Cholesteatoma Treatment in Sydney

A cholesteatoma is an abnormal growth of skin cells trapped within the middle ear or mastoid bone. Despite not being cancerous, it behaves aggressively, growing progressively and eroding surrounding bone structures. Without surgical treatment, a cholesteatoma can destroy the hearing bones, damage the facial nerve, erode into the inner ear and, in rare cases, lead to serious intracranial complications.

What Is a Cholesteatoma?

A cholesteatoma is a sac-like pocket of keratinised (dead) skin cells that accumulates in the middle ear cleft, typically in the attic (epitympanum) or posterior-superior portion of the middle ear. The trapped skin debris cannot shed naturally, so it builds up progressively, releasing enzymes and inflammatory proteins that erode the surrounding temporal bone.

Cholesteatomas are classified as either congenital (present from birth, found behind an intact eardrum) or acquired (developing later in life, usually associated with eardrum retraction or perforation). Acquired cholesteatomas are far more common and typically arise from chronic Eustachian tube dysfunction, recurrent ear infections or eardrum retraction pockets.

Symptoms of Cholesteatoma

Cholesteatomas often develop slowly, and symptoms may be present for months or years before diagnosis:

Persistent, foul-smelling ear discharge: often the earliest and most characteristic symptom
Progressive hearing loss in the affected ear, typically conductive in nature
A feeling of fullness or pressure deep within the ear
Dizziness or vertigo: suggesting erosion into the inner ear (labyrinth)
Facial weakness or drooping: indicating involvement of the facial nerve
Persistent ear pain: uncommon but may indicate infection or complications
Tinnitus (ringing in the ear)

Any combination of persistent ear discharge with progressive hearing loss should prompt specialist assessment to exclude cholesteatoma.

Causes and Risk Factors

The most common mechanism for acquired cholesteatoma formation involves:

Eardrum retraction: chronic negative middle ear pressure (from Eustachian tube dysfunction) draws a portion of the eardrum inward, creating a pocket where skin cells accumulate
Eardrum perforation: skin from the ear canal can migrate through a chronic perforation into the middle ear
Chronic ear infections: repeated infections damage the eardrum and promote retraction pocket formation
Eustachian tube dysfunction: poor ventilation of the middle ear creates the negative pressure that initiates retraction
Previous ear surgery: occasionally cholesteatoma can develop behind a repaired eardrum
Congenital: rare cases where skin cell rests are trapped behind the eardrum during fetal development

Diagnosis

At Central Sydney ENT, cholesteatoma is diagnosed through a combination of clinical assessment and imaging:

Microscopic ear examination: Using a binocular operating microscope, the ENT surgeon can visualise the eardrum in detail, identifying retraction pockets, perforations, crusting or the white pearly mass characteristic of cholesteatoma. Micro-suction may be needed to clear discharge and debris for a thorough view.

CT scan of the temporal bone: High-resolution CT scanning is the primary imaging modality, showing the extent of bone erosion and helping the surgeon plan the surgical approach. CT reveals the relationship of the cholesteatoma to critical structures including the facial nerve, inner ear and brain coverings (dura).

MRI with diffusion-weighted imaging (DWI): Increasingly used alongside CT to differentiate cholesteatoma from other tissue (such as scar or granulation), and essential for detecting residual or recurrent disease after surgery without the need for repeat surgery.

Audiometry: Hearing tests to document the type and degree of hearing loss, which helps guide surgical planning for possible hearing reconstruction.

Treatment Options

Surgery is the only definitive treatment for cholesteatoma. The condition will not resolve with antibiotics or ear drops alone, although these may be used to manage infection before surgery.

Mastoidectomy and Tympanoplasty

The standard surgical procedure involves mastoidectomy (opening the mastoid bone behind the ear) combined with tympanoplasty (eardrum repair). The goals of surgery are complete removal of the cholesteatoma, creation of a safe and dry ear, eardrum reconstruction, and hearing restoration where possible.

Two main surgical approaches are used:

Canal wall up (intact canal wall) mastoidectomy: preserves the posterior ear canal wall, maintaining more normal ear anatomy. Preferred when possible, but may require a planned second-look procedure to check for recurrence.
Canal wall down (modified radical) mastoidectomy: removes the posterior canal wall to create a mastoid cavity that can be inspected in the clinic. Used for extensive disease or revision cases. Requires periodic cavity cleaning.

Surgery is performed under general anaesthesia through an incision behind the ear. The procedure typically takes two to four hours and usually requires one night in hospital. Our otology-trained surgeons, including Dr Sam Hwang, Dr Philip Yeung and Dr Arjuna Ananda, perform cholesteatoma surgery using high-powered operating microscopes.

Ossicular Chain Reconstruction

When the cholesteatoma has eroded the hearing bones (ossicles), reconstruction may be performed during the same procedure or as a second-stage operation. This involves replacing damaged ossicles with prosthetic devices or reshaped bone to restore the sound-conducting mechanism.

When to See an ENT Specialist

You should seek a referral to an ENT specialist if:

You have persistent, foul-smelling ear discharge that does not clear with treatment
You notice progressive hearing loss in one ear
You have a known eardrum perforation or retraction pocket
You experience dizziness or vertigo alongside ear symptoms
You develop facial weakness or asymmetry associated with ear problems
You have a history of chronic ear infections or previous ear surgery

Related Conditions

Cholesteatoma is closely linked to several other conditions treated at Central Sydney ENT:

Ear Infections (Otitis Media): chronic infections are a major risk factor for cholesteatoma development
Hearing Loss: cholesteatoma is an important cause of progressive conductive hearing loss
Vertigo and Dizziness: inner ear erosion by cholesteatoma can cause vestibular symptoms

Common Questions

Cholesteatoma FAQ

Is a cholesteatoma cancerous? +

No. A cholesteatoma is not a cancer or tumour. It is an abnormal collection of skin cells (keratinised squamous epithelium) that becomes trapped in the middle ear or mastoid. However, it behaves aggressively by growing progressively and eroding surrounding bone, which is why surgical removal is necessary to prevent serious complications.

What happens if a cholesteatoma is left untreated? +

If left untreated, a cholesteatoma will continue to enlarge and erode the surrounding bone structures. This can lead to progressive hearing loss, chronic ear discharge, damage to the facial nerve causing facial paralysis, erosion into the inner ear causing vertigo and permanent hearing loss, and in rare cases, intracranial complications such as meningitis or brain abscess.

How is cholesteatoma surgery performed? +

Cholesteatoma surgery (mastoidectomy with tympanoplasty) is performed under general anaesthesia, typically through an incision behind the ear. The surgeon uses an operating microscope to carefully remove all cholesteatoma tissue from the middle ear and mastoid. The eardrum is repaired and, where possible, the hearing mechanism is reconstructed. Surgery usually takes two to four hours and may require an overnight hospital stay.

Can a cholesteatoma come back after surgery? +

Cholesteatoma can recur in approximately 10 to 30 percent of cases, depending on the extent of disease and the surgical technique used. This is why long-term follow-up with regular ear examinations and periodic imaging (CT or MRI) is essential after surgery. A second-look procedure may be recommended 9 to 12 months after the initial surgery to check for residual or recurrent disease.

Does Central Sydney ENT perform cholesteatoma surgery? +

Yes. Central Sydney ENT has seven FRACS-qualified ENT surgeons with expertise in otologic surgery including cholesteatoma removal. We offer comprehensive ear assessment, mastoidectomy, tympanoplasty and ossicular reconstruction across seven Sydney locations including Burwood, Campbelltown, Gregory Hills, Ultimo, Drummoyne, Hunters Hill and Miranda.