Cholesteotoma and chronic middle-ear infection
This transcript provides background information about cholesteotoma, chronic middle ear infection and the reasons for surgical treatment. It is not a substitute for advice from your surgeon. Although technical terms are used, be certain to read this entire transcript carefully.
While the risk of a major complication is low (less than two patients in 100 procedures), many different types of complications are possible.
Although patients should be as informed as possible about the surgical treatment, every aspect cannot be covered in this transcript. Therefore, patients are advised to seek a full explanation of their case from their surgeon, as every case is different.
Discuss all aspects of your surgery with your surgeon, including:
- the diagnosis
- whether all non-surgical treatment options have been considered
- risks, complications and limitations of surgery, and
- the chances of success and failure.
Your surgeon cannot guarantee that surgery will meet all your expectations or that surgery has no risks. If you are uncertain, you are encouraged to seek the opinion of another specialist. This transcript should only be used in consultation with your surgeon.
Consent form: If you decide to have treatment, your surgeon will ask you to sign a consent form. Read it carefully. If you have any questions, ask your surgeon.
Cholesteotoma is a cyst like mass that grows inside the ear. The growth consists of skin cells and is not cancerous. As shown in the illustration, a cholesteotoma forms in the middle ear and sometimes can invade the mastoid cavity.
An untreated cholesteotoma can erode the small bones of the middle ear (the hammer. Anvil and stirrup) and cause loss of hearing. As it grows, the cholesteotoma can erode the bony coverings over the inner ear, causing dizziness, loss of balance, and occasionally total deafness in that ear. It can rarely press on the facial nerve as it runs through the ear and cause muscle weakness or paralysis on the sane side of the face as the cholesteotoma.
Severe erosion of bone around the middle ear and mastoid can cause ear pain. It can also allow infection to spread to the brain and cause a life-threatening brain abscess or meningitis.
Formation of cholesteotoma
The Eustachian tube can become blocked due to chronic infection or inflammation. As a result, a vacuum can develop inside the middle ear, and weakened parts of the ear4drum may be sucked in to form a pocket. Lined by skin cells, this pocket can slowly grow into a larger cyst-like mass, which is a cholesteotoma.
Congenital cholesteotoma: In young children, a cholesteotoma can sometimes result from skin cyst formation during development of the ear before birth.
Diagnosis of Cholesteotoma
A cholesteotoma can be diagnosed by examination of the ear. The condition may be suspected if the patient has a history of long-standing ear infection associated with a smelly discharge from the ear canal. Further investigations, such as a hearing test and sometimes a CT scan of the middle and inner ear, also help the surgeon to evaluate the cholesteotoma.
Principles of treatment
Surgery: Once a cholesteotoma has been diagnosed, surgical removal is the treatment of choice. If a cholesteotoma is left without observation and treatment, it is likely to worsen.
As complications of cholesteotomas can seriously affect hearing and may be life threatening, the aim of surgery is to completely remove them.
The extent of surgery depends on the size of the cholesteotoma, any infection that is present, and complications caused by the cholesteotoma.
Conservative treatment: A few patients with cholesteotoma may be treated using conservative measures such as removal of dead skin from within the cholesteotoma using suction under the guidance of an operating microscope.
However, this procedure only keeps the cholesteotoma under control. As it does not cure the condition, the procedure has to be repeated at regular intervals. Conservative treatment may be suitable for elderly patients or those with serious health problems for whom surgery would be too risky
Preparation for surgery
Your surgeon needs to know your complete medical history to plan the best treatment.
Disclose all health problems and symptoms.
Some health problems may interfere with surgery, anaesthesia, sedation and care after surgery.
Your surgeon needs to know about:
- any allergy or bad reaction to any antibiotic, anaesthetic drug, sedative or any other medicine.
- your smoking history; smoking interferes with healing and Eustachian tube function, so quit at least two weeks before surgery.
