This document discusses the natural history and management of active squamous cholesteatoma. It notes that cholesteatoma can remain active or become inactive over time. Surgical removal is the primary treatment and can be done via canal wall down mastoidectomy or intact canal wall mastoidectomy. Canal wall down mastoidectomy has a lower recurrence rate of 5-15% but often results in a larger cavity that requires more care, while intact canal wall mastoidectomy has a higher recurrence rate of 20-25% but preserves the ear anatomy. Post-operative care and potential cavity issues are also outlined.

1. Natural history ,management of
active squamous COM(Cholesteatoma)
Active squamous epithelial disease may remain active or become inactive.
In well-pneumatized temporal bone,such as in children,the disease is frequently extensive expanding
down the well-formed tracts.
Squamous epithelial disease is commonly found in poorly pneumatized sclerotic bones. The
evidence suggests that the most important factor in the development of mastoid sclerosis is poor
Eustachian function.Poor Eustachian function & reduced middle ear cleft volumne has been shown
to be the characteristic of ears with Cholesteatoma.
Progression Towards healing
Patients with active squamous disease which heal but patient has a well-formed atticotomy or
mastoidectomy cavity. In these cases disease process has eroded bony outer attic wall & in some
cases the whole posterior meatal wall. Ear develops a normal widen external meatus or
automastoidectomy cavity.
In a proportion of cases ,no longer produces or accumulates squamous epithelium but revert to a
clean, nonprogressive retraction.
Progression of active disease
The natural history of cholesteatoma is anatomical progression of disease with inevitable
involvement of the ossicular chain & possible involvement of the labyrinth by erosion of the lateral
semicircular canal.
Many patients live with active squamous epithelial disease with minimal disability or inconvenience.
Erosion take place by the mechanism of osteoclastic & osteoblastic remodelling.Although bone
erosion in cholesteatoma takes place in the absence acute inflammation &granulation tissue
formation, the disease process to be associated with chronic granulation tissue formation with
osteitis in the adjacent bone.
Hearing in active squamous COM
Hearing is preserved in spite of the ossicular chain being disrupted.Cholesteatoma sac bridges the
gap between the functioning part of the ossicular chain & inner ear.involvment of the incus in cases
of cholesteatoma is almost universal.
Presentation
Classically active squamous COM presents with foul smelling otorrhea & hearing impairment.
However ,many patients complain only of hearing impairment & are unware of any discharge from

2. ear .>small quantity >dry up> crust>mistake for wax.Wax occur if patient pushes it inner ear with a
cotton bud.
Examination
Microscopic examination is required to clean of the discharge& to confirm the diagnosis.
In the very inflamed ear cholesteatoma may not be visible at first presentation. Sometimes aural
polyp obscure the attic or posterior pars tensa.when debris is removed from a retraction pocket in
the attic or posterior pars tensa ,the extent of the retraction pocket may not be visible with a
microscope.
Radiology
X-ray shows the anatomy of the mastoid,position of the tegmen tympani, sigmoid sinus& degree of
pneumatisation of mastoid.holesteatoma is seen as soft tissue density.
CT scan can often demotrate erosion of the inner ear with fistula formation or dehiscence of the
facial nerve but negative does not rule out of a fistula.
MRI shows a soft tissue mass but does not provide enough bony detail.
Management
Surgical removal is the only effective treatment for Cholesteatoma.
Aims of the surgery:1)eradication of disease;
2)an epithelialized ,self-cleaning ear;
3)hearing improvement.
Canal wall down mastoidectomy The traditional method for removal of cholesteatoma was MRM
using the posterior to anterior approach.(forward through the aditus into the attic with removal of
the posteror bony wall .These resulted in a large cavity.Large cavity can be problematic, may
continue to discharge,they even don’t self-cleaning so regular clinic attendance is required for
removal of debris & wax.
Small cavity mastoidectomy or attico-antrostomy ,anterior to posterior approach .Cholesteatoma is
identified in the epitympanum or posterior mesotympanum and followed backwards.
When the cholesteatoma is small surgery can be limited to atticotomy& defect in the attic wall can
be closed with tragal or choncal cartilage.
Why active cavities: high facial ridge
Sump in cavity below the floor of external auditory canal.
Perforation of the TM,
Small external canal.

3. Canal wall down surgery has lower rate of recurrence of cholesteatoma(5-15%)& recurrence is
easily identified in the out patients clinic,2nd look operation rarely necessary.A significant number of
patients (20-25%) continue to have otorrhoea.
Intact canal wall mastoidectomy (combined approach tympanoplasty):
Intact external canal & no mastoid cavity.
The incidence of recurrence of cholesteatoma is high(20-25%),therefore second look operation is
necessary after 12 to 18 months in almost all cases.
Intact canal wall versus canal wall down mastoidectomy
Reconstruction of the middle ear can be achieve with either technique & there is no evidence that
the long term hearing result differ between procedures.it has been claimed at times that post
operative hearing results are better following intact canal wall mastoidectomy.
Pars tensa cholesteatoma
Cholesteatoma arising from the pars tensa may be confined to the middle ear ,most commonly
growing into the fascial recess.complete clearance from the oval window ,especially when there is
an intact stapes superstructure,can be difficult.If there is any doubt over clearance of the disease ,
TM can be closed & the ear reopened after 12-18months.
Problem mastoid cavities
Most commonly the problem arise because of poor surgical technique at the initial mastoidectomy:
The meatus may be too small .
A high facial ridge .
A sump in the mastoid tip.
TM has not been closed.
Skin does not readily grow on bare bone & naturally moist environment in the ear encourage the
growth of the respiratory mucosa. The cavity can be smaller by obliteration by bone pate or
hydroxyapatite granules, covered by a vascularised fascioperiosteal flap.