Case Presentation
A 12-year-old Korean boy presented to the ENT clinic with a complaint of a whitish mass on the right tympanic membrane one month before his visit. The boy had no prior history of ear disease, surgery, or hearing loss. However, he complained of a traumatic perforation in the right tympanic membrane that had occurred one year earlier. Doctors treated the perforation successfully with a paper patch placed within the ear.
Examination and Investigations
During the physical examination, doctors found a round, white-coloured mass on the right tympanic membrane. They performed a computed tomography (CT) scan of the temporal bone, which showed a small soft tissue density measuring 0.3 x 0.3 cm, located in the right tympanic membrane and touching the malleus bone. They made a diagnosis of an intratympanic membrane cholesteatoma and planned surgical removal of the cystic lesion.
Management
During surgery, the doctors extracted the mass with the aid of a microscope while the patient was under local anaesthesia. They found the mass on the external layer of the right tympanic membrane. It had not spread to the inner mucosal or middle fibrous layers. Furthermore, they confirmed the diagnosis of cholesteatoma through histopathological examination. The membrane healed without complications. On follow-up, after six months there was no sign of recurrence.
Cholesteatoma: Introduction
Cholesteatoma is an abnormal growth or cyst that can develop in the middle ear behind the eardrum. It is usually a non-cancerous, but potentially dangerous, condition that can cause hearing loss and damage to the bones of the middle ear.
Cholesteatoma is typically caused by a buildup of dead skin cells and debris that accumulate in the middle ear, often as a result of repeated infection or inflammation. Over time, this buildup can form a sac-like growth that can expand and invade nearby structures, such as the bones of the middle ear, the mastoid bone, or even the brain.
Cholesteatoma: Symptoms and Investigations
Cholesteatoma can cause a variety of symptoms, including ear pain, drainage from the ear, hearing loss, dizziness or vertigo, and a feeling of fullness or pressure in the ear. In some cases, a cholesteatoma may be asymptomatic. Moreover, the only indication of its presence may be a persistent ear infection that does not respond to treatment. Over time, the cholesteatoma can erode the bones of the middle ear, leading to more severe symptoms such as facial muscle weakness, paralysis, or even brain abscesses. If left untreated, the cholesteatoma can result in permanent hearing loss and other serious complications, making early detection and treatment crucial.
The diagnosis of cholesteatoma usually requires a thorough ear examination by an otolaryngologist. Doctors may perform audiometry to evaluate hearing loss, which is a common symptom of cholesteatoma. They may also order imaging studies such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) to assess the extent of bone destruction and the location of the cholesteatoma.
Cholesteatoma: Management
In cases where the cholesteatoma is suspected of having invaded the mastoid bone, doctors will perform a high-resolution CT scan of the temporal bone to evaluate the extent of bony erosion. In addition, they will perform a biopsy or culture of the drainage from the ear to identify any infection or inflammation.
The treatment depends on the size and extent of the growth. Surgery is typically required to remove the mass and prevent further damage to the ear. There are several surgical approaches to removing cholesteatoma, including the transcanal approach, the endoscopic approach, and the retro auricular approach. The transcanal approach involves making an incision in the ear canal and removing the cholesteatoma through this incision. The endoscopic approach uses a camera and specialized instruments to remove the cholesteatoma through a small incision. The retro auricular approach involves making an incision behind the ear and removing the cholesteatoma through this incision.
After surgery, a patient may need to use antibiotic ear drops or take oral antibiotics to prevent infections. In some cases, a second surgery may be necessary if the cholesteatoma recurs or if complications such as hearing loss or facial nerve paralysis occur.
In addition to surgery, doctors recommend hearing aids or other assistive devices to manage hearing loss caused by cholesteatoma. Regular follow-up appointments with an otolaryngologist are important to monitor for recurrence or complications.
It is important to note that early detection and treatment of cholesteatoma can help prevent serious complications and improve outcomes.
Discussion
Tympanic membrane cholesteatoma is a rare condition first reported by Hinton in 1863. It appears as a white, round mass on the tympanic membrane and is typically asymptomatic, often found incidentally in children. The cause is not fully understood. It may be due to iatrogenic or traumatic tympanic membrane perforation, metaplasia within the tympanic membrane induced by recurrent otitis media and local inflammation or local inflammation congenital.
Cholesteatoma should be differentiated from other conditions, such as tympanosclerosis, which is characterized by calcified plaques in the tympanic membrane and appears as thin plates. A histopathologic examination is necessary to confirm the diagnosis after surgical excision. Although surgical removal may be delayed until 1 or 2 years of age, it may be necessary as soon as possible to prevent the disease from enlarging and expanding into the middle ear, which can result in middle ear cholesteatoma.
