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Cholesteatoma Treatment (Mastoid Surgery)

by , last modified on 4/13/21.

Cholesteatoma is an abnormal sac-like skin growth within the middle ear behind the eardrum. It could be congenital, but more commonly is acquired from recurrent ear infections. Cholesteatoma, once formed, can itself trigger recurrent ear infections that may be resistant to standard treatments with antibiotic pills or ear drops. Chronic ear drainage and hearing loss is common.

Although cholesteatoma is non-cancerous, it often behaves in an aggressive fashion slowly destorying the bone within the middle ear causing hearing loss initially and if left untreated, can ultimately result in taste loss, dizziness, and facial paralysis.

As such, cholesteatoma treatment is first and foremost geared towards removing the growth thoroughly and restoring a safe and dry ear. A safe ear being complete cholesteatoma eradication thereby avoiding further bone damage/erosion. A dry ear being one that no longer drains and gets infected repeatedly.

A secondary goal would be to restore normal hearing.

Unfortunately these goals are not easily accomplished and often require a minimum of two or more surgeries spread out over months if not years.

Watch Video of Mastoid Surgery with actual surgical footage. This video is animation only.

The Mastoid Surgery

The workup for cholesteatoma includes a basic good ear examination, CT scan of the temporal bone, and hearing tests. Once cholesteatoma is confirmed, surgery is than anticipated.

The traditional approach to cholesteatoma removal requires TWO surgeries spaced about 4-6 months apart although in very rare situations when the cholesteatoma is very small and completely isolated, a single surgery may be all that is required.

The first surgery typically entails an operation called mastoidectomy which is often combined with a tympanic (or ear canal) approach. The two approaches together is collectively called "tympanomastoidectomy."

This surgery typically entails removing all of the mastoid bone behind the ear as well as entering the space behind the eardrum by going through the ear canal itself. The reason is because complete cholesteatoma removal is often not possible without going through both the ear canal and mastoid due to numerous ridges, crevaseses, and holes where the cholesteatoma may hide in. To use an analogy, cholesteatoma surgery is like looking through a small mousehole to determine if any mice are present (the more different opening and angles to look in, the better).

Depending on how extensive the cholesteatoma is based on exam, CT scan findings, and appearance during the surgery, there are several different variations which differ only in terms of aggressiveness. To explain what differentiates how aggressive the surgery is, think of a normal ear divided into 3 different compartments: ear canal, mastoid, and middle ear space.

Minimally aggressive tympanomastoidectomy is when all 3 different compartments (ear canal, mastoid, and middle ear space) are all still divided into separate compartments by the end of the surgery. The most aggressive mastoid surgery (radical mastoidectomy) is when all the compartments are merged into one giant single cavity.

Regardless of what type of tympanomastoidectomy is performed, the initial steps are all identical.

An incision is made behind the ear over the mastoid bone. The incision is than opened and the ear flipped forward in fully expose not only the mastoid bone, but also the ear canal.

Canal-Wall-Up Tympanomastoidectomy

A simple mastoidectomy is performed whereby all of the bone behind the ear is removed. At the same time, an approach through the ear canal is also performed.

The middle ear bones (malleus, incus, and stapes) may be surgically removed if involved with cholesteatoma. However, at the end of the surgery, there is still a distinct ear canal, mastoid, and middle ear space.

Please note, when performing a mastoidectomy from this point and onward, the main risks are damage to the:

• Facial nerve which can cause permanent facial paralysis
• Permanent taste loss or change (chorda tympani nerve can get damaged)
• Bleeding (large blood vessel is present on the back wall of the mastoid cavity)
• Brain fluid leak (note that only a thin boney wall separates the mastoid from the brain cavity)

Canal-Wall-Up Tympanomastoidectomy with Facial Recess Dissection

This is by far the most common procedure tried first unless there is already extensive cholesteatoma involvement.

This operation is when a canal-wall-up tympanomastoidectomy is performed followed by more aggresive bone removal in the area called the facial recess within the mastoid cavity. Middle ear bones are almost always removed in this situation given more extensive cholesteatoma involvement.

This more aggressive approach allows for further exposure into the middle ear space not accessible through the ear canal. However, at the end of the surgery, there is still a distinct ear canal, mastoid, and middle ear space.

Canal-Wall-Down Tympanomastoidectomy

This more aggressive surgical approach removes the back wall of the ear canal in order to achieve greater exposure of the middle ear space. The ear canal and mastoid cavity are now connected into one large space rather than 2 separate cavities. The middle ear space is still respected.

This procedure is also performed in order to make it easer to detect recurrent cholesteatoma.

Radical Tympanomastoidectomy

This MOST aggressive (as well as rarely performed) surgical approach further removes the eardrum and all middle ears bones such that the ear canal, mastoid, and middle ear space have all been merged into just one giant cavity. Obviously, hearing would be greatly diminised with this type of surgery.

Second Stage Surgery

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The second surgery is performed typically 4-6 months after the first surgery to ensure cholesteatoma has not come back. If it has, the cholesteatoma is removed (again). Assuming cholesteatoma has not recurred, the middle ear bones are reconstructed in order to restore hearing as close back to baseline as possible.

Post-Operative Experience

If a canal-wall-up tympanomastoidectomy was performed, typically no aftercare is required after post-operative healing.

If a canal-wall-down tympanomastoidectomy or radical mastoidectomy was performed, routine ear cleaning (every 4-8 months) is required as earwax may no longer come out the ear canal normally causing an exuberant earwax buildup to occur within the post-surgical cavity.

Careful examination is also performed to make sure cholesteatoma has not come back which unfortuantely is not uncommon years or even decades after the first and second stage surgery has been performed.

In order to further reduce these recurrences, surgeons are now incorporating endoscopic tools which enable magnified examination into difficult to see crevices within the ear to make sure cholesteatoma has been completely eradicated during the first and second stage surgeries.

Please note that Dr. Chang no longer performs cholesteatoma surgeries.

The video below is animation only. If you wish to watch actual surgical footage, watch this video instead.

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