Acquired cholesteatoma is an abnormal, non-cancerous collection of skin cells that develops in the middle ear space, behind the eardrum. This growth forms a cyst-like structure that continuously sheds keratin and debris, causing a progressive and destructive disease process. Because this trapped skin growth expands physically, it cannot resolve on its own. Active treatment is necessary to manage the condition, which focuses on stopping the growth and removing the damage caused by the lesion.
What Acquired Cholesteatoma Is
Acquired cholesteatoma begins when skin from the outer eardrum or ear canal is drawn inward into the middle ear or mastoid bone, often due to chronic negative pressure or a previous eardrum perforation. This displaced skin sheds dead cells, which become trapped and accumulate to form a mass. The resulting cyst is filled with keratin debris, the white, flaky material characteristic of the growth.
This accumulation gradually increases in size, exerting pressure on the delicate structures of the ear. The cholesteatoma also causes an inflammatory response, releasing enzymes that actively erode the surrounding bone. This destructive behavior can damage the tiny hearing bones (ossicles) and the bony walls separating the middle ear from the inner ear and the brain.
Without intervention, the cholesteatoma continues to grow and cause damage. Potential complications include permanent hearing loss, chronic infection, dizziness, and, rarely, facial nerve paralysis or the spread of infection into the brain. Because the growth is physically expanding and chemically destructive, it requires physical removal.
The Necessity of Surgical Intervention
Surgery is the definitive and only available treatment for acquired cholesteatoma, as it is the only method that can physically remove the diseased tissue and halt the destructive process. The primary goals are to completely eradicate the cholesteatoma, create a safe and dry ear, and, if possible, preserve or restore hearing function.
Procedures typically involve a mastoidectomy, which is the surgical removal of diseased air cells and bone from the mastoid bone behind the ear. This step is necessary to access and remove the cholesteatoma matrix, the lining of the cyst that must be entirely taken out to prevent recurrence. The surgeon chooses between a canal-wall-up or a canal-wall-down technique based on the scope of the disease.
The operation often combines the mastoidectomy with a tympanoplasty, which repairs the eardrum and reconstructs the hearing mechanism. If the cholesteatoma has eroded the ossicles, the surgeon may use prosthetics or bone grafts to rebuild the chain of hearing bones. This reconstruction may require a staged approach, where a second surgery is performed six to eighteen months later to maximize hearing improvement after the disease is confirmed eradicated.
The procedure effectively reverses the disease process by removing the physical cause of the destruction. It stops the growth, prevents further bone erosion, and mitigates the risk of life-threatening complications. Success is measured by the complete removal of the abnormal tissue and the achievement of a non-infected, stable ear cavity.
Why Non-Surgical Options Are Ineffective
Acquired cholesteatoma is a physical accumulation of tissue, making non-surgical treatments ineffective for reversal. Medication, such as antibiotics, cannot dissolve the physical cyst or remove the trapped, keratin-shedding skin cells. Pharmacological treatments are only useful for managing secondary infections that frequently develop within the debris.
Antibiotic therapy can temporarily alleviate symptoms by reducing inflammation and clearing discharge. However, medical management does not address the underlying pathology—the expanding skin cyst that continues to destroy bone. The biological nature of the growth requires physical removal, which only surgery can accomplish.
Observation without surgery is generally not a safe option because the condition is progressive and destructive. Delaying treatment allows the growth to cause more extensive damage to middle ear structures and increases the risk of serious complications. The physical growth will continue to expand, making observation a risky choice for most patients.
Monitoring After Treatment
Following the definitive surgical removal of an acquired cholesteatoma, long-term monitoring is necessary. The primary concern is the risk of recurrence, which can be due to residual disease (a small fragment of the matrix left behind) or a recurrent growth (a new retraction pocket). This risk can be significant, sometimes reaching 5 to 15%.
Regular post-operative checkups monitor the ear canal and middle ear space for early signs of returning disease. Historically, a routine “second-look” surgery was often performed six to eighteen months after the initial procedure to check for residual disease. This practice is now increasingly being replaced by specialized imaging techniques.
A non-invasive method frequently employed is Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI). This specialized MRI sequence is highly effective at detecting cholesteatoma tissue, which appears as a bright spot on the scan, often down to three millimeters. This imaging allows clinicians to screen for recurrence without a second operation, significantly reducing patient risk and recovery time.
Surveillance with DW-MRI is typically performed at specific intervals, such as one, three, and five years after the initial surgery, especially following a canal-wall-up procedure. This long-term follow-up is important because a cholesteatoma can take many years to regrow to a symptomatic size. Early detection ensures the long-term success of the initial treatment.