Surgery for Cholesteatoma
Surgery is the definitive treatment for cholesteatoma. The aim of any cholesteatoma operation is straightforward to state, even if the operation itself can be involved: remove all of the disease, deal with any infected tissue, and leave a safe, dry ear that does not need ongoing medical attention. Hearing improvement is a secondary aim. The priority is always to clear the disease and leave the ear safe, because cholesteatoma left behind will simply continue to grow and cause problems.
This page covers the operation itself: what's involved, the different approaches I might use, the recovery, the risks, and the long-term follow-up that is so important after this kind of surgery. If you haven't already read it, my cholesteatoma page covers what the condition is, how it's diagnosed, and why it needs treating in the first place.
I should say up front that cholesteatoma surgery is not a one-size-fits-all operation. Every ear is different, and the right operation depends on where the disease is sitting, how far it has spread, and what state the ear is in by the time we operate. I'll go through the planned approach with you in clinic before the operation, but I'll also explain why some decisions can only really be finalised once I'm in the ear and can see exactly what's there.
What does the operation aim to do?
The aims of cholesteatoma surgery, in order of priority, are:
To remove all of the disease, so it cannot continue to grow or cause complications
To leave you with a safe, healthy, dry ear that does not need repeated antibiotics
Where possible, to repair the eardrum so it is intact and waterproof
Where possible and appropriate, to preserve or improve hearing
Hearing is a secondary consideration. The hearing structures (the small bones of the middle ear) may already have been eroded by the cholesteatoma by the time we operate, and what we can do for the hearing depends on what we find. I cover the question of hearing reconstruction (ossiculoplasty) further down this page.
How is the operation done?
The operation is performed under general anaesthetic, meaning you'll be fully asleep. Most patients go home the same day as a day case, although a small number need to stay in hospital overnight for various reasons. Examples include the operation being more involved than expected, slower than usual recovery from the anaesthetic, or practical reasons such as living a long way from the hospital.
I usually use a combination of the operating microscope and a high-definition endoscope during cholesteatoma surgery. The microscope gives excellent magnification and depth perception in straight-line views, and the endoscope is particularly useful for looking around corners, into recesses of the middle ear that are difficult to see down a microscope and where small remnants of cholesteatoma can otherwise be missed. Using both tools, where each is best suited, gives the most thorough clearance of the disease.
There are several different operations used to deal with cholesteatoma, and the right one for you depends on where the disease is and how far it has reached.
Atticotomy
This is the most limited of the operations and is suitable for small, well-defined cholesteatomas confined to the upper part of the middle ear (the attic). The operation involves removing a small piece of bone from the upper edge of the ear canal to expose the disease and clear it. It is typically done through the ear canal without a cut behind the ear, often with the endoscope playing a major role.
Atticotomy is the right choice when:
The cholesteatoma is small and localised
It hasn't spread back into the mastoid bone behind the ear
The full extent of the disease can be reached and cleared through this approach
It is the most minimally invasive option, but only a minority of cholesteatomas are suitable for it. Trying to do a limited operation on disease that has already spread further would risk leaving cholesteatoma behind, and that's not a compromise worth making.
Combined approach tympanoplasty (canal wall up mastoidectomy)
This is the operation I do most often for cholesteatomas that have extended beyond the attic into the mastoid bone behind the ear. It involves a small cut behind the ear, opening up the mastoid bone to clear any disease there, then accessing the middle ear from both behind (through the mastoid) and in front (through the ear canal) to make sure the entire cholesteatoma is removed. The bony wall of the ear canal is preserved, which is why it's also called a canal wall up procedure.
The advantage of this operation is that the ear canal is left looking essentially normal afterwards. There is no large open cavity that needs ongoing cleaning, and patients can usually swim, wear hearing aids, and otherwise carry on with normal life once everything has healed.
The trade-off is that recurrence rates are higher with this approach than with a more extensive operation, because some recesses of the middle ear can be difficult to fully visualise when the canal wall is preserved. This is one of the reasons I use the endoscope alongside the microscope, since being able to look around corners reduces the chance of leaving any small remnant behind. It's also why follow-up after this operation needs to be thorough and long-term (more on this below).