- all medications you are taking, including insulin, warfarin or other blood thinning agents
- any bleeding disorder or easy bruising
- recent illnesses, including recent infections
- thick, raised scarring (keloid) after previous surgery
- long-term illnesses and lung or heart conditions
- any personal or family history of deep venous thrombosis (DVT)
For three weeks before surgery, do NOT take aspirin, anti-inflammatory drugs (such as ibuprofen), vitamin E tablets, garlic tablets, over the counter preparations, or therapies from a naturopath or health food provider because any of these may cause excessive bleeding that will usually interfere with the success of the surgery.
Surgery for cholestestoma
The main aim of surgery is to remove the cholesteotoma, make the ear safe, and leave a clean, infection-free ear. The second aim is to preserve or partly restore hearing, if possible.
The surgical approach depends on the size and characteristics of the cholesteotoma. For most patients, the incision is made behind the ear, allowing the surgeon to remove the cholesteotoma more easily through a larger incision. Un fewer cases, the cholesteotoma is removed using an incision in the roof of the ear canal. The operation is performed with the help of a microscope.
An atticotomy can be performed if the cholesteotoma is small and is confirned to the middle ear and the “attic”, the space near the roof of the middle ear that lies above the eardrum. By removing the bony roof of the deeper portion of the ear canal, the outer wall of the attic can be removed. This makes it possible to see and remove the cholesteotoma.
It is not always possible for the surgeon to know the exact size and extent of a cholesteotoma before operating. Therefore the surgeon may have to do a more extensive operation if the cholesteotoma is larger than suspected and has grown outside the attic area.
During the procedure, the surgeon may find that the hammer, anvil and stirrup (known as the ossicular chain) have been affected by the cholesteotoma. Reconstruction of the ossicular chain may be needed.
After the cholesteotoma is removed, a graft of tissue is used to repair the hole in the eardrum.
Modified radical mastoidectomy
A modified radical mastoidectomy is the most common operation performed on the middle ear and mastoid to remove the cholesteotoma.
During this surgery, the back wall and roof of the deeper portion of the ear canal are removed, as well as the outer wall of the mastoid cavity. The cholesteotoma can then be seen and removed, together with any debris, chronically infected or dead tissue, scar tissue or polyps.
By removing the roof and back wall of the deep ear canal, the mastoid cavity and attic areas are made continuous with the deep ear canal.
The moist tissues that line these cavities and numerous mastoid air cells are removed so that during healing, skin from the deep ear canal grows to cover the bare bone of the mastoid cavity. The result is that the deep ear canal and mastoid cavity will, after healing, be one skin-lined cavity.
After operation, this cavity may require regular cleaning. Some patients may have problems if the mastoid cavity gets wet, and the wearing of an ear plug may be necessary to keep water out of the ear. If on-going infection in the mastoid cavity results in a persistent discharge from the ear, revision surgery may be needed.
If the cholesteotoma regrows after this type of surgery, it can be seen by the surgeon and removed during another operation.
Intact canal wall mastoidectomy
An intact canal wall mastoidectomy is an operation where the bony wall between the ear canal and mastoid is not removed. Water can enter the ear after surgery without the risk of complications. However, the disadvantages are that it is more difficult to see the cholesteotoma during surgery and to remove it fully. This means that it may grow again. If it does, the cholesteotoma cannot be seen easily when looking down the ear canal, so early detection is usually not possible. Recurrence of cholesteotoma may not result in early symptoms, so complications may occur without warning. Due to this risk, many surgeons recommend a second operation one or two years later to check whether regrowth has occurred .
A myringoplasty is an operation to repair the eardrum. It is usually done at the same time as the mastoidectomy. A graft, which has been taken from tissue deep to where the surgeon made the skin incision, is used to close of the hole in the eardrum. If the eardrum heals well, it stops fluid and secretions from the middle ear and the Eustachian tube leaking out of the ear. If the hole in the eardrum does not heal, a discharge from the ear may occur.
A meatoplsty is a procedure to widen the outer opening of the ear canal. This allows better circulation of air into the depths of the ear canal and the mastoid cavity. Due to the wider opening, the surgeon can more easily inspect the ear to check for recurrence of the cholesteotoma.
