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