There are several ways a cholesteatoma can develop.

Eardrum Retraction

The most common mechanism involves an eardrum retraction pocket. When the Eustachian tube does not adequately equalize pressure in the middle ear, negative pressure can pull part of the eardrum inward. Skin cells that normally migrate outward can become trapped in this pocket. Over time, the trapped skin and keratin can accumulate and form a cholesteatoma.

Chronic Ear Infections

Repeated or chronic middle-ear infections can contribute to the development of cholesteatoma. Chronic inflammation and changes in the eardrum can create conditions that allow skin cells to accumulate behind the eardrum.

Perforated Eardrum

A persistent perforated eardrum can also be associated with cholesteatoma.

Eustachian Tube Dysfunction

The Eustachian tube helps regulate pressure in the middle ear. Dysfunction can create negative pressure and contribute to eardrum retraction, which may lead to a cholesteatoma.

Congenital Cholesteatoma

Some cholesteatomas develop without a history of chronic ear infections or eardrum perforation. These are called congenital cholesteatomas and may be discovered during childhood or, in some cases, later in life.

Symptoms can vary considerably. Some people have noticeable ear problems, while others have relatively few symptoms until the cholesteatoma becomes more advanced. Common symptoms include:

• Persistent or recurrent ear drainage
• Foul-smelling discharge from the ear
• Hearing loss
• Recurrent ear infections
• Ear fullness or pressure
• Ear pain or discomfort
• Tinnitus
• Dizziness or balance problems

A foul-smelling discharge that repeatedly returns despite treatment is an important symptom that should be evaluated by an ENT specialist.

Yes. Hearing loss is one of the most common complications of cholesteatoma. A cholesteatoma can damage the ossicles, the three small bones of the middle ear that transmit sound vibrations from the eardrum to the inner ear. Damage to these bones can result in conductive hearing loss.

Hearing loss may also occur if the disease extends far enough to affect the inner ear. The degree of hearing loss depends on the location and extent of the cholesteatoma and which structures have been affected.

Yes. A cholesteatoma can cause dizziness or vertigo, particularly if the disease affects structures involved in balance or extends toward the inner ear. Dizziness associated with persistent ear drainage, hearing loss, or recurrent ear infections should be evaluated rather than assumed to be a routine ear infection.

Diagnosis begins with a careful examination of the ear by an ENT or otologist.

Microscopic Ear Examination

A detailed microscopic examination of the ear allows the physician to evaluate the eardrum, ear canal, retraction pockets, drainage, and visible skin debris. This examination may reveal a cholesteatoma or findings that require additional investigation.

Hearing Test

A comprehensive audiogram measures hearing in each ear and determines whether conductive, sensorineural, or mixed hearing loss is present. A hearing test is particularly important when a cholesteatoma has affected the ossicles or other structures involved in sound transmission.

CT Scan of the Temporal Bone

A CT scan of the temporal bone may be used to evaluate the extent of disease and identify erosion or involvement of the mastoid and middle-ear structures. CT imaging can help the surgeon understand the anatomy and plan treatment.

MRI

In selected situations, MRI—particularly specialized diffusion-weighted imaging—may be used to evaluate residual or recurrent cholesteatoma after treatment. The appropriate imaging study depends on the clinical situation.

Treatment depends on the size and location of the cholesteatoma, whether infection is present, whether hearing has been affected, and whether surrounding structures have been damaged. The primary goal is to remove the cholesteatoma and prevent further damage. Hearing restoration is an important consideration, but it is generally secondary to completely controlling the disease.

Microscopic Ear Cleaning

In selected small or limited cases, an ENT specialist may be able to clean the affected area under microscopic visualization and control associated infection. This does not necessarily eliminate an established cholesteatoma. Continued monitoring is important because cholesteatoma can continue to grow or recur.

Medication

If infection or inflammation is present, medication may be used as supportive treatment. Antibiotics or ear drops may help control an associated infection, but medication does not remove an established cholesteatoma.

Surgery

When a cholesteatoma is established or has progressed beyond what can safely be managed in the office, surgical removal is generally required. Common procedures include:

• Mastoidectomy
• Tympanoplasty
• Ossicular chain reconstruction

The specific operation depends on how far the disease has spread and which structures are involved.

The purpose of cholesteatoma surgery is to remove the abnormal skin and keratin, control infection, and create a safe, stable ear.

Mastoidectomy

A mastoidectomy removes diseased tissue from the mastoid bone behind the ear. It is commonly performed when a cholesteatoma has extended into the mastoid. Different surgical approaches may be appropriate depending on the extent and location of the disease.

Tympanoplasty

Tympanoplasty repairs the eardrum and, when appropriate, helps reconstruct the middle-ear sound-conduction system. It may be performed together with cholesteatoma removal when the eardrum has been damaged or perforated.

Ossicular Chain Reconstruction

The cholesteatoma may erode one or more of the three tiny middle-ear bones. If the ossicles have been damaged, ossicular chain reconstruction may be performed to rebuild the pathway through which sound travels to the inner ear. Hearing restoration is an important consideration, but the exact reconstruction depends on the condition of the ear at the time of surgery.

It can improve hearing in some patients, particularly when conductive hearing loss is caused by damage to the middle-ear sound-conduction system. However, hearing restoration is not guaranteed. The ability to improve hearing depends on factors such as:

• How extensive the cholesteatoma is
• Whether the ossicles are intact
• Whether the eardrum is damaged
• Whether the inner ear has been affected
• The type of reconstruction required

The first objective of surgery is to establish a safe, disease-free ear. Hearing reconstruction may be performed at the same time or considered separately depending on the individual case.

An established cholesteatoma generally cannot be permanently eliminated with medication alone. Limited disease may sometimes be managed with careful microscopic cleaning and close observation in selected circumstances, but surgical removal is the standard definitive treatment for established cholesteatoma. The appropriate approach depends on the patient’s examination, imaging, symptoms, and extent of disease.

A cholesteatoma can continue to enlarge and erode nearby structures. Potential complications include:

• Progressive conductive hearing loss
• Damage to the ossicles
• Persistent ear drainage
• Damage to the inner ear
• Vertigo or balance problems
• Facial nerve injury or facial weakness
• Chronic infection
• Meningitis
• Intracranial infection or abscess

Serious complications are uncommon, but they can occur when disease progresses into surrounding structures. This is why persistent ear drainage or unexplained hearing loss should not simply be treated repeatedly as an ordinary ear infection without determining the underlying cause.

Recurrence or residual disease is one reason long-term follow-up is important. Follow-up may include:

• Microscopic ear examinations
• Hearing tests
• Repeat imaging when indicated
• Additional surgery in selected cases

The appropriate surveillance plan depends on the type and extent of the original disease and the surgical approach used.

You should consider an ENT evaluation if you experience:

• Persistent or recurrent ear drainage
• Foul-smelling ear discharge
• Repeated ear infections in the same ear
• Unexplained hearing loss
• A persistent feeling of ear pressure or fullness
• Dizziness associated with chronic ear symptoms
• A known eardrum retraction or perforation
• Hearing loss that continues after an ear infection has been treated

Persistent foul-smelling drainage combined with hearing loss deserves particular attention. These symptoms can occur with cholesteatoma and should be evaluated rather than repeatedly treated without identifying the underlying cause.