
CHOLESTEATOMA
Definition: Cholesteatoma is the presence of squamous epithelial pocket or sac, filled with keratin debris within the middle ear cleft. It is a cause of Active Squamous epithelial type of Chronic otitis media.
Origin of Cholesteatoma:
- Presence of congenital cell rests.
- Invagination of tympanic membrane in the form of retraction pockets (Wittmaack’s theory).
- Basal cell hyperplasia (Ruedi’s theory)– The basal cells grows under the influence of infection and forms keratinizing squamous epithelium.
- Epithelial invasion (Habermann’s theory)– The epithelium grows inside middle ear through a pre-existing perforation especially of marginal type.
- Metaplasia (Sade’s theory)– Middle ear respiratory mucosa undergoes metaplasia due to repeated infections and changes into squamous epithelium.
Cholesteatoma is divided into 3 types:

Congenital Cholesteatoma: They are squamous epithelial cells arising from temporal bone. It arises from ectodermal cell nest.
It is classified into:

Clinical features:
Patient presents with:
- Severe sensorineural hearing loss.
- Facial weakness.
- X-ray mastoid Schuller’s view shows bone erosion.
- HRCT scan plain 1mm cuts will be noting the extent of disease and bony erosion in temporal bone.
- MRI temporal bone plain and contrast with facial nerve studies are useful in advanced cases.
Acquired Cholesteatoma:
- Primary:
- Invagination of Pars flaccida.
- Basal cell hyperplasia.
- Squamous metaplasia.
- Invagination of Pars flaccida.
- Secondary:
- Migration of squamous epithelium from external auditory canal and tympanic membrane through the perforation present in the tympanic membrane.
- Metaplasia due to repeated infections of middle ear through the pre-existing tympanic membrane perforation.
Clinical features:
- Otorrhoea: The discharge is scanty, foul smelling, continuous and yellowish.
- Deafness: There is moderate to severe hearing loss. It may be conductive and mixed.
- Otalgia.
- Tinnitus.
- Vertigo.
- Patients may also present with intracranial, or extracranial complications.

Investigation:
- Routine blood count, X-ray chest, ECG.
- Suction microscopy: to clear out any discharge, confirm clinical findings and examination of the discharge for pus culture and antibiotic sensitivity.
- Tuning fork tests: They help in clinical evaluation of hearing loss.
- Pure tone audiometry: this is useful for a qualitative and quantitative analysis of the patients hearing. It also helps for pre-operative and post-operative assessment of the hearing loss and for medico-legal purposes.
- X-ray mastoid Schuller’s view: to diagnose the extent of the disease and status of the mastoid air cells, sinus plate, dural plate and sinodural angle.
- HRCT temporal bone is extremely useful in patients with complications or impending complications.
- MRI temporal bone plain with contrast helps diagnosing soft tissue extension.
- Make the ear safe and prevent complications.
- Make the ear dry.
- Restore maximum possible hearing.
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