Cholesteatoma: The Ear Condition You Need to Know About

Cholesteatoma is an abnormal collection of skin cells growing within the middle ear that, without treatment, progressively erodes surrounding structures including the hearing bones, facial nerve canal, and in rare cases the bone separating the ear from the brain. It is not cancerous but it is serious — surgery is the only treatment, and the earlier it is performed the less complex and more successful the outcome.

• Cholesteatoma is an abnormal growth of skin cells in the middle ear — not cancerous, but serious

• Without treatment it progressively erodes hearing bones, the facial nerve canal, and surrounding structures

• It appears as a pearly white mass within the ear canal or behind the eardrum

• Surgery is the only treatment; earlier surgery means a simpler operation and better outcome

Cholesteatoma appears as a pearly white mass within the ear canal or middle ear. Without surgical removal it continues to grow, eroding the hearing bones, facial nerve canal, and surrounding structures.

Cholesteatoma is one of the most important ear conditions in ENT practice — not because it is common, but because it is serious, progressive, and requires surgical treatment to prevent potentially significant complications. It is also one of the most frequently misunderstood conditions, often initially dismissed or misdiagnosed as a recurrent ear infection.

This article explains what cholesteatoma is, why it needs to be taken seriously, and what treatment involves.

What Is a Cholesteatoma?

A cholesteatoma is an abnormal collection of skin cells that grows within the middle ear — the space behind the eardrum — or in the mastoid bone behind the ear. Despite its name (which means something like "fatty tumour"), it is not a tumour and it is not cancerous. It is, however, destructive.

Skin cells shed their surface layer continuously as part of normal renewal. In the external ear canal, this shedded skin migrates outward naturally and falls away. When skin becomes trapped in the middle ear — through a defect in the eardrum or from an area of retraction — this normal shedding process cannot occur. Instead, the shed skin accumulates, forming an expanding cyst-like structure.

This expanding mass of keratin — the protein in skin — does not stop growing. Over time it erodes the structures of the middle ear, including the ossicles (the tiny bones of hearing), the bone surrounding the ear, and in advanced cases the bone separating the ear from the brain and the facial nerve canal. Left untreated, cholesteatoma continues to grow and destroy.

How Does Cholesteatoma Develop?

Acquired Cholesteatoma — The Most Common Type

The majority of cholesteatomas are acquired — they develop during life rather than being present from birth.

Retraction pocket cholesteatoma is the most common mechanism. Chronic Eustachian tube dysfunction creates persistent negative pressure in the middle ear. This negative pressure gradually sucks the eardrum inward — a process called retraction. The most vulnerable part of the eardrum is the pars flaccida, the upper, less supported portion. As the retraction deepens over time, skin from the surface of the eardrum becomes trapped in the pocket, and a cholesteatoma forms.

Perforation-related cholesteatoma develops when skin from the edge of a eardrum perforation grows inward through the perforation into the middle ear space.

Congenital Cholesteatoma

A small proportion of cholesteatomas are congenital — present from birth due to a rest of epithelial cells trapped in the middle ear during foetal development. Congenital cholesteatoma typically presents as a white mass visible behind an intact eardrum in a young child, often discovered incidentally.

Symptoms of Cholesteatoma

Cholesteatoma can be insidious — symptoms may be mild or intermittent for years before the diagnosis is made. Common symptoms include:

Ear Discharge

A persistent or recurrent discharge from the ear — often described as smelly or offensive — is one of the most characteristic symptoms. The discharge occurs because the keratin in the cholesteatoma is a good medium for bacterial growth, and secondary infection is common. Unlike the clear or mucoid discharge of middle ear infections, cholesteatoma discharge is often thick, white, and has a distinctive foul odour.

Hearing Loss

As the cholesteatoma erodes the ossicles — the tiny chain of three bones (malleus, incus, stapes) that transmit sound from the eardrum to the inner ear — hearing loss develops. This is typically a conductive hearing loss, meaning the sound transmission mechanism is disrupted rather than the inner ear being damaged. In advanced cases, the inner ear itself may be affected, causing sensorineural hearing loss.

Ear Pain or Fullness

Discomfort or a sensation of fullness in the ear is common, particularly during episodes of secondary infection.

Tinnitus

Ringing or other sounds in the affected ear, related to the hearing loss or middle ear involvement.

Why Cholesteatoma Is Serious — The Complications

Unlike most middle ear conditions, cholesteatoma does not remain contained. Without treatment, it progressively erodes surrounding structures, potentially causing serious and in some cases life-threatening complications:

Ossicular Erosion and Hearing Loss

Erosion of the ossicles — most commonly the long process of the incus — causes progressive conductive hearing loss. This is the most common complication and may develop gradually over years.

Labyrinthine Fistula

Erosion of the bony wall of the inner ear — most commonly into the lateral semicircular canal — creates a fistula (opening) between the cholesteatoma and the inner ear fluid. This can cause vertigo and, if the inner ear is entered by infected material, sensorineural hearing loss.

Facial Nerve Palsy

The facial nerve passes through the middle ear in a bony canal. Erosion of this canal by cholesteatoma can compress or expose the nerve, causing facial weakness. This is one of the most serious non-intracranial complications.

Intracranial Complications

Erosion through the tegmen (the thin bone separating the middle ear from the brain) or the posterior wall of the mastoid (adjacent to the sigmoid sinus) can lead to intracranial infection — meningitis, brain abscess, or sigmoid sinus thrombosis. These are rare but life-threatening complications that require emergency surgical and neurosurgical management.