Ossicular chain reconstruction
The three ossicles (the hammer, anvil and stirrup, called the ossicular chain) are often damaged by a cholesteotoma. Damage to these bones leads to significant hearing loss that may have been the reason for the cholesteotoma being detected in the first place.
Sometimes the cholesteotoma may not have damaged the ossicles, but the surgeon may still need to remove certain ossicles during the operation to gain access and ensure that all of the cholesteotoma is removed. This means that hearing may become worse after surgery than it was before. However, hearing in those oatients would have ultimately been affected anyway due to the enlargement of the cholesteotoma that occurs with time.
Reconstruction of the damaged ossicles is sometimes performked at the same operation as the removal of the cholesteotoma. It is done by using cartilage from the ear canal or by repositiuonaing part of an ossicle or by using a synthetic material to reconstruct the sound-transferring function of the ossicles. Sometimes a second operation is needed to try to improve hearing if the first attempt is unsuccessful.
Reconstruction is not necessarily performed at the first operation. The presence of infection, bleeding from inflamed tissues. Or complications from the cholesteotoma may make reconstruction too difficult at that time. If so, the surgeon can perform it at a later time.
Surgical treatment for middle-ear infection without cholesteotoma
Chronic infection that does not respond to antibiotics may require surgery to clear the infection. Persistent discharge from an ear, hearing difficulties and pain in the ear, especially in children, can be helped by the surgical removal of the pus and chronically infected tissue.
A cortical mastoidectomy is an operation to remove the outer bony wall of the mastoid cavity just behind the ear. This allows the drainage of chronic infection and pus from the middle ear and mastoid spaces. It is also performed to remove chronic infection of the lining of the mastoid cavity that is often accompanied by a persistent discharge through a hole in the eardrum.
After the infected linings are removed, the eardrum is repaired by myringoplasty.
If the infection is severe and extends further into the attic and other areas of the middle ear, this procedure may have to be extended to an intact canal wall mastoidectomy. The aim is to provide adequate drainage and ventilation of the mastoid cavity and attic areas. Occasionally, a modified radical mastoidectomy is necessary to control chronic, extensive infection.
RECOVERY AFTER SURGERY
Most mastoid and middle ear surgery is performed under a general anaesthetic. For most patients, an overnight stay is needed. If severe infection is present, treatment with intravenous antibiotics may require a further stay in hospital. On discharge from hospital, you will usually be wearing a bandage over the ear and still have a medicated pack in the ear canal that will be removed by your surgeon at a postoperative visit. Usually there is some leakage of blood stained fluid around the pack. One to two weeks off work are usually required after surgery. Avoid getting water in your ear. Your surgeon will discuss with you how best to care for your ear. You may be prescribed a course of antibiotics. Take the complete course. Pain killers may also be prescribed.
Initially, follow-up visits are necessary until the operated area has healed. In the longer term, follow-up visits are necessary to check for recurrence of cholesteotoma over the next few years.
Grommets are small tubes about the size of a match head that are placed in the eardrum to help treat recurrent otitis media and glue ear. Also called “ventilating tubes”, grommets allow air to flow into the middle ear, restoring an equal air pressure between the middle ear and the atmosphere, allowing the “glue” to drain down the Eustachian tube or to be reabsorbed into the tissues. This equalisation of pressure is important for good health and function of the middle ear and Eustachian tube.
Treatment with grommets may be recommended when:
- Three or more significant ear infections occur within six months, or
- Glue ear is present for more than 3 months, especially if hearing loss or eardrum damage is present.
Benefits of grommets
Hearing: Grommets improve hearing in most patients with a chronic glue ear that causes a
“ conductive hearing loss” (that is, hearing loss due to impairment of the passage of sound through the middle ear). Restoration of good hearing may be especially important in children with delayed speech development or learning difficulties.
Behaviour of children: Behavioural problems associated with glue ear may be improved by grommet insertion.
Stopping or slowing damage: As a grommet permits air to enter the middle ear and allows a retracted eardrum to return to its normal position, it may prevent further damage to the eardrum and to the small bones of the middle ear.
