Cholesteatoma: What It Is, Why It Happens, and How It Is Treated

Your ear is doing something unusual. There is a persistent smell coming from it, a feeling of fullness that will not go away, and your hearing seems slightly off. It is easy to dismiss these signs as a lingering ear infection. But sometimes, they point to something that needs closer attention, like a cholesteatoma.

The name sounds complicated, but understanding what it is, how it develops, and what can be done about it goes a long way in helping you act with confidence rather than worry.

What Is Cholesteatoma?

A cholesteatoma is an abnormal growth of skin cells that develops in the middle ear, behind the eardrum. It starts as a small cyst or pocket that fills with layers of dead skin. Over time, as those layers accumulate, the growth expands and begins to press against and erode the delicate structures of the middle ear.

Although the name may sound alarming, a cholesteatoma is not cancerous. However, it does not behave like a simple cyst either. It releases enzymes that actively break down the surrounding bone, meaning it can cause serious and progressive damage if left untreated.

Is Cholesteatoma a Tumour or Cancer?

A cholesteatoma is neither a tumour in the traditional sense nor a form of cancer. It is a benign growth, meaning it does not spread to other parts of the body the way cancer does. However, it is destructive locally. Its ability to erode bone and expand into surrounding structures makes it medically significant and something that requires prompt attention. Calling it benign should not be mistaken for harmless. Without treatment, it can cause permanent hearing damage and, in rare cases, serious complications.

How Cholesteatoma Develops

The middle ear is a small, air-filled space that relies on a delicate pressure balance to function correctly. When that balance is disrupted, usually because the Eustachian tube is not working properly, the eardrum can be pulled inward. This creates a retracted pocket that gradually fills with shed skin cells.

Normally, skin cells shed outward. In this retracted pocket, they have nowhere to go. They accumulate, layer upon layer, forming a growing mass. Over time, this mass expands, pressing against the ossicles (the three tiny bones of the middle ear) and the surrounding bone. The enzymes it produces accelerate this destruction, widening the damage as the cholesteatoma grows.

In some cases, a cholesteatoma develops through a hole or perforation in the eardrum, through which skin cells migrate into the middle ear space. In rarer cases, it is present from birth.

Types of Cholesteatoma

• Congenital cholesteatoma: This type is present from birth. It develops when skin cells become trapped in the middle ear during foetal development. A congenital cholesteatoma may not cause any symptoms until it grows large enough to affect hearing or other structures. It is sometimes discovered incidentally during a routine ear examination in children.
• Acquired cholesteatoma: This is the more common form and develops over time. It is further divided into two subtypes. The first is primary acquired cholesteatoma, which develops when a retracted eardrum creates a pocket that traps skin cells. The second is secondary acquired cholesteatoma, which develops when skin cells enter the middle ear through a perforation in the eardrum, often as a result of a chronic ear infection or injury.

Causes of Cholesteatoma

• Eustachian tube dysfunction: When the tube that connects the middle ear to the back of the throat does not open and close properly, it disrupts air pressure in the middle ear, which can cause the eardrum to retract and form a pocket.
• Chronic ear infection: Repeated or long-standing ear infections are one of the most common contributors to acquired cholesteatoma. They can weaken the eardrum and create the conditions needed for a cholesteatoma to form.
• Eardrum perforation: A hole in the eardrum, whether from infection, trauma, or previous surgery, can allow skin cells to migrate into the middle ear and accumulate.
• Developmental factors: In congenital cases, the cause is related to the entrapment of skin cells during early foetal development, before birth.
• Previous ear surgery: In some cases, a cholesteatoma can develop as a complication following ear surgery.

Symptoms of Cholesteatoma

Symptoms often develop gradually, especially in the early stages. Being aware of them helps in seeking timely care.

• Ear discharge: A persistent, foul-smelling discharge from the ear, sometimes resembling pus, is often the most noticeable early symptom. This is one of the key symptoms to watch for as it is a common sign of ear discharge associated with cholesteatoma.
• Hearing loss: Typically affects one ear and progresses slowly. It often reflects damage to the ossicles responsible for transmitting sound.
• A feeling of pressure or fullness in the ear: This can feel similar to the sensation of a blocked ear that will not clear.
• Dizziness or balance problems: If the cholesteatoma grows large enough to affect the inner ear, it can cause a spinning sensation or unsteadiness.
• Tinnitus: A ringing or buzzing sound in the affected ear may accompany hearing loss.
• Facial weakness: In rare, more advanced cases, if the growth presses on the facial nerve, it can cause weakness or numbness on one side of the face.
• Recurrent ear infections: Repeated infections that do not fully resolve may be a sign of an underlying cholesteatoma.

