A cholesteatoma is a growth of trapped skin cells in the middle ear, usually starting from a retraction pocket of the eardrum after long-standing eustachian tube problems or chronic infection. It is not cancer, yet it slowly erodes the tiny ear bones and nearby bone, which can cause hearing loss, facial nerve damage and infections that spread inside the skull.
Key symptoms
- Painless, foul-smelling ear discharge that keeps coming back
- Gradual hearing loss in one ear
- Feeling of fullness in the ear
- Dizziness or vertigo in advanced cases
- Ear pain or headache if infection spreads
What you find on exam
- Otoscopy: white, pearly mass or debris in a pocket of the eardrum
- Retraction pocket or perforation, often in the upper part of the eardrum (attic)
- Discharge that persists despite ear drops
- Tuning forks: Weber goes to the affected ear, bone conduction louder than air (Rinne negative)
- Facial nerve function and nystagmus
Tests
- Audiogram: conductive hearing loss, sometimes mixed
- CT of the temporal bones: bone erosion and extent
- MRI with diffusion-weighted imaging if recurrence or a complication is suspected
- Culture of the discharge if infection does not settle
Treatment basics
- Refer to ENT; surgery (tympanomastoidectomy) is the definitive treatment
- Clean the ear canal and use antibiotic drops such as ofloxacin to control infection before surgery
- Keep the ear dry
- Long-term follow-up for recurrence, with a second-look operation or MRI
- Hearing rehabilitation: ossicle reconstruction or hearing aids
Red flags
- Facial weakness on the same side
- Severe headache, fever, neck stiffness or confusion
- Sudden vertigo with vomiting or a sudden drop in hearing
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.