Decreasing the frequency of infections: In children who have recurrent otitis media, grommets usually decrease the frequency of infection. In some children infections stop completely while grommets are in place.
There is some debate among doctors about whether grommets are used too often. Often, fluid within the middle ear will slowly disappear without surgery or by using antibiotic (and sometimes steroid) treatment. For children six years and older, nasal balloon technique can be tried.
Other doctors believe that, after a reasonable period of observation, the immediate benefits of a grommet fully justify their use. Also, there is increasing concern about the emergence of antibiotic resistant bacteria due to antibiotics that are sometimes taken for as long as three months during non-surgical treatment.
POSSIBLE COMPLICATIONS OF SURGERY
General risks of surgery
- Infection of the auricle (external ear) and surrounding tissues is an uncommon complication. Infection of the ear lobe and cartilage may result in a “floppy” or distorted ear.
- Bleeding can occur from the large blood vessels that run close to the ear and mastoid.
- A raised, unsightly and itchy scar called a keloid may develop from the healed incision. A keloid can be annoying but is not a threat to health.
Specific risks of mastoid and middle-ear surgery
- Facial nerve damage. The facial nerve supplies the muscles to one side of the face. As this nerve travels close to the middle ear space, damage to it can be a serious complication of middle ear and mastoid surgery. The incidence of damage is about one in every 200 operations. This can leave the muscles on one half of the face paralysed, leading to permanent disfigurement. The person may not be able to smile normally and close the eye and mouth completely on that side of the face. A damaged facial nerve can sometimes be repaired, but some facial paralysis may still be evident.
- Tinnitus is a constant ringing or other sound in the operated ear. This symptom can be troublesome and difficult to treat.
- Total and permanent deafness in the operated ear. This is more likely to happen if the bone covering the inner ear has been eroded by a cholesteotoma. In this situation, the deafness is usually permanent and is often associated with vertigo.
- Worse hearing is usually due to surgical disruption of the ossicular chain, which is necessary to completely remove the cholesteotoma. If hearing was normal in that ear before surgery, the likelihood is that it will be worse after surgery; even successful reconstruction of the new ossicular chain may not result in normal hearing. Damage to the inner ear is another possible cause of hearing loss after surgery. This is not curable.
- Vertigo is a sensation of dizziness and imbalance. It may be present for some months after the surgery. The sense of balance does not always return completely normal.
- Partial numbness of the top half of the ear occurs when the surgeon makes the incision behind the ear. Numbness normally resolves within six months, but uncommonly, it can be permanent.
- Loss of taste(on the sane side of the tongue as the surgery) can occur if the thin nerve (chorda tympani) that supplies the taste buds needs to be stretched or cut to remove the disease or construct the mastoid cavity. As this nerve runs through the middle ear, removal of a cholesteotoma poses a particular risk; however, the loss of taste often occurs due to pressure from the cholesteotoma before the operation. Dryness of the same side of the mouth can also occur.
- CSF leak and meningitis. Extensive disease and surgery can result in a leak of cerebrospinal fluid (CSF) that surrounds the brain. This occurs if the lining of the brain has been disrupted and is more likely in revision surgery. The surgeon may notice and repair this during the operation or the leak may not be obvious until after the operation. The leak can be readily repaired, but a second operation may be needed. An unrepaired CSF leak has a high risk of meningitis.
- Encephalocoele is a rare, small hernia of brain tissue that may occur through the floor of the skull base into the middle ear or mastoid. If scar tissue forms after surgery to repair an encephalocoele, there is a risk of epilepsy.
- Recurrence of cholesteotoma. In about 10 to20 cases out of 100, the cholesteotoma may recur, even after it has been carefully removed. People who have had cholesteotoma surgery must have regular follow-ups with their ear surgeon, who can identify an early regrowth.
- The tissue graft to fix a hole in the eardrum may not heal well and may not be successful.
- Further surgery in patients with chronic middle ear disease may be necessary, especially in children. Persistent discharge may occur, accompanied by poor hearing. For example, the graft applied to the hole in the eardrum might not take. In some cases, several operations may be needed to treat the condition.