Cholesteatoma: skin growing inside the ear

What is cholesteatoma?

The middle ear is the air-filled chamber behind the eardrum that holds the three hearing bones. It should not have skin inside it. Cholesteatoma is exactly that: skin growing in this space, forming a build-up that enlarges over time.

Because skin sheds continuously, the cholesteatoma keeps growing and, as it grows, wears away the surrounding bone. This slow erosion explains the risks of the disease.

Why does it develop?

• Eardrum retraction. When the middle ear is poorly ventilated, for example after many ear infections, part of the eardrum can be drawn inwards and form a pocket. Skin collects in this pocket and cannot get out.
• Eardrum perforation. In some cases of chronic otitis, skin from the ear canal migrates through the edge of the perforation into the middle ear.
• From birth. Less commonly, congenital cholesteatoma appears in children, behind an intact eardrum, with no history of ear infections.

What are the symptoms?

• Ear discharge that comes and goes, often foul-smelling, even with treatment.
• Hearing loss on the affected side, usually increasing slowly.
• A blocked or pressured feeling in the ear.
• Little or no pain, in most cases.

Seek assessment promptly if you develop spinning dizziness, severe pain, fever, persistent headache or weakness on one side of the face.

What are the risks of leaving it untreated?

Cholesteatoma grows slowly, but it does not stop. Over time it can reach:

• The hearing bones, causing conductive hearing loss.
• The labyrinth, the balance organ, causing dizziness and sensorineural hearing loss.
• The facial nerve, which runs beside the middle ear, causing weakness on one side of the face.
• Structures next to the skull, in rare but serious complications.

Most people never reach this point, which is why early diagnosis matters: the sooner a cholesteatoma is identified, the less it has already reached.

How is it diagnosed at Clínica Rhinus?

The consultation starts with your history — how long the ear has been discharging, any previous surgery, any hearing loss — and an examination of the ear with otoscopy and, when needed, a microscope or endoscope. Tests usually include:

• Audiometry and tympanometry, to measure the degree and type of hearing loss.
• CT scan of the temporal bones, to show the extent of the cholesteatoma and the state of the bone, the hearing bones and nearby structures.
• MRI, in specific situations, especially for follow-up after surgery.

How is it treated?

Cholesteatoma is treated surgically. The most common operation is tympanomastoidectomy, which removes the cholesteatoma from the middle ear and the mastoid, the bone behind the ear. It is performed in hospital, under general anaesthesia.

Surgery has two goals, in order of priority:

1. Remove the disease and leave the ear dry and safe.
2. Rebuild hearing, when possible, by reconstructing the eardrum and the hearing bones. Sometimes this reconstruction is done in a second stage.

The technique depends on the extent of the cholesteatoma, the hearing in both ears and each patient’s history. More details on the ear surgery page.

And after surgery?

Cholesteatoma can come back, even after well-performed surgery. That is why follow-up with the otolaryngologist continues for years, with ear examinations and, when indicated, MRI or a second-stage operation to confirm that the ear remains free of disease.

Sources: Brazilian Society of Otology (SBO) · Brazilian Association of Otorhinolaryngology and Cervicofacial Surgery (ABORL-CCF) · Flint PW, Francis HW, Haughey BH, et al. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Elsevier; 2020.