Complications of Untreated Cholesteatoma

Because a cholesteatoma erodes bone progressively, delaying treatment allows it to cause increasingly serious damage.

• Permanent conductive hearing loss: As the ossicles (the malleus, incus, and stapes) are destroyed, sound can no longer be transmitted effectively to the inner ear, resulting in lasting hearing impairment.
• Sensorineural hearing loss: If the cholesteatoma breaches the inner ear, it can damage the cochlea, causing a deeper, more permanent form of hearing loss.
• Vertigo and balance disorders: Inner ear involvement disrupts the vestibular system, leading to severe dizziness and difficulty maintaining balance.
• Facial nerve damage: If the growth reaches the facial nerve canal, it can cause facial paralysis or weakness on the affected side.
• Mastoiditis: Spread of infection to the mastoid bone (the bony structure behind the ear) can cause pain, swelling, and systemic infection.
• Meningitis: In rare and severe cases, infection from a cholesteatoma can spread to the membranes surrounding the brain, a medical emergency.
• Brain abscess: Infection spreading beyond the ear into the brain is a rare but life-threatening complication.

These risks are exactly why a cholesteatoma, despite being non-cancerous, should never be left untreated.

How Cholesteatoma Is Diagnosed

Diagnosis involves a combination of clinical examination and investigations.

• Medical history: Your doctor will ask about symptoms such as ear discharge, hearing changes, recurring ear infections, or any previous ear surgery or injury.
• Otoscopic examination: Using an otoscope, the doctor examines the ear canal and eardrum for signs of retraction, perforation, or a visible mass. A white, pearly growth visible through or near the eardrum is a classic finding.
• Referral to an ENT specialist: If a cholesteatoma is suspected, you will be referred to an otolaryngologist (ear, nose, and throat specialist) or an otologist for further evaluation and management.
• Hearing tests: An audiogram and tympanometry test help assess the degree of hearing loss and how well the eardrum and middle ear are functioning.
• CT scan: A computed tomography scan of the temporal bone provides detailed images of the middle ear and surrounding structures, helping assess the size and extent of the cholesteatoma and the degree of bone erosion.

Treatment Options for Cholesteatoma

Surgery is the only definitive treatment for a cholesteatoma. No medication can shrink or remove it.

• Mastoidectomy: This is the most common surgical procedure for cholesteatoma. The surgeon removes the cholesteatoma and any infected or damaged bone in the mastoid (the air-filled bone behind the ear). There are different types of mastoidectomy, and the approach used depends on the size and spread of the cholesteatoma.
• Tympanoplasty: This procedure repairs the eardrum, often performed alongside a mastoidectomy. If the ossicles have been damaged, ossiculoplasty (reconstruction of the small bones) may also be carried out to restore hearing function.
• Staged surgery: In some cases, particularly when the cholesteatoma is extensive, surgery is carried out in two stages. The first removes the cholesteatoma, and the second, performed several months later, checks for any recurrence and completes the hearing reconstruction.
• Ear cleaning (debridement): For those who are not suitable for surgery, regular cleaning under a microscope by a specialist can help manage the condition, though it does not remove the cholesteatoma.

Recovery After Cholesteatoma Surgery

Recovery varies depending on the extent of surgery, but most people can expect to return to normal activities within a few weeks. Your surgeon will advise you to keep the ear dry during the healing period, typically for several weeks. Dressings may need to be changed at follow-up appointments.

It is important to attend all post-operative visits, as the specialist will check for healing, monitor hearing recovery, and look for any signs of recurrence. Some people experience temporary dizziness or altered hearing after surgery, which usually improves as the ear heals. In cases where ossiculoplasty was performed, hearing improvement may take a few months to become apparent.

Because cholesteatomas can recur, long-term follow-up ear examinations and hearing tests are an essential part of care after surgery.

Preventing Cholesteatoma

Congenital cholesteatoma cannot be prevented. However, for acquired cholesteatoma, there are steps you can take to reduce your risk.

• Treat ear infections promptly and completely, and avoid letting them become chronic.
• See a doctor if you experience repeated ear infections that keep coming back.
• Protect your ears from injury and activities that could cause eardrum perforation.
• Avoid inserting objects into the ear canal, which can damage the eardrum.
• Seek early medical advice for persistent ear discharge, muffled hearing, or a feeling of blocked ears.

Ear Infection Management

Chronic ear infection is one of the leading risk factors for acquired cholesteatoma. Managing ear infections well is an important part of prevention.

• Complete the full course of antibiotics prescribed for an ear infection, even if symptoms improve early.
• Attend follow-up appointments to confirm the infection has fully cleared.
• Discuss with your doctor if ear infections keep recurring, as there may be an underlying reason such as Eustachian tube dysfunction that needs to be addressed.
• Avoid swimming or getting water in the ear during and after an active infection.
• Do not use cotton buds or other objects to clean inside the ear canal, as this can push debris inward or damage the eardrum.