Mastoiditis

Extension of cholesteatoma into the mastoid air cells causes mastoiditis, which may present as swelling, redness, and tenderness behind the ear.

Diagnosis

Clinical Examination

Otoscopy — examination of the ear with an otoscope — is the most important diagnostic step. The characteristic appearance of a cholesteatoma is a white or pearly mass, often with a retraction pocket in the upper part of the eardrum (pars flaccida), with or without discharge. Skin debris or a keratin plug within the retraction may also be visible.

Not all cholesteatomas are immediately obvious on examination — some lie behind an area of eardrum that is difficult to visualise, or are small and early. A high index of suspicion in a patient with recurrent offensive discharge and hearing loss is essential.

Audiometry

A formal hearing test documents the degree and type of hearing loss and provides a baseline for monitoring.

CT Scanning

CT scanning of the temporal bone provides detailed anatomical information about the extent of the cholesteatoma, erosion of adjacent structures, and surgical planning. It cannot always distinguish cholesteatoma from other soft tissue within the middle ear, but it is invaluable for assessing the degree of bone erosion and the relationship of the disease to critical structures.

MRI

Diffusion-weighted MRI has become an increasingly important tool for detecting cholesteatoma — including residual or recurrent disease after surgery — without exposing the patient to radiation.

Treatment — Surgery

There is no medical treatment for cholesteatoma. Surgery is the only way to remove it and prevent progression. The aims of surgery are:

1. Complete removal of the cholesteatoma

2. Prevention of recurrence

3. Reconstruction of hearing where possible

4. Creation of a safe, dry ear

Types of Surgery

Canal wall up (CWU) tympanomastoidectomy — the mastoid is opened and the cholesteatoma removed while preserving the posterior wall of the ear canal. The advantage is a more anatomically normal ear that can tolerate water. The disadvantage is a higher rate of residual or recurrent disease, requiring a planned second-look operation approximately one year later.

Canal wall down (CWD) mastoidectomy (modified radical mastoidectomy) — the posterior canal wall is removed, creating a large open cavity (mastoid bowl) that is easier to inspect and clean. This reduces the risk of recurrent disease but creates a cavity that requires lifelong care and is sensitive to water.

The choice of surgical approach depends on the extent of disease, the anatomy of the ear, and the preferences and experience of the surgeon. Both approaches are performed under general anaesthetic, typically taking two to four hours.

Ossicular Reconstruction

Where the ossicles have been eroded by cholesteatoma, hearing reconstruction can be performed at the same time as cholesteatoma removal or as a planned second-stage procedure. Prosthetic ossicles (ossicular chain prostheses) are used to bridge the gap and restore sound transmission.

Recovery After Surgery

Recovery from ear surgery varies depending on the extent of the procedure. Most patients:

• Stay one to two nights in hospital

• Have packing in the ear canal for one to two weeks

• Are advised to keep the ear dry for several weeks

• Return to work within two to four weeks depending on the nature of their job

• Attend regular follow-up to monitor healing and check for residual or recurrent disease

Hearing results following surgery depend on the preoperative hearing, the degree of ossicular damage, and whether reconstruction was possible. Improvement in hearing is not always achievable, but prevention of further deterioration is always a goal.

Long-Term Follow-Up

Cholesteatoma has a tendency to recur — particularly the canal wall up approach, where residual microscopic disease may re-grow over months to years. Long-term ENT follow-up is therefore essential, typically with annual or biannual otoscopy and periodic MRI imaging.

Patients who have had cholesteatoma surgery should attend their follow-up appointments reliably and report any new discharge, hearing change, or ear symptoms between scheduled visits.

Frequently Asked Questions

Is cholesteatoma cancerous?

No. Cholesteatoma is not a cancer and does not spread to other parts of the body in the way cancers do. It is, however, locally destructive and requires surgical removal.

Can cholesteatoma be treated without surgery?

No. There is no medication that will remove or stop the growth of a cholesteatoma. Regular microsuction can help manage the discharge and remove accessible keratin debris, but this is not curative — it is a temporising measure to reduce infection and allow assessment while surgical planning takes place.

Will my hearing improve after surgery?

This depends on the extent of damage to the ossicles. Where the ossicular chain is intact or can be reconstructed, hearing improvement is possible. Where the damage is extensive, the priority is creating a safe, dry ear and preventing further deterioration. Hearing rehabilitation with a hearing aid may be appropriate after surgery.

Can children get cholesteatoma?

Yes. Cholesteatoma occurs in children as well as adults. Congenital cholesteatoma in particular presents in childhood. Children with recurrent ear infections, persistent ear discharge, or hearing loss should be assessed by an ENT specialist.

What happens if cholesteatoma is left untreated?

Untreated cholesteatoma continues to grow and erode surrounding structures, progressively worsening hearing loss and risking the serious complications described above — including facial nerve palsy and, in rare cases, intracranial infection. The longer it is left, the more complex and difficult the surgery becomes.

Book an Assessment

If you have been told you have a cholesteatoma, or if you have persistent ear discharge, hearing loss, or recurrent ear infections that have not been fully investigated, a specialist assessment is important.

Dr Vyas Prasad consults at Absolute ENT, Camden Medical Centre, 1 Orchard Boulevard, #09-08, Singapore. Contact the clinic by WhatsApp on +65 8060 8079 or by email at camden.mmc@gmail.com.