Complications
Cholesteatoma has a tendency to recur despite treatment, and may occur long after the initial surgical excision.
The risk of recurrence after surgery in children has been shown to be higher if the disease involves the posterior mesotympanum, or if the ossicular chain is interrupted after excision, or both. A relative lack of experience of the surgeon (and presumed incomplete excision of the disease) may also contribute to disease recurrence.[51]
Recurrent disease may be detected on follow-up otoscopy or present as a persistent aural discharge.
Treatment is by further surgery.
Patients with cholesteatoma commonly present with a conductive hearing loss. There may be a mixed conductive and sensorineural hearing loss in patients with cochlear damage or in those with a preexisting hearing loss (e.g., congenital or presbycusis).
One of the most common complications of cholesteatoma (occurs in 7% of patients).[52] The horizontal semicircular canal is most often involved (90%).
Symptoms include vertigo, and patients may have a positive fistula test. Diagnosis can be made preoperatively with a CT scan of the petrous temporal bone.[53]
Treatment is closure of the fistula at the time of mastoidectomy, but surgical manipulation may result in sensorineural hearing loss.
Cholesteatoma may cause facial paralysis via involvement of a dehiscent facial nerve or via bone erosion of the facial canal. Facial paralysis is often slowly progressive and has a worse prognosis.[54]
Diagnosis is clinical. A CT scan of the petrous temporal bone can be useful in surgical planning as well as demonstrating other potential complications such as a labyrinthine fistula. Treatment involves mastoidectomy for removal of the cholesteatoma in contact with the facial nerve.[32][33]
Meningitis occurs in approximately 0.1% of patients.[55][56]
Common symptoms are fever, persistent headache, nausea and vomiting, lethargy, and irritability. Clinical signs include nuchal rigidity, new-onset seizures, ataxia, and decreased mental status.
If confirmed on cranial CT or MRI brain and lumbar puncture, treatment includes intravenous antibiotics and corticosteroids.
This often occurs in the temporal lobe of the brain or cerebellum.
Proteus species is the most common causative organism, but many abscesses are sterile on culture.
Clinical signs include the initial encephalitic change with nausea and vomiting, fever, headache, seizures, and change in mental state, followed by a quiescent phase of lethargy, and a final stage of worsening of the acute symptoms.[54][55]
Treatment includes intravenous antibiotics and corticosteroids with drainage of the abscess and mastoidectomy.
Involvement of the internal jugular vein may cause septic pulmonary emboli.
Classic presenting symptoms are spiking temperatures (picket fence pattern) with headache and lethargy. Diagnosis is made with a cranial contrast CT or MRI.
Treatment includes intravenous antibiotics and mastoidectomy.[57]
This is an acute infection of the temporal bone that occurs more commonly in acute otitis media but may occur in chronic otitis media with cholesteatoma.
Patients present with postauricular erythema, swelling, tenderness, fever, and an inferiorly and laterally displaced pinna.
Treatment is intravenous antibiotics and mastoidectomy to remove revitalized bone and cholesteatoma.
Inflammation may spread to the petrous apex of temporal bone, resulting in localized osteomyelitis and reactive meningitis.
Classic symptoms include deep retro-orbital pain, ear discharge, and sixth nerve palsy (Gradenigo syndrome). Diagnosis is made via a CT scan of the petrous temporal bone.
Treatment includes intravenous antibiotics, corticosteroids, and a tympanomastoidectomy to remove the cholesteatoma and granulations.[54]
Clinical signs may be subtle and include increased otalgia or headache. Diagnosis is made via a CT scan with contrast or an MRI scan.
Treatment is surgical and the abscess may be drained via the mastoidectomy if found intra-operatively.[58]
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