Cholesteatoma is a benign, cystic structure in the middle ear characterized by a growth of keratinizing epithelium that can erode bone and lead to various complications, primarily presenting with persistent foul-smelling discharge and conductive hearing loss. Treatment mainly involves surgical intervention, with options including mastoid exploration and different types of mastoid surgeries aimed at eradicating the disease and reconstructing hearing mechanisms. Postoperative complications may include facial nerve injury and infections.

1. - Dr. Alka Kapil
( Assistant Professor,
Dept. of ENT & Head Neck Surgery )
CHR NIC TITIS MEDIA

2. Cholesteatoma
 It is a growth of keratinizing squamous epithelium originating from the external layer of the
tympanic membrane or ear canal that invades the middle ear cleft
 Cholesteatoma has two components—
i. the acellular keratin debris, which forms the contents of the sac,
ii. the matrix, which forms the sac itself
 Misnomer : neither cholesterol crystals nor a tumour
 BONE ERODING PROPERTY
 enzymes like collagenases , acid proteases
& acid phosphatases

3. Definition :
A benign keratinizing epithelial lined cystic structure found in the
middle ear & mastoid having bone eroding properties

4. Right ear large cholesteatoma filling the mastoid antrum

5. Theories of Cholesteatoma Pathogenesis
Wittmaack's
Sade's
Ruedi's
Habermann's

6. Types of Cholesteatoma
Congenital Acquired
Primary Secondary
- Develops Secondary to
perforation
- Hebermann’s theory
- Develops from Congenital
cell rest

7. Levenson’s Criteria for Congenital cholesteatoma

8. GENESIS OF PRIMARY AND SECONDARY CHOLESTEATOMAS

9. Tos Classification of Pars Flaccida Retraction
partial erosion of scutum definite erosion of scutum
PF retraction
not adherent to the malleus
PF retraction
adherent to the malleus

10. i. In stage 1, the pars flaccida is dimpled and more retracted than
normal but not adherent to the malleus
ii. In stage 2, the retraction is adherent to the neck of the malleus
and the full extent of the retraction can be seen
iii. In stage 3, part of the retraction is out of view and there may be
partial erosion of the bony attic wall
iv. In stage 4, there is definite erosion of the attic wall with the full
extent of the retraction being uncertain because it is out of view

11. Sadé classification of Pars Tensa retraction
I. Stage I: Retracted tympanic membrane
II. Stage II: Retraction with contact onto the incus
III. Stage III: Middle ear atelectasis
IV. Stage IV: Adhesive otitis media

12. Pathology in squamosal COM
Cholesteatoma
Granulation tissue
Osteitis
Ossicular necrosis Cholesterol granuloma

13. Cinical features of Squamosal COM
1. Otorrhea
- A persistent ,scanty ,foul-smelling painless otorrhea is the hallmark of cholesteatoma
- patients not responsive to systemic antibiotics, topical antibiotics may help temporarily
2. Hearing Loss
- A conductive hearing loss is a common finding in cholesteatoma, as ossicular chain erosion is common (70%) ; however,
a relatively good hearing could be present even the ossicular chain is eroded, this is the result of the conductive mass
effect of the cholesteatoma itself ( Cholesteatoma hearers )
- Evidence of sensorineural hearing loss may indicate an involvement of the labyrinth.
3. Vertigo/Imbalance
- A destruction of the bone which overlies the otic capsule, especially the lateral semicircular canal, can trigger vertigo
or a balance dysfunction.
4 . Facial Nerve Palsy
5. Otalgia, headache, vomiting, and fever are not typical presentations of cholesteatoma; however, their occurrence indicates
the possibility of impending intratemporal or intracranial complications.

