Although surgery is rarely urgent, once a cholesteatoma is found, surgery is your only choice. Surgery usually involves a mastoidectomy to remove the disease from the bone, and tympanoplasty to repair your eardrum. Usually the exact type of operation won’t be known until the time of surgery.
- Mastoidectomy. When an infection or cholesteatoma has grown into the mastoid (the bone behind your ear), we will open the bone to remove the disease. Sometimes this requires removing all the bony walls within your ear to create an open cavity. This process is called an "open cavity," "canal wall down," or a "radical mastoidectomy." Sometimes the boney partitions can be preserved.
- Tympanoplasty. This refers to repair of your eardrum and hearing mechanism. At Mount Sinai, we lift your eardrum away from the bone of your ear canal and repair it with a graft of cartilage or fascia (the lining of the muscle behind your ear). Usually this type of repair is successful in closing holes in the eardrum permanently. If the small bones involved in hearing are damaged, we will try to repair them with natural bone or cartilage, or synthetic prostheses made of bone mineral. We use natural bone whenever possible.
If your hearing bones are involved, we will try to preserve or repair them if possible. We then repair the portion of your eardrum that gave rise to the cholesteatoma using a graft of tissue (cartilage or fascia) from behind your ear. Surgery usually takes about three hours, and you may go home the same day.
Cholesteatoma surgery is delicate surgery performed under a microscope. It is very important to remove the disease completely, or it may grow back. The rate of re-growth is higher in children than adults. Because of the aggressive nature of cholesteatoma, we require that you come in regularly for careful follow-up. Sometimes a second operation will be necessary.
This photograph shows the typical appearance of cholesteatoma at surgery. The arrow points to the origin of the cholesteatoma at the eardrum. A mastoidectomy has been performed. The instrument is lifting the cholesteatoma out of the mastoid cavity.
Options in surgery
At Mount Sinai, we use a single-stage approach whenever possible. Because of differences in the extent of the disease and differences in the anatomy of patients' ears, we usually decide on the exact details of the operation at the time of surgery.
- Single-staged procedure. In a single-stage operation, we remove the disease completely and reconstruct your ear in the best manner possible. If we take down the canal wall, we often reconstruct the bone to avoid creating a large postoperative cavity. If we find a lot of inflammation and scarring, however, we might not be able to reconstruct your ear. In this situation, we can attempt a second-stage operation after about a year.
- Open vs. closed procedures. An open cavity ("canal wall down" mastoidectomy) decreases the risk of your cholesteatoma returning. However, you will need to see your doctor once or twice a year to remove wax. If you have an open cavity, you will usually need to wear earplugs when swimming. A closed cavity ("canal wall up") heals more like a normal ear but carries the risk that recurrent disease might be hidden behind the bone. Some surgeons routinely recommend a second operation to search for recurrent disease when a closed technique is used.
Hearing status after cholesteatoma surgery
Patients with cholesteatoma usually have hearing loss prior to surgery. We try to reconstruct the hearing whenever possible. This usually results in hearing improvement, but not always. Inflammation and scar tissue can sometimes prevent a good hearing result. A second-stage operation can be attempted in the future when your ear is more stable and there is no more disease.
A few patients with cholesteatoma will have very good hearing. We always attempt to preserve the hearing bones, but if they are diseased, this is not possible. Even after primary hearing reconstruction, it is possible to end up with partial hearing loss. Deafness, however, is fortunately rare.
There is a small risk to the facial nerve with any type of surgery. Fortunately, in experienced hands, the risk of facial weakness is extremely low.
What are the results of surgery?
Surgery results in the complete removal of cholesteatoma in the majority of cases. Hearing loss can often be restored to some degree. If the disease prevents effective hearing restoration, a smaller operation in the future may be the best way to improve your hearing.
Surgery is generally safe. However, as with any operation, there are risks as well as benefits. The most common risks are:
- Recurrence of the cholesteatoma
- Hearing loss or failure to improve hearing
- The need for more than one operation
Even in the best of hands, cholesteatoma may recur, and additional surgery may be necessary in the future.
Your first post-operative appointment is one to two weeks after surgery. At this time, your doctor will remove the medicated gauze packing from your ear.
Your follow-up visits will continue about every two weeks until your ear is completely healed — usually six weeks or so. A hearing test will be conducted when your ear has healed. Since surgery is often performed for a chronic, recurring condition, we strongly recommend continuous long-term follow-up every six months.
Recurrent cholesteatoma can happen even in the most experienced surgeon's hands. This is because cholesteatoma is an aggressive disease.
Recurrence comes in two forms: the first is when a small piece of cholesteatoma lining is left behind ("residual cholesteatoma"), and a new ball of skin re-forms behind the eardrum. The second is when a new cholesteatoma growth develops in the middle ear or mastoid cavity (a true "recurrence").
Recurrence is usually detected in the office, which is why regular follow-up is so important. Occasionally it will cause a drop in hearing or drainage from your ear. If recurrence is detected early, we may be able to manage it in the office. If the cholesteatoma has reached a significant size, though, we will need to perform surgery (revision mastoidectomy).
The goal of revision mastoidectomy is to remove all remaining cholesteatoma, to eliminate drainage from the ear, and occasionally to try to improve hearing. In revision mastoidectomy, we remove any remaining cholesteatoma and infected tissue. If the original procedure was canal wall up, the canal wall usually must be taken down. Muscle, cartilage, bone, and/or skin grafts may be used to re-line the cavity. We may perform a tympanoplasty to try to restore your hearing. Surgical details vary, depending on the original surgery and the nature of the current problem. A third operation is rarely necessary, but continued long-term follow up is still important.
We can help
U.S. News & World Report ranks The Mount Sinai Medical Center among the top 20 hospitals in the United States for the treatment of ear, nose, and throat disease — including cholesteatoma. Our Hearing and Balance Center has considerable experience in treating cholesteatoma. Please call the Mount Sinai Hearing and Balance Center at 212-241-9410 to schedule an appointment.