Modified radical mastoidectomy (canal wall down mastoidectomy)
For more extensive cholesteatomas, particularly those that have eroded the canal wall itself, or that wrap around the inner ear or facial nerve, the bony back wall of the ear canal sometimes has to be taken down to give proper access and to make sure all the disease can be cleared. This operation creates a single open cavity that combines the mastoid and the ear canal.
The advantage of this approach is the very low rate of recurrence, because everything is open to view and any future disease would be visible during a normal clinic check. The trade-off is that the cavity needs occasional cleaning in clinic to remove skin debris and wax, and patients are usually advised to keep water out of the ear long-term. Hearing aids can sometimes be more difficult to fit comfortably in a mastoid cavity, although modern hearing aid technology has made this much less of an issue than it used to be.
This is the right operation when getting all the disease out is the priority and a more limited approach simply wouldn't achieve that. And in cholesteatoma, getting all the disease out is the priority.
Mastoid obliteration
After a modified radical mastoidectomy, the open cavity that has been created can sometimes be partly filled in at the end of the operation. This is called mastoid obliteration. The materials used vary, sometimes the patient's own bone, sometimes muscle taken from nearby, and sometimes biocompatible material designed for the purpose. The aim is to reduce the size of the open cavity, which can make the ear easier to look after long-term, reduce the amount of routine cleaning needed, and lower the risk of recurrence. Whether this is appropriate in your case is something I'll discuss with you, and again it's a decision that is sometimes finalised during the operation itself once the extent of the disease and the size of the resulting cavity is fully clear.
What is laser used for?
Laser is sometimes used as part of cholesteatoma surgery to reduce the risk of recurrence. The point of using it is to treat any microscopic disease that might otherwise be left behind. Even very tiny amounts of cholesteatoma, too small to see properly, can grow back over months or years and cause the disease to recur, so anything that helps eliminate that microscopic residue is worth doing.
I use the laser in two main situations. The first is in delicate areas, where the lining (matrix) of the cholesteatoma sits over structures like the small hearing bones, the inner ear, or the facial nerve. In these areas, mechanical dissection carries a higher risk of damage, and laser treatment of the matrix can be safer than trying to peel it off. The second is in the mastoid cavity itself, where the laser can be used to treat the bone surface and any tiny remnants on it. The principle is the same in both cases: deal with what the eye can't reliably see, and reduce the risk of disease coming back.
Will I have a graft?
Practically all cholesteatoma operations involve some form of graft to repair the eardrum. The reason is that there is almost always a defect or retraction related to the cholesteatoma. There may be an existing hole in the eardrum that the cholesteatoma has been growing through, or a portion of the eardrum that has been pulled inwards into the retraction pocket where the cholesteatoma originally formed, or an area that has had to be opened during the operation to access and clear the disease. Whatever the cause, leaving the eardrum intact and properly sealed at the end of the operation is part of giving you a safe, dry ear.
As with myringoplasty, my preferred graft material is cartilage and perichondrium taken from the tragus (the small flap of cartilage at the front of the ear). It is sturdy, durable, and well-suited to ears that have had ongoing inflammation or repeated infections. Sometimes a combination of materials is used. The exact choice is partly made before the operation and partly during it, depending on what the eardrum looks like.
Taking the graft leaves a small cut on the inner side of the tragus, closed with dissolvable stitches that don't need to be removed.
What about my hearing?
This is one of the most important conversations to have before cholesteatoma surgery, and one I always cover in detail in clinic.
By the time many cholesteatomas come to surgery, the small hearing bones have been partly or wholly eroded by the disease. If that's the case, hearing on the affected side will already be reduced, and the operation itself does not automatically restore it. Repair of the hearing bones, a procedure called ossiculoplasty, is one option, but it isn't always the right one.