When to See an ENT Specialist

You should seek medical attention promptly if you notice:

• A persistent foul-smelling or unusual discharge from one ear
• Gradual hearing loss in one ear, particularly if it is getting worse
• A feeling of pressure or fullness in the ear that does not resolve
• Repeated ear infections that keep returning
• Dizziness or balance problems alongside ear symptoms
• Ringing in one ear without an obvious cause
• Any facial weakness or numbness alongside ear symptoms

These symptoms should not be dismissed as a simple infection, particularly if they persist or worsen. Seeing an ENT specialist early allows for accurate diagnosis and timely intervention before the condition progresses.

Take a Proactive Approach to Your Ear and Overall Health

If you or someone you care for has been experiencing symptoms that may point to a cholesteatoma, acting early makes a significant difference. While the diagnosis and treatment of cholesteatoma itself involves specialist care, supporting your overall health through regular monitoring is something you can actively do.

Metropolis Healthcare offers a wide range of diagnostic tests, including speciality hearing-related investigations and full body health checkups, to give you a clearer picture of your health. With home sample collection available across an extensive network, easy booking through the website, app, WhatsApp, or phone, and quick, reliable reports, Metropolis makes proactive health management simple and accessible. Because staying informed about your health should never feel complicated.

Frequently Asked Questions

Is Cholesteatoma Dangerous?

A cholesteatoma is not cancerous, but it is medically serious. If left untreated, it erodes bone and damages the structures of the middle and inner ear, potentially causing permanent hearing loss, vertigo, facial nerve damage, and, in rare cases, life-threatening complications like meningitis. Early treatment significantly reduces these risks.

Can Cholesteatoma Come Back?

Yes, cholesteatoma can recur after surgery. This is why long-term follow-up is so important. Your ENT specialist will schedule regular ear examinations and hearing tests to monitor for any signs of regrowth. In some cases, a planned second operation is part of the initial treatment strategy to check for recurrence and complete reconstruction.

Can Cholesteatoma Heal Without Surgery?

No, a cholesteatoma cannot heal or resolve on its own. Surgery is the only effective treatment. Some people who are not fit for surgery may receive regular ear cleaning to manage the condition, but this does not remove the cholesteatoma and is not a cure. Delaying surgery allows the growth to expand and cause more damage.

Does Cholesteatoma Cause Hearing Loss?

Yes, hearing loss is one of the most common consequences of cholesteatoma. As the growth erodes the ossicles, the tiny bones responsible for transmitting sound, it leads to progressive conductive hearing loss. If the inner ear is affected, sensorineural hearing loss can also develop. In some cases, hearing can be partially restored through reconstructive surgery, but early treatment offers the best outcomes.

How Common Is Cholesteatoma?

Cholesteatoma is not a common condition, but it is not extremely rare either. It is seen more frequently in people with a history of chronic ear infections or recurrent middle ear problems. Congenital cholesteatoma is less common than the acquired form. Because symptoms can be subtle at first, some cases are diagnosed later than ideal.

How Long Is Recovery After Surgery?

Recovery after cholesteatoma surgery depends on the type and extent of the procedure. Most people can return to light daily activities within one to two weeks. Complete healing of the ear may take several weeks to a few months. Your surgeon will advise you on when it is safe to get the ear wet, return to work, and resume physical activity. Regular follow-up appointments are essential during the recovery period.

References

• Kuo CL, Shiao AS, Yung M, et al. Updates and knowledge gaps in cholesteatoma research. Biomed Res Int. 2015;2015:854024.
• Persaud R, Hajioff D, Trinidade A, et al. Evidence-based review of aetiopathogenesis of otitis media with effusion. Clin Otolaryngol. 2004;29(4):318-325.
• Yung MW. The use of middle ear endoscopy: has it come of age? J Laryngol Otol. 2004;118(2):87-92.
• Jackler RK, Luxford WM, House WF. Congenital cholesteatoma of the middle ear and mastoid: a panel discussion on the role of CT scanning. Otolaryngol Head Neck Surg. 1987;96(1):12-17.
• Mehta RP, Harris JP. Mastoid surgery. Curr Opin Otolaryngol Head Neck Surg. 2001;9(5):313-317.
• Dornhoffer JL, Milewski C. Management of the open mastoid cavity. Otolaryngol Clin North Am. 1994;27(1):47-56.
• Quaranta A, Campobasso G, Piazza F, Quaranta N, Salonna I. Cholesteatoma of the middle ear: evaluation of the factors influencing surgical outcome in open and closed tympanoplasty. Acta Otolaryngol. 2001;121(2):243-248.