CSOM-Cholesteatoma
Choleasteatoma is an abnormal skin growth (squamous epithelium) in the middle ear behind the eardrum. Repeated infections and retracted ear drum can allow skin to grow into the middle ear. Cholesteatomas often develop as cysts or pouches that shed layers of old skin like onion skin, which build up inside the middle ear. Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear leading to hearing loss. Permanent hearing loss, dizziness, and facial muscle paralysis are rare, but can result from continued cholesteatoma growth.
A rare congenital form of cholesteatoma (one present at birth) can occur in the middle ear and elsewhere, such as in the nearby skull bones. However, the type of cholesteatoma associated with ear infections is most common.
The sequence of events begins with eustachian tube dysfunction which leads to negative pressure in the middle ear. The eardrum is sucked into the middle ear and slowly forms a pocket. The pocket enlarges and retracts deep into the ear. Skin debris gets caught; it becomes infected and slowly expands
Treatment
An examination by an ENT surgeon can confirm the presence of a cholesteatoma. Initial treatment may consist of a careful cleaning of the ear, antibiotics, and ear drops. Therapy aims to stop drainage in the ear by controlling the infection.
A large or complicated cholesteatoma usually requires surgical treatment to protect the patient from serious complications. Hearing and balance tests, and CT scans (3-DCT scan) of the mastoid may be necessary. These tests are performed to determine the hearing level in the ear and the extent of destruction the cholesteatoma has caused.
Mastoid Surgery
Surgery is performed under general anesthesia. The primary purpose of surgery is to remove the cholesteotoma to eliminate the infection and create a dry ear. A second stage surgery is sometimes necessary both to ensure that the cholesteatoma is gone as well as to attempt reconstruction of the damaged middle ear bones in an effort to improve hearing.
Reconstruction of the middle ear is not always possible in one operation; therefore, another operation may be performed six to 12 months later. This operation will attempt to restore hearing and, at the same time, allow the surgeon to inspect the middle ear space and mastoid for residual cholesteatoma.
After surgery, follow-up OPD visits are necessary to evaluate results and to check for recurrence. In cases requiring the creation of an open mastoidectomy cavity, OPD visits every few months are needed to clean out the mastoid cavity and prevent new infections. Some patients will need lifelong periodic ear examinations.
Two types of mastoidectomies are performed, canal wall down and canal wall up. The canal wall up operation preserves the ear canal and has less post operative care. However, there is upto a 40% chance of recurrence or persistence of the cholesteatoma.
The patient’s canal wall up mastoidectomy was converted to a canal wall down mastoidectomy.
In a canal wall down operation the entire mastoid is exteriorized into the ear canal and the posterior and superior portion of the ear canal is removed down to the region of the facial nerve. The facial nerve is left intact covered by a ridge of bone called the facial ridge. This leaves a large cavity called a mastoid bowl which has to be cleaned by the doctor every 3 to 12 months. In order to clean this cavity, the meatus or the external opening into the ear canal is surgically widened –Meatoplasty.
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