Cholesteatoma in the Ear: What to Know

Medically Reviewed By Nicole Leigh Aaronson, MD, MBA, CPE, FACS, FAAP
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A cholesteatoma is an overgrowth of skin cells in the middle ear, where skin does not belong. It develops behind the eardrum and can cause hearing loss and dizziness. A cholesteatoma itself is benign, which means not harmful. However, it can cause serious complications without treatment. The usual treatment is surgery to remove it.

This article explains cholesteatoma, including its causes, symptoms, and treatment options.

What is a cholesteatoma?

young female getting ear exam with otoscope
Sean Locke/Stocksy United

A cholesteatoma is a skin cell, and sometimes ear wax,

overgrowth in the middle ear. It grows behind the eardrum and can damage surrounding structures, including the ossicles, which are the three bones in the middle ear. This can cause hearing loss.

Cholesteatomas usually form in one ear. They can take a long time to develop but will continue to grow without treatment.

There are two types of cholesteatomas: congenital and acquired. In the rarer congenital form, babies are born with a cholesteatoma, and it resembles a pearl in an ear exam. The acquired form often occurs due to chronic ear infections. The main treatment option for both kinds is surgery to remove the growth.

Is a cholesteatoma serious?

A cholesteatoma can become serious without treatment. It can spread to other tissues, including adjacent bone, and to the nervous system. It can also cause hearing loss, which can lead to problems at school or work.

Getting regular medical care to identify a potential ear problem and seeking care when you or your child has ear symptoms can help reduce the chance of experiencing a more significant health problem.

What causes a cholesteatoma?

A congenital cholesteatoma arises during development. Skin cells get trapped behind the eardrum. 

An acquired cholesteatoma is usually the result of chronic ear infections and problems with the eustachian tube. This tube connects the middle ear to the nose and sinuses. It allows fluid to drain and pressure to equalize in the middle ear. When it does not work correctly, the middle ear does not ventilate the way it should. This can weaken the eardrum, creating a pocket where skin cells and ear wax accumulate. 

It is also possible to have a hole in the eardrum that allows cells to enter the middle ear and form a cholesteatoma.

The average age at diagnosis for an acquired cholesteatoma is about 10 years. It is more common in males than females. In addition, certain conditions may increase the risk of eustachian tube problems, including:

What are the symptoms of a cholesteatoma?

The most common symptom of a cholesteatoma is painless ear drainage. The fluid draining from the ear may have a foul odor. Hearing loss is also common. If the growth erodes the bones of the middle ear, the hearing loss can be permanent.

Other symptoms of a cholesteatoma can include:

  • earache or pain
  • dizziness or vertigo
  • facial numbness or muscle weakness on one side
  • a feeling of fullness or pressure in one ear
  • recurrent ear infections
  • ringing in the ear

If these symptoms are present, contact a doctor as soon as you can. It might be necessary to see an ear, nose, and throat specialist.

Without treatment, a cholesteatoma can lead to serious problems, such as meningitis. Some possible symptoms of a more serious condition include:

Seek immediate medical attention for these symptoms.

Learn more about ear symptoms here.

What can I do to prevent a cholesteatoma?

Preventing a cholesteatoma relies on identifying eustachian tube problems and addressing them. Tympanostomy, or the placement of ear tubes, may help. This is a common treatment option for children with chronic middle ear fluid or infections. These tubes can help equalize middle ear pressure and improve ventilation. This, in turn, may help prevent a cholesteatoma from developing.

Get the facts on ear tube surgery here.

How do doctors diagnose a cholesteatoma?

To diagnose a cholesteatoma, a doctor will ask about your symptoms and medical history. A physical exam will focus on the head and neck, and it will include the doctor using an otoscope to look at your eardrum. An otoscope is a lighted instrument with lenses that magnify the eardrum. An experienced doctor can see a cholesteatoma with this device. The doctor may also use an otoendoscope, which provides more powerful magnification. This is usually all that is necessary to make the diagnosis.

For surgical planning, doctors often order imaging exams. CT scans are the most common, but some doctors may use MRI scans instead.

Part of your preparation for surgery will also include undergoing hearing tests. These establish a baseline for the future.

What are the treatment options for a cholesteatoma?

Surgical removal of the cholesteatoma is the only treatment option. Doctors may use oral antibiotics or antibiotic ear drops when there is evidence of a bacterial infection.

There are different surgical techniques available to access the middle ear and remove the growth. These include:

  • Microscopic ear surgery (MES): The surgeon makes an incision behind the outer ear to access the middle ear and eardrum. They view the surgical area with a microscope.
  • Transcanal endoscopic ear surgery (TEES): The surgeon passes an endoscope — which is a thin tube with a high powered camera on the end — into the ear. It travels through the ear canal and past the eardrum to provide access to the middle ear and allow the surgeon to view the surgical area.
  • Combined endoscopic and microscopic middle ear surgery: The surgeon performs MES with the aid of TEES.

To completely remove the cholesteatoma, your surgeon may also need to remove the ossicles, the eardrum, and part of the mastoid bone, which is behind the ear. A second surgery to reconstruct the ossicles may improve hearing with time. Baseline hearing tests before surgery give doctors a measuring stick for comparison after surgery.

It is important to keep the ear dry as you undergo treatment. You can purchase ear covers for when you wash your hair. Ask your doctor or surgeon for recommendations.

In children, healthcare professionals tend to take a more conservative approach in surgery to preserve more of the ear structure and ease healing and recovery. However, this method — known as canal wall up — is more likely to lead to a recurrence of the cholesteatoma. For this reason, the surgeon typically plans a so-called second-look procedure 6–12 months later, and they will remove additional tissue as necessary.

Surgery can be successful. However, you will need to visit a doctor afterward for ear cleanings. You will also need long-term follow-up care to make sure that the cholesteatoma does not recur. Recurrence rates are in the range of 5–50%. These rates can vary with the surgical technique.

Talk with your surgeon about the specific technique they will use and why, and be sure to ask about its typical success rate.

What is the outlook for someone with a cholesteatoma?

Without treatment, cholesteatomas usually continue to grow. As they grow, they can degrade the three hearing bones in the middle ear. They can also damage structures surrounding the ear, such as the bones of the skull or face. This can lead to serious complications, including:

  • blood clots in the brain’s venous sinuses, which are located near the mastoid bone
  • brain or epidural abscesses
  • meningitis
  • permanent hearing loss or deafness

Summary

A cholesteatoma is an unusual growth of skin cells in the middle ear, behind the eardrum. Most people develop it due to a chronic ear infection.

Since the cholesteatoma will continue to grow, surgical removal is the only treatment option. Surgery can prevent complications from it eroding bone and invading other tissues. However, hearing loss does not always improve after surgery.

Long-term monitoring is necessary, as recurrence is possible.

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Medical Reviewer: Nicole Leigh Aaronson, MD, MBA, CPE, FACS, FAAP
Last Review Date: 2022 May 25
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