14. Complications of squamosal COM

15. Investigations
and
Assessment
1. Examination under microscope
2.Audiogram - PTA

16. 3. Culture & sensitivity of ear discharge
4. Routine haematological workup
5. Radiology – X ray b/l mastoids Schuller's view
Investigations
and
Assessment

17. 6. High resolution CT scan B/L temporal bone
Investigations
and
Assessment

18. Treatment
1. Conservative : little role only where surgery is not possible
2. Surgical : Mastoid exploration
- The main aim of the surgery is to give the patient a safe, dry and hearing ear by eradicating
the disease and reconstructing the hearing mechanism
-Types of mastoid surgeries ( Intact canal wall ; Canal wall down )

19. Postaural incisions for ear surgery
Types of postaural ( Wilde’s) incisions. (A) Sulcus incision. (B) Postaural incision in adults. (C) Postaural incision in infants.

20. Cortical mastoidectomy
Exposure of the mastoid in preparation for mastoidectomy. Note the surface landmarks

21. Initial removal of the mastoid cortex behind and above the ear canal is conducted with a cutting burr

22. Removal of the outer cortex reveals the peripheral air cell system in the well pneumatized temporal
bone

23. Thinning of the bony ear canal by removing air cells

25. Identifying the tegmen mastoideum: note the smooth sheet of bone

27. Initial entry into the mastoid antrum

28. Thinning of the bony shelf over the ossicles in the epitympanum.

30. Thinning of air cells over the sigmoid sinus and the sinodural angle (also known as Citelli’s
angle)

31. Tip cells are opened as necessitated by the extent of pneumatization

33. Steps of Cortical Mastoidectomy
1. Incision
2. Exposure of lateral surface of mastoid and Macewen’s triangle
3. Removal of mastoid cortex and exposure of antrum
4. Removal of mastoid air cells
5. Removal of mastoid tip and finishing the cavity
6. Closure of wound
Sinodural angle
Posterior wall of EAC
Sinus Plate
Dural
plate

34. Cortical Mastoidectomy Modified Radical Mastoidectomy
It is an exenteration of all accessible mastoid air
cells preserving the posterior meatal wall
It is an operation to eradicate disease of the attic and
mastoid, both of which are exteriorized into the
external auditory canal by removal of the posterior
meatal and lateral attic walls

35. Steps of Modified Radical Mastoidectomy
1. Incision
2. Exposure of lateral surface of mastoid and Macewen’s triangle
3. Removal of mastoid cortex and exposure of antrum
4. Removal of diseased tissue & mastoid air cells
5. Posterior wall of EAC is sacrificed : Facial ridge is lowered & bridge is broken ;
anterior & posterior buttress removed
6. Removal of mastoid tip and finishing the cavity
7. Meatoplasty
8. Closure of wound

37. Complications of Mastoid surgery
1. Injury to facial nerve.
2. Dislocation of incus.
3. Injury to horizontal semicircular canal.
Patient will have postoperative giddiness and nystagmus.
4. Injury to sigmoid sinus with profuse bleeding.
5. Injury to dura of middle cranial fossa.
6. Postoperative wound infection and wound breakdown.

38. CSOM MUCOSAL v/s SQUAMOSAL TYPE

39. Management of chronic otitis media (COM)

40. Clinicals
1. All of the following are the features of the disease shown in the
picture except:
a. Filled with keratinized stratified squamous epithelium
b. Deafness
c. Erodes bone
d. Lymphatic permeation

41. 2. Cholesteatoma is usually present at:
a. Anteroinferior quadrant of TM
b. Posteroinferior quadrant of TM
c. Attic region
d. Central part

42. 3. Scanty, foul smelling , painless discharge from the ear is characteristic
feature of which of the following lesions:
a. ASOM
b. Cholesteatoma
c. Central perforation
d. Otitis externa

43. 3. An old man presents with foul smelling ear discharge. On further exploration a
small perforation is found in the pars flaccida of the tympanic membrane. Most
appropriate next step in the management would be:
a. Topical antibiotics and decongestants for 4 weeks
b. I/V antibiotics and follow up after a month
c. Tympanoplasty
d. Tympanomastoid exploration

44. 4. A 5-year-old boy has been diagnosed to have posterior superior retraction
pocket. All would constitute part of the management except:
a. Audiometry
b. Mastoid exploration
c. Tympanoplasty
d. Myringoplasty

45. Thank You