Download CHOLESTEATOMA

Department of Otorhinolaryngology
CHOLESTEATOMA
Chronic Suppurative Otitis Media
Attico-Antral Type
Cholesteatoma
• Is epidermal cyst of the middle ear and/or Temporal
bone with a squamous epithelial lining.
• Contain keratin and desquamated epithelium.
• Can be congenital or acquired
• Natural history is progressive growth with erosion of
surrounding bone due to pressure effects and
osteoclast activation.
It is skin in wrong place
Cholesteatoma
It erodes bone by:
1.Enzymatic activity.
2.Pressure necrosis (expansion of the
sac).
This may open pathways for spread of
infection (Bony or Unsafe type o CSOM)
Pathogenesis of Cholesteatoma
Congenital Cholesteatoma:
Arises from embryonic epithelial tissue in the
temporal bone ( may be in ME cavity or temporal
bone especially the petrous apex).
Epidermal cysts usually present in the anterior
superior quadrant of the middle ear near the
Eustachian tube orifice.
Congenital
Cholesteatoma:
Diagnosed as a
pearly white mass
behind an intact
tympanic
membrane in a
child with no
history of chronic
ear disease.
Acquired Cholesteatoma
Pathogenesis
Squamous epithelium may be found in the middle ear as a
result of:
• Invagination
• Migration (through a perforation)
• Squamous metaplasia
Acquired Cholesteatoma
Pathogenesis
Acquired Cholesteatoma
1) Invagination Theory ( primary acquired )
Prolonged ET obstruction creates negative
ME pressure leading to retraction of pars
flaccida (or the superior part of the
membrana tensa) which becomes an
invaginated into the ME (retraction pocket)
and gradually distend with accumulated
keratin and later on separate from the drum
membrane.
Primary acquired cholesteatoma
Normal TM
Primary acquired (M Flaccida)
Primary acquired cholesteatoma
Normal TM
Mesotympanic Type (primary)
Primary acquired cholesteatoma
Pathogenesis Of
Cholesteatoma (cont.)
2) Migration Theory (Secondry acquired)
The stratified squamous epithelium of the deep
external auditory meatus grows through a marginal
perforation into the middle ear cavity.
3) Metaplasia Theory
Long standing suppuration can stimulate metaplasia
of the simple squamous epithelium of the middle
ear to stratified squamous epithelium.
Secondary Acquired Cholesteatoma
• Migration Theory – most accepted
• Originates from a tympanic membrane perforation
• As the edges of the TM try to heal, the squamous
epithelium migrates into the middle ear
Clinical Picture
symptoms
1) Hearing loss (marked) and tinnitus.
Sometimes HL is minimal as the sac may bridges
the gap between the necrosed ossicles.
2) Foul smelling ear discharge.
Signs
1- Fetid scanty purulent ear discharge
2- Perforated DM with cholesteatoma debris
3- Conductive or mixed HL
Clinical Picture
• Mass behind intact tympanic membrane in
cases of congenital cholesteatoma
• Sometimes the first presentation is with
one of complications e.g. facial nerve
paralysis or lateral sinus thrombophlebitis
• Granulation tissue or aural polyp may fill
the ear canal with bloody ear discharge
Investigations
1- Culture and Sensitivity: of the ear discharge.
2- Audiological assessment
- CHL, mixed HL or dead ear
3- Imaging of the temporal bone: Only in cases with
- Suspected or presence of complications,
- Congenital cholesteatoma or
- History of previous ear surgery
Imaging of Temporal
Axial Section
Coronal Section
Cholesteatoma Imaging
Treatment of Cholesteatoma
Is Surgical, No role for medical treatment
except for active ear infection (ototopical
drops)
Tympanoplasty with Mastoidectomy is the
standard surgical procedure
In cases with total HL radical mastoidectomy
is indicated
Mastoidectomy
• Intact (bony ear) canal wall
mastoidectomy
• Canal wall down mastoidectomy
– Radical Mastoidectomy ( dead ear)
– Modified Radical Mastoidectomy
Cholesterol Granuloma
CGs, first reported in the mastoid and middle ear in
1894, may occur anywhere in the air cell system of
temporal bone when eustachian tube obstruction,
mucosal edema, temporal bone fracture,
cholesteatoma, chronic otitis media or any another
process blocks the air cell tracts.
Cholesterol Granuloma
• Cholesterol granuloma is a histological term used
for the description of a tissue response to a foreign
body such as cholesterol crystals released by the
breakdown of blood and local tissue.
• It may arise any portion of the pneumatized
temporal bone but most frequently involves the
petrous apex
Cholesterol Granuloma
CG can be a perfectly localized and isolated mass in
any pneumatized area in the temporal bone, the
middle ear cavity, mastoid antrum, external
auditory canal and the petrous apex.
Cholesterol Granuloma
Cholesterol granuloma (CG) of the middle ear typically
presents with a conductive hearing loss and a blue
eardrum; those at the petrous apex either manifest
with side-effects from bony erosion (with
sensorineural hearing loss, tinnitus, vertigo or
cranial nerve impairment), or are identified as
incidental findings.
OTORRHOEA
Definition:
Discharge of abnormal material through the external
ear canal
Ear Wax is considered as normal external ear secretion
not discharge
OTORRHOEA
Description
Amount:
Scanty or profuse
Nature:
Watery, mucoid (& muco-purulent), purulent or
bloody (sanginous)
Smell:
Cholesteatoma & external otitis
OTORRHOEA
The source of ear discharge:
1- External ear
2- Middle ear
3- Intracranial (CSF)
WATERY OTORRHOEA
CSF Otorrhoea: Mostly traumatic
- Skull base fracture (commonly the
longitudinal type)
- Iatrogenic (post-operative)
- Rarely, malignant neoplasm eroding the skull
base
Bloody Otorrhoea
• Traumatic:
Trauma of the external, middle ear and skull
base
• Inflammatory:
Bullous myringitis, acute and chronic otitis
media
• Neoplastic:
glomus , carcinoma of external or middle ear
Mucopurulent Otorrhoea
Always from middle ear;
Acute and chronic otitis media
Pulsating ear discharge:
Acute or acute on top of chronic suppurative
otitis media with small perforation of drum
membrane
Intra-cranial complications of suppurative otitis
media ( extra-dural abscess)
Muc-opurulent Otorrhoea
Reservoir Sign:
Rapid recollection of discharge in the external
ear canal which indicates coalescent
mastoiditis
PURULENT OTORRHOEA
External otitis and cholesteatoma
Usually smelly (fetid)
Management of cases of ear discharge is
according to the cause
N.B. No packing of external ear in suspected
cases of CSF otorrhoea.