Cholesteatoma

Secretion flows from the ear.

Hearing can be improved with modern titanium hearing implants.
If there is a foul-smelling discharge from the ear, a cholesteatoma may be the cause. A cholesteatoma is an adhesion in the middle ear or behind the eardrum, which is caused by the proliferation of a special tissue in the middle ear (squamous epithelium), which under normal circumstances should not be in the middle ear. This tissue leads to chronic inflammation and can attack the bone, which is why cholesteatoma is also called chronic bone suppuration. The onion-skin-like growth of the cholesteatoma is typical. If the cholesteatoma grows over a longer period of time, it can enlarge and destroy the surrounding fine bones of the middle ear and also the ossicular chain. Further progression can lead to hearing loss, dizziness and, in rare cases, facial muscle paralysis. Cholesteatoma usually manifests itself in the form of ear discharge. Such complaints should prompt you to have yourself examined. What is the cause of a cholesteatoma? A cholesteatoma is often caused by an inflammation of the middle ear or a malfunction of the Eustachian tube. This usually results in negative pressure in the middle ear. A so-called epitympanal retraction of the eardrum can occur.
Normally, the Eustachian tube conducts air from the back of the nose into the middle ear. This regulates the normal pressure in the middle ear. An allergic reaction, a cold, a cleft lip and palate, radiation or sinusitis can impair the normal function of the Eustachian tube. A vacuum can develop in the middle ear. The vacuum created sucks in parts of the eardrum that have been weakened by inflammation. This can then be the precursor of a cholesteatoma. Very rarely, there are also congenital cholesteatomas. However, the most common cause of cholesteatomas is ear infections.

Is a cholesteatoma dangerous?
If the cholesteatoma is not consistently removed, dangerous changes can occur. The ossicular chain is often destroyed by the cholesteatoma. Therefore, a foul-smelling secretion from the ear canal should never be ignored. This is because the cholesteatomas can spread to the surrounding organs, such as the inner ear, vestibular organ or brain, over a longer period of time. If left untreated, this can lead to irreparable health problems such as deafness, facial nerve damage, meningitis or a brain abscess. The most severe clinical pictures of untreated cholesteatomas are rare, but in other countries they can still lead to death.

The treatment

An ear, nose and throat doctor can diagnose a cholesteatoma using ear microscopy. First, the ear must be carefully cleaned. Hearing and dizziness tests are required and an x-ray may be useful to assess the damage caused by the cholesteatoma before surgery. The correct treatment of choice is then microscopic ear surgery, because the aim must be to bring the cholesteatoma under control as quickly as possible in order to spare the patient the consequences of a severe clinical picture. Hearing-improving ear operations are performed using microsurgery. With the help of high-resolution ear microscopes, the operation is performed with an accuracy of less than 1 mm in the middle ear. In most cases, operations are performed under anesthesia. The main aim of the operation is to remove the cholesteatoma and reduce the annoying discharge from the ear. If the ossicular chain is affected, the second goal is to restore the normal function of the ossicular chain. Nowadays, this can be achieved with modern implants made of titanium. These are particularly lightweight and are characterized by excellent sound transmission. This is because it is important for sound transmission that an implant is very light. A modern titanium prosthesis, for example, weighs only 4 mg. It can be particularly effective in restoring the function of the ossicular chain.
It may often be necessary to perform the operation in two stages. In the first operation, the cholesteatoma is removed and in the second operation, also known as the second-look operation, it is checked whether the cholesteatoma has been completely removed. Sometimes an auditory reconstruction, i.e. the restoration of the ossicular chain, is only carried out in the second operation. The second operation is performed between six and twelve months after the first operation.
It is usually possible to be discharged a few days after the operation. In rare cases of very severe inflammation, a longer stay in hospital with appropriate medication is necessary.

What should I bear in mind after the operation?
The skin sutures on the ear are removed between the fifth and seventh day. The ear tamponade inserted into the ear canal is removed in the practice three weeks after the operation. This is done without anesthesia. Only in small children is it sometimes advisable to remove the tamponade under anesthesia. For three weeks after the operation, no water or soap may come into contact with the operated ear. If there is a smelly discharge from the ear or dizziness, the doctor should be informed. To ensure that no further inflammation occurs, follow-up examinations should also be carried out a long time after the operation. In patients who had to have a larger part of the ear bone (mastoid) removed during the operation, the examination period extends over several months. In the case of major operations, however, regular ear microscopic examination and cleaning of the cavity is also necessary in the long term.

Summary
Cholesteatoma is a serious but treatable condition that can only be diagnosed and treated by a specialist. Alarm signals that may indicate a cholesteatoma are persistent ear pain, foul-smelling discharge, pressure, dizziness and hearing loss as well as facial muscle relaxation.

Literature:
1.Maassen M.M., Lüdtke R., Lehner R., Reischl G., Zenner H.P.: New methods of type II tympanoplasty for arrosion of the long process of the incus. HNO 45 (1997) 133-139 IF 0.621 1997

2.Maassen M.M., Plinkert P.K., Lüdtke R. and Zenner H.P.: Functional outcomes after cholesteatoma surgery in adulthood. Laryngol Rhinol Otol 77 (1998) 74-81 IF 0.473 2002

3.Maassen M.M., Zenner H.P.: Tympanoplasty type II with ionomeric cement and titanium-gold-angle prosthesis Amer J Otol 19 (1998) 693-699 IF. 1.338 2002

4 Eiber A., Freitag H.-G., Burckhardt C., Hemmert W.,Maassen M.M., Rodriguez J., Zenner H.P.: Dynamics of Middle Ear Prostheses – Simulations and Measurements Audiology and Neurootology 4 (1999) 178-184 IF 2.123 2002 Highest ranked Journal in Otolaryngology

5 Surgical handling properties of titanium prosthesis in ossiculoplasty Maassen M.M., Löwenheim H., Pfister M., Herberhold S., Rodriguez-Jorge J., Baumann I., Nüsser A., Zimmermann R., Brosch S., Zenner H.P. Ear Nose Throat J 2005 84 (3):142-4,147-9