Cholesteatoma: A Detailed Explanation

Introduction

Cholesteatoma is an abnormal, non-cancerous growth of skin cells that occurs in the middle ear, behind the eardrum. While it is benign in nature, cholesteatoma can be locally destructive and lead to serious complications if left untreated, particularly due to its potential to erode bone and disrupt normal ear function.

What Is Cholesteatoma?

The term “cholesteatoma” is derived from the Greek words “chole” (bile or cholesterol), “steat” (fat), and “oma” (tumour), although the condition does not actually contain cholesterol or fat. Instead, it refers to a collection of keratinising squamous epithelium (skin cells) trapped in the middle ear or mastoid, which can slowly enlarge over time.

Causes and Risk Factors

Cholesteatoma can be either congenital (present at birth) or, more commonly, acquired during life. The main causes and risk factors include:

• Chronic Ear Infections: Repeated or persistent infections can lead to the formation of a retraction pocket in the eardrum, where skin cells accumulate.
• Eustachian Tube Dysfunction: Poor function of the Eustachian tube (which equalises ear pressure) can result in negative pressure and the inward pulling of the eardrum.
• Perforation of the Eardrum: An existing hole in the eardrum can allow skin cells to migrate into the middle ear.
• Congenital Factors: Rarely, a cholesteatoma can be present at birth due to developmental anomalies.

Signs and Symptoms

Cholesteatoma may develop slowly and often presents with the following symptoms:

• Persistent Ear Discharge: A foul-smelling, sometimes blood-stained, discharge from the affected ear.
• Hearing Loss: Conductive hearing loss is common due to disruption of the ossicles (tiny bones of hearing).
• Ear Fullness or Pressure: A sense of blockage or pressure in the ear.
• Ear Pain: Less common, but may occur if infection is present.
• Tinnitus: Ringing or buzzing sounds in the ear.
• Dizziness or Balance Problems: In advanced cases, if the inner ear is affected.

If left untreated, cholesteatoma can erode nearby bones, leading to serious complications such as facial nerve paralysis, brain abscess, meningitis, or labyrinthitis.

Diagnosis

Diagnosis of cholesteatoma typically involves:

• Clinical Examination: An ENT specialist examines the ear using an otoscope or microscope to look for characteristic features such as a retraction pocket or a mass behind the eardrum.
• Hearing Tests: Audiometry is performed to assess the degree and type of hearing loss.
• Imaging: CT scans of the temporal bone may be used to determine the extent of disease and bone involvement.

Management and Treatment

The primary treatment for cholesteatoma is surgical removal. Key aspects include:

• Surgery: The goal is to completely remove the cholesteatoma and prevent recurrence. Common procedures are tympanomastoidectomy or mastoidectomy, depending on the extent.
• Medical Management: Antibiotics and ear drops may be used to control infection before and after surgery.
• Follow-Up: Regular post-operative monitoring is essential as cholesteatoma can recur, necessitating further intervention.
• Hearing Rehabilitation: Hearing aids or reconstructive surgery may be needed if hearing loss persists after removal.

Complications

Potential complications of untreated or advanced cholesteatoma include:

• Destruction of the ossicles leading to permanent hearing loss
• Facial nerve paralysis
• Intracranial infections such as meningitis or brain abscess
• Labyrinthitis (inner ear infection causing vertigo)
• Mastoiditis (infection of the mastoid bone)

Prevention

• While congenital cholesteatoma is not preventable, acquired cholesteatoma risk can be minimised by:
• Regular ear check-ups, especially for those with a history of chronic ear problems or eardrum perforations
• Prompt treatment of ear infections
• Managing allergies and sinus issues to maintain Eustachian tube function

Nursing Care of Patients with Cholesteatoma

This abnormal skin growth can erode the delicate bones of the middle ear, leading to hearing loss, infection, and potentially severe complications if untreated. Providing holistic and evidence-based nursing care is essential for optimizing patient outcomes and minimizing morbidity.

Nursing Assessment

Initial Assessment:

• Obtain a thorough history, focusing on recurrent ear infections, previous ear surgeries, hearing difficulties, and duration of symptoms.
• Assess for signs of infection or complications (e.g., fever, severe headache, neck stiffness, neurological deficits).
• Inspect the external ear for discharge, swelling, erythema, or deformity.
• Evaluate hearing using tuning fork tests (Rinne, Weber) or by observing the patient’s response to spoken commands.
• Monitor for signs of facial weakness or paralysis.

Preoperative Considerations:

• Assess understanding of the surgical procedure, potential risks, and expected outcomes.
• Establish baseline neurological and hearing status.
• Evaluate nutritional status, as some patients may have poor intake due to chronic infection.
• Screen for allergies, especially to antibiotics and anesthesia agents.

Nursing Diagnoses

Based on assessment findings, possible nursing diagnoses may include:

• Risk for infection related to chronic ear discharge and surgical intervention.
• Impaired sensory perception (hearing) related to structural changes in the middle ear.
• Acute pain related to infection and inflammation.
• Knowledge deficit regarding disease process and self-care after surgery.
• Risk of injury related to vertigo or balance disturbances.
• Disturbed body image related to hearing device use or surgical scars.

