Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – surgery

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ACUTE
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1st line – 

surgery

The definitive treatment of cholesteatoma is surgery. There are two main surgical procedures in use: canal wall up mastoidectomy and canal wall down mastoidectomy (combined approach tympanoplasty).

A canal wall up mastoidectomy allows removal of cholesteatoma but leaves the canal wall intact. It involves removal of the mastoid air cells lateral to the facial nerve and otic capsule, leaving the posterior and superior parts of the external canal wall intact.[42] This necessitates a second-look procedure after 9 to 12 months to ensure that the cholesteatoma has not recurred. Alternatively, a non-echo-planar diffusion-weighted MRI may be used in some patients to check for recurrence.[28][29][30]​ Patients will require continued follow-up.[45][46][47]​ This technique is often preferred for children, as it avoids long-term complications of a mastoid cavity.

A canal wall down mastoidectomy aims to remove the disease by drilling from the attic wall posteriorly. The size of the resultant cavity will depend on the extent of the cholesteatoma. A less invasive procedure resulting in a minimal cavity is called an atticotomy or atticoantrostomy; a more invasive procedure resulting in a larger cavity is called a modified radical mastoidectomy. A canal wall down procedure may allow examination of the cavity for recurrence but if the attic has been reconstructed, a second-look procedure may be necessary to examine the middle ear for recurrent disease.

Microscopic and endoscopic techniques are both in use. One systematic review showed that rates of residual and recurrent disease were lower with endoscopic ear surgery for middle ear cholesteatoma.[40]​ There was insufficient evidence, however, that operative time, uptake of the graft, or hearing results were improved with endoscopic versus microscopic techniques. Utilisation of high definition visualisation, such as a 4K magnification endoscope and narrow band imaging filter, has been shown to improve visualisation of tissue based on varying degrees of vascularity; this allows for better differentiation between pathology and normal anatomy.[41]

Consider – preoperative topical antibiotics + aural care

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ACUTE
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all patients
Consider – 

preoperative topical antibiotics + aural care

Additional treatment recommended for SOME patients in selected patient group

On initial presentation, if aural discharge is evident, it may be appropriate to treat the aural discharge with topical antibiotics prior to definitive surgical treatment.

Agents containing quinolone are effective in both adults and in children, either alone or in combination with a topical corticosteroid.[1]

Aural cleaning may also reduce symptomatic discharge.

Prior to the use of topical ear drops, the ear canal may need to be cleaned of any debris or wax.

Patients who have severe swelling of the ear canal may have difficulty applying ear drops. A wick should be inserted in the ear canal to allow for drug delivery.

Debridement of granulation tissue may be necessary.

Primary options

ciprofloxacin/dexamethasone otic: (0.3%/0.1%) 4 drops into the affected ear(s) twice daily for 7-10 days

OR

ofloxacin otic: (0.3%) 10 drops into the affected ear(s) once daily for 7 days

Consider – second-look surgery or MRI

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Consider – 

second-look surgery or MRI

Additional treatment recommended for SOME patients in selected patient group

A second-look procedure is indicated after 9 to 12 months after a canal wall up mastoidectomy to ensure that the cholesteatoma has not recurred. A meta-analysis found an increased incidence of postoperative cholesteatoma when using an intact wall approach rather than canal wall down approach.[43]

Alternatively, a non-echo-planar diffusion-weighted MRI may be used in some patients to check for recurrence.[28][29][30]​ There continues to be debate regarding which type of MRI best examines for recurrent cholesteatoma. Some authors advocate routine MRI scans (such as non-echo-planar, fast-spin echo, or diffusion-weighted sequences) for follow-up, but caution that a negative scan may not be completely accurate as residual or recurrent disease may not yet be detectable. Non-echo-planar imaging was found to be more reliable compared with echo-planar imaging in identifying residual/recurrent cholesteatoma in one systematic review.[44] Another systematic review found that non-echo-planar diffusion-weighted MRI is highly sensitive and specific in identifying middle-ear cholesteatoma.[30]

Patients will require continued follow-up.[45][46][47]

A canal wall down procedure may allow examination of the cavity for recurrence but if the attic has been reconstructed, a second-look procedure may be necessary to examine the middle ear for recurrent disease.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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