The decision is made on a case-by-case basis and follows a clear logic. If, at the time of the cholesteatoma operation, I'm confident that the disease has been fully cleared, that the risk of recurrence is low, and that reconstruction is technically possible with a reasonable chance of success, I will go ahead and reconstruct the hearing in the same operation. If I'm not confident on those points, for example if the disease has been extensive, or if reconstructing the hearing in that ear is unlikely to give a good result, then it's better not to. In those cases the options are either to leave hearing reconstruction as a planned second-stage operation a few months later, once we know the cholesteatoma has been cleared, or to consider a hearing aid as a better long-term solution. Where the realistic chances of an ossiculoplasty being successful are low, a well-fitted hearing aid will often give better hearing than another operation would.
Even where a second-stage ossiculoplasty is being considered, it's usually worth trialling a hearing aid first. There are two reasons. The first is practical. Many patients find that a hearing aid gives them very good hearing on that side without needing any further surgery, and once they've experienced that they may not feel another operation is necessary. The second is that it gives a sense of what hearing might feel like with that ear restored, which helps inform the decision about whether to go through with surgery.
The priority of cholesteatoma surgery is always to clear the disease and leave a safe ear; what happens with the hearing is then a separate decision, taken with all the information about your particular ear in front of us.
What are the risks of cholesteatoma surgery?
Cholesteatoma surgery is generally safe, but it's a more involved operation than a simple myringoplasty and the risks are slightly higher because of where the disease tends to sit. I always discuss these in detail in clinic so you can weigh things up properly before deciding to go ahead.
The disease coming back. This is the most important risk to understand and is covered in its own section below.
A change in hearing. Most patients have hearing that is similar to before or slightly improved once everything has healed. Uncommonly the hearing on the operated side ends up slightly worse, and a significant or permanent hearing loss is rare but more likely than after a simple myringoplasty, particularly if the hearing bones have been heavily affected by the disease.
Tinnitus. New or louder ringing or buzzing in the ear is fairly common in the early weeks and usually settles.
Dizziness or unsteadiness. Common in the first few hours to days, particularly if the disease has been close to the balance organ. Usually settles. Persistent dizziness is uncommon.
Altered or metallic taste on one side of the tongue. This is caused by handling of the chorda tympani, the small taste nerve that runs through the middle ear, and is often temporary. In patients who have had years of ear disease the chorda tympani may already not be working well, in which case no change in taste is noticed.
Facial weakness. The facial nerve runs through the middle ear and is sometimes very close to where the cholesteatoma sits. There is a small risk of injury. If facial weakness does occur it is usually temporary and recovers over weeks to months. Very rarely it can be permanent. To minimise this risk, a facial nerve monitor is used throughout every cholesteatoma operation, which alerts me immediately if the nerve is being approached. With this in place, long-term facial nerve damage is extremely rare.
Damage to the inner ear with severe hearing loss or persistent dizziness. Rare, but more likely in extensive disease that has already reached the inner ear.
Infection of the operated ear in the early weeks. Uncommon if the post-operative instructions are followed.
A small scar on the inner side of the tragus, and a scar behind the ear that fades into the natural skin crease and is almost always hidden once settled.
General anaesthetic risks. Generally low in fit, healthy adults, and discussed separately by the anaesthetist.
Will the cholesteatoma come back?
Cholesteatoma can come back even after a technically successful operation, and this is one of the most important things to understand before going ahead with surgery. There are two ways it can happen:
Residual disease. A small, sometimes microscopic remnant of cholesteatoma is left behind during the original operation and grows back over the following months or years. This is the more common pattern after canal wall up surgery, where some recesses of the middle ear can be hard to fully visualise.
Recurrent disease. The underlying problem (poor ventilation of the middle ear from a struggling Eustachian tube) continues, and a fresh retraction pocket forms in the years after surgery, eventually producing a new cholesteatoma.
Recurrence rates depend heavily on how extensive the original disease was, which operation was done, and how long follow-up continues for. Across the literature, recurrence rates can range from low single figures with the more extensive operations and adjuncts like mastoid obliteration, up to substantially higher figures, particularly in extensive disease followed up over many years. The longer follow-up continues, the more recurrence shows up, which is part of why long-term surveillance is so important. I'll be honest with you about your individual risk based on what I find at the time of surgery.