Nursing Interventions

1. Infection Control and Prevention

• Maintain strict aseptic technique during ear cleaning or dressing changes.
• Educate patient on proper hand hygiene and avoidance of water entry into the affected ear.
• Administer prescribed antibiotics (topical/systemic) as ordered; monitor for adverse reactions.
• Monitor for signs of increased infection or complications (e.g., increased pain, swelling, fever, or changes in mental status).

2. Management of Ear Discharge

• Perform gentle cleaning of external auditory canal using sterile swabs or gauze; avoid trauma to the canal.
• Keep the affected ear dry; use cotton with petroleum jelly as a barrier when bathing.
• Change dressings as directed and document color, odor, and amount of drainage.
• Educate patient and family regarding signs of abnormal or excessive discharge that require medical attention.

3. Pain Management

• Assess pain level regularly using an appropriate pain scale.
• Administer analgesics as prescribed.
• Teach non-pharmacological techniques for pain relief (e.g., relaxation, distraction).
• Encourage rest and minimize activities that exacerbate pain or discomfort.

4. Monitoring and Promoting Hearing

• Facilitate audiological evaluation pre- and post-operatively.
• Encourage the use of assistive devices as indicated (e.g., hearing aids).
• Communicate using clear speech, facing the patient, and minimizing background noise.
• Arrange follow-up with audiology and otolaryngology as needed.

5. Patient and Family Education

• Provide information about the nature of cholesteatoma, the need for surgery, and the importance of follow-up.
• Teach wound care, medication administration, and ear protection techniques post-operatively.
• Discuss signs of complications (e.g., persistent or worsening pain, fever, dizziness, facial weakness) and encourage prompt reporting.
• Advise avoidance of swimming or immersing the affected ear in water until cleared by the healthcare provider.
• Promote adherence to the follow-up schedule and audiological monitoring.

6. Supporting Emotional and Psychosocial Needs

• Offer emotional support, address concerns about hearing loss, surgery, or body image changes.
• Encourage family involvement and participation in care whenever possible.
• Refer to counseling or support groups if necessary.

7. Prevention of Injury and Complications

• Monitor for vertigo or imbalance; assist with ambulation as needed.
• Ensure a safe environment to prevent falls or injuries, especially in the postoperative period.
• Educate about the risks of self-cleaning the ear or inserting foreign objects into the canal.

Postoperative Care

Most patients with cholesteatoma undergo surgical treatment, typically mastoidectomy or tympanoplasty, to remove the lesion and reconstruct the middle ear.

Postoperative nursing care includes:

• Monitoring vital signs and neurological status closely.
• Assessing the surgical site for bleeding, swelling, or signs of infection.
• Maintaining head elevation to reduce swelling.
• Observing for changes in facial movement, which may indicate nerve injury.
• Administering pain medications and antibiotics as ordered.
• Reinforcing teaching on wound care, medication regimen, activity restrictions, and follow-up appointments.
• Documenting findings accurately and reporting any abnormalities promptly.

Patient Discharge and Community Care

Discharge planning should begin early and involve the interdisciplinary team. Coordination with outpatient services, home health, or community nursing may be required for ongoing wound care, medication administration, and hearing rehabilitation.

Discharge instructions may include:

• How to keep the surgical site clean and dry.
• How and when to take prescribed medications.
• Warning signs of complications and when to seek immediate medical care.
• The importance of regular follow-up with ENT specialists and audiologists.
• Encouragement to avoid activities that may traumatize the ear until fully healed.

REFERENCES

1. Castle JT. Cholesteatoma Pearls: Practical Points and Update/ . https://pubmed.ncbi.nlm.nih.gov/30069838/. Head Neck Pathol. 2018 Sep;12(3):419-429.
2. Genetic and Rare Diseases Information Center (U.S.). Cholesteatoma. https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/cholesteatoma/. Updated 11/2023.
3. Kuo CL, Shiao AS, Yung M, et al. Updates and knowledge gaps in cholesteatoma research. https://pubmed.ncbi.nlm.nih.gov/25866816/. Biomed Res Int. 2015;2015:854024.
4. Kennedy KL, Singh AK. Middle Ear Cholesteatoma. [Updated 2024 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448108/
5. Pachpande TG, Singh CV. Diagnosis and Treatment Modalities of Cholesteatomas: A Review. https://pubmed.ncbi.nlm.nih.gov/36505121/. Cureus. 2022 Nov 6;14(11):e31153.
6. Mohamed FS, Lokman FL, Mansoor WNBW, Shakri NBM, Hussain RI, Abdullah A. Recurrent cholesteatoma: why it occurs? Int Tinnitus J. 2024;27(2):242-246. doi:10.5935/0946-5448.20230037
7. Vestibular Disorders Association. Cholesteatoma. https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/cholesteatoma/. Updated 5/21/2021.
8. Wei B, Zhou P, Zheng Y, Zhao Y, Li T, Zheng Y. Congenital cholesteatoma clinical and surgical management.. https://pubmed.ncbi.nlm.nih.gov/36512880/ Int J Pediatr Otorhinolaryngol. 2023 Jan;164:111401.
9. Pachpande TG, Singh CV. Diagnosis and treatment modalities of cholesteatomas: a review. Cureus. 2022;14(11):e31153. doi:10.7759/cureus.31153
10. Delsmann MM, Bonik P, Ocokoljic A, et al. Cholesteatoma severely impacts the integrity and bone material quality of the incus. Calcif Tissue Int. 2023;113(6):609-617. doi:10.1007/s00223-023-01144-6

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