ask me
COMPLAINING OF DISCHARGE FROM THE RIGHT EAR FOR 3 It is a benign growth of the skin in an abnormal location
DAYS. Cholesteatoma DAP – growth in the middle ear or inner
TASK: HISTORY, DO PHYSICAL EXAMINATION AND ear
MANAGEMENT What happens is that the skin cells always die and is
shed off with the wax but when dead cells accumulate in
Discharge in the upper part of tympanic membrane the middle ear and cannot be expelled out, what happens
is that it produces enzymes (like cytokines) which causes
Ear discharge destruction of bones and surrounding tissues.
Color, amount smell Which may lead to recurrent infections and hearing
Is this the first episode problems
Is it only in one ear or both ears?
When did you notice ear discharge? What can we do at this stage?
Hearing We need to do some investigations
Hearing loss changes in hearing on ear or both ears
Do you find difficulty in hearing in noisy places or in 1. FBE, ESR, CRP
quiet places? 2. We need to refer you to an ENT specialist who
Progressive hearing loss might consider doing CT scan – will give an idea
Do you hear well on the phone? If No – sensorineural of the bony structures – bone erosion, erosion of
Any associated symptoms? Fever dizziness, vertigo, the osicles and the labyrinth
tinnitus, headache nausea and vomiting, He might consider MRI – to see the soft tissue – dura
Sore throat, runny nose involvement, abscess, facial nerve inflammation, and
Any ear infection in the past? During childhood? venous sinus thrombosis.
Do you have any history of trauma to the head or direct 3. Arrange audiometry
trauma to the ear 4. Safe and dry ear
Past medical history
Medication and allergies
SAD Management:
Family history of hearing loss Urgent referral for ENT surgeon
Aim of treatment: safe and dry ear
Physical Examination: GA VS Remove the cholesteaoma and restore hearing
Check the face – facial asymmetry (facial palsy –
complication of cholesteatoma) Mechanism of Cholesteatoma: 3 mechanisms:
Neck stiffness – meningitis 1. congenital – born with remnant of skin tissue in the
Check the hearing – check by inspection – obvious middle ear
discharge 2. perforation of the tympanic membrane either due to
Any scars, signs of trauma recurrent otitis media or direct trauma to the ear
Check lymph nodes (pre and post auricular) 3. when there is negative pressure of the middle ear (due
Otoscope: pull upwards and backwards to malfunction of the Eustachian tube – balance the
Hearing: whisper test or hair rub test (distance should be pressure) there will be a sac or outpouchiing of the
60 cm tympanic membrane into the middle ear and this
Weber’s test – forehead? Which one is better? Right outpouching dies and causes the cholesteatoma
Is there any difference with the hearing Complications:
Bone conduction in the right ear or sensorineural ear on 1. Conductive hearing loss – affects the middle
the left ear or ossicles
Rinne’s Test (Tuning fork 256) AC>BC 2. Affect the facial nerve and cause facial palsy
Screen first – do you hear AC? BC? 3. affect the bone and cause mastoiditis or
Put it on the mastoid bone. Do you hear that? BC Tell me petrositis
when it stops 4. it might affect the inner ear causing labyrinthitis
Do you hear that? (AC) – which may lead to dizziness and vertigo
Pneumoscope or pneumometry? Check the mobility of 5. it may lead to sensorineural hearing loss
the tympanic membrane 6. it might go to the brain causing meningitis or
In the affected ear – tympanic membrane doesn’t move cerebral abscess
because the tympanic membrane is perforated 7. it might go to the lateral venous sinus and
cause thrombosis – and cause obstruaction and
Explanation: cause hydrocephalus
I think you have a condition called cholesteatoma. It is not Differential Diagnosis:
a very common condition. It is not precancerous. Have Chronic Suppurative Otitis Media
you ever heard about it? Wax Impaction
Otosclerosis
Prognosis: 5% recurrence after surgery 15-30% if you
treat it medically

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CHOLESTEATOMA What it is, causes, how it is managed and if you have any

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