If recurrence is identified, it can usually be dealt with, sometimes with a clean-out in clinic, and sometimes with another operation. Catching it early is the whole point of long-term follow-up.
What happens after the operation?
The post-operative care is broadly similar to that of a myringoplasty, and there's more detail on the Surgery to Repair a Hole in the Eardrum page which is worth reading alongside this one. Reassuringly, cholesteatoma surgery is usually not a particularly painful operation. Most patients are comfortable on simple painkillers like paracetamol and ibuprofen and don't need anything stronger. Some discomfort around the ear, in the cut behind the ear if there is one, or a feeling of pressure in the ear is normal in the first few days, but severe pain is unusual and would need to be reported.
Most patients go home the same day as a day case, although a small number need to stay in hospital overnight.
The ear is packed with a dissolvable material (Spongostan) that gradually dissolves over a few weeks. This makes the ear feel completely blocked and the hearing on that side muffled, which is entirely expected and not a sign that something has gone wrong.
Some of the packing may work its way out of the ear canal on its own over the first few weeks, sometimes mixed with a little blood-stained fluid. This looks alarming but is normal, and there is plenty more packing inside doing its job.
Lay a towel over your pillow on the operated side for the first week or two. There's often a little discharge from the ear in the early days, particularly overnight.
Keep the ear canal dry. When showering, place a fresh ball of cotton wool smeared with Vaseline in the outer ear, and throw it away afterwards.
Wash your hands thoroughly before changing the cotton wool or using any prescribed ear drops.
Don't poke or clean inside the ear. The packing must be left undisturbed.
Avoid blowing your nose hard. Sneeze with your mouth open.
Avoid heavy lifting, strenuous exercise, and contact sports for two to three weeks.
The cut behind the ear should be kept dry for the first seven days. It is closed with dissolvable stitches under the skin, with paper strips on the outside that come off after about a week.
Hair washing in the first three weeks needs a little planning. Leaning back over a sink, dry shampoo, or showering with a Vaseline cotton wool plug all work. The wound behind the ear must stay dry until the paper strips come off.
Most patients take around two weeks off work; longer if the job is physically demanding.
Avoid flying for around six weeks after the operation.
Driving should be avoided for at least 48 hours after a general anaesthetic.
What follow-up will I need?
This is where cholesteatoma surgery differs from other ear operations: follow-up is long. I follow patients up for a minimum of five years after cholesteatoma surgery, and often longer, because cholesteatoma can come back at any point in that window, and sometimes beyond it.
Follow-up usually involves:
A first appointment at around three weeks, to remove any remaining packing and check the early healing.
An appointment at around three months with a hearing test, to confirm the eardrum has healed and assess the hearing.
Regular clinic appointments thereafter, with examination of the ear under the microscope and hearing tests at intervals.
Surveillance MRI scans at planned intervals (typically the first one at around 12 months after the operation, with further scans over the following years). The specific MRI sequence used (diffusion-weighted imaging) is excellent at picking up small areas of recurrent cholesteatoma, often before they cause any symptoms, which means they can be dealt with early.
A planned second-look operation in some cases, particularly if there was a high suspicion of disease being left behind or if a second-stage hearing reconstruction was planned at the time of the first operation.
Long-term follow-up isn't always convenient, but it's a fundamental part of the care plan after cholesteatoma surgery. It's how we make sure that a successful operation stays successful.
When should you come and see me?
Come and see me if:
You are concerned that you might have a cholesteatoma
You've been told you have cholesteatoma and are weighing up whether to have surgery
You've had cholesteatoma surgery elsewhere and want experienced long-term follow-up
You're concerned about a recurrence after previous cholesteatoma surgery
You simply want to understand the operation in more detail before making a decision
I'll examine your ear under the microscope, arrange any scans that are needed, and talk you through the realistic options for your particular case in plain language.
Helpful resources
Disclaimer
This page is intended as general information only. It does not replace a consultation, examination, or individual medical advice. If you are considering cholesteatoma surgery, please get in touch to book an appointment so I can examine your ear properly, review your scans, and give you advice specific to your situation.