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ENT

Cholesteatoma

Cholesteatoma is a self-renewing collection of keratinising squamous epithelium in the middle-ear cleft or mastoid that can erode bone, damage hearing and spread infection; it is not a tumour and needs specialist ENT assessment.

In a nutshell

Cholesteatoma is trapped keratinising skin in the middle ear or mastoid, usually from an attic/posterosuperior retraction pocket. It presents with persistent foul-smelling otorrhoea and progressive conductive hearing loss. Look carefully at the tympanic membrane, refer to ENT for microsuction, audiometry and imaging as indicated, treat active infection locally and remember that definitive treatment is usually surgery because drops do not remove the sac.

Classic presentation

A patient with unilateral chronic smelly ear discharge and progressive conductive hearing loss whose otoscopy shows an attic retraction pocket or keratin debris.

Key points

  • It is trapped keratinising epithelium, not cholesterol and not a tumour.
  • The classic site is the attic/pars flaccida or posterosuperior tympanic membrane.
  • Persistent foul-smelling discharge and an abnormal drum need ENT assessment; repeated drops alone are not definitive.
  • Ossicular erosion causes conductive hearing loss; labyrinthine or facial-canal disease causes vertigo or facial weakness.
  • CT maps pre-operative bony disease; postoperative non-EPI DWI MRI may detect residual or recurrent disease.
  • Facial palsy, vestibular failure or intracranial infection symptoms are emergencies.

First-line investigation

Otoscopy with ENT microscopy/microsuction and audiometry; CT temporal bones or postoperative non-EPI DWI MRI is selected by ENT context.

Management

Recognise the unsafe ear

  • Persistent/recurrent otorrhoea, an abnormal drum or an attic keratin pocket warrants ENT referral; facial palsy, vestibular failure or intracranial features need emergency escalation.5,3

Examine and measure hearing

  • Arrange complete otoscopy with ENT microscopy/microsuction and pure-tone audiometry; do not let discharge or wax prevent assessment of the drum.1,5,3

Map and remove disease

  • Use CT to map bony disease and plan surgery; definitive treatment is usually mastoid/middle-ear surgery to remove the keratinising sac and make the ear safe.1,2

Control discharge safely

  • Keep the ear dry and use ENT-directed microsuction and topical treatment for active infection; drops do not cure cholesteatoma and otic product choice depends on the drum.1,3,4

Act on complications

  • Escalate immediately for facial weakness, vestibular failure, mastoiditis or severe headache, fever, neck stiffness, altered consciousness or focal neurological signs.3,1,2

Surveil for recurrence

  • Plan long-term ENT and hearing follow-up; non-EPI DWI MRI or second-look surgery may be used to detect residual/recurrent disease according to the operation and specialist protocol.1,6

Exam traps

  • A painless ear does not make chronic foul-smelling discharge safe.
  • Do not mistake a keratin-filled attic retraction pocket for simple otitis externa or wax.
  • Topical antibiotics may settle infection but cannot eradicate cholesteatoma.
  • Vertigo or facial weakness indicates possible bony complication and needs emergency ENT escalation.
  • A dry postoperative ear does not eliminate the need for long-term recurrence surveillance.

Illustrations

Otoscopic view of cholesteatomaAn otoscopic photograph showing an attic retraction pocket filled with white keratin debris in the posterosuperior tympanic membrane, the characteristic appearance of cholesteatoma.welleschik, Wikimedia Commons · CC-BY-2.5
External auditory canal cholesteatoma on CTAxial and coronal temporal-bone CT images showing a cholesteatoma as a well-defined external auditory canal mass with erosion of the posterior bony canal wall, marked by arrows.Yamahara K et al., Cureus 2025, CC-BY-4.0 · CC-BY-4.0

Key sources

  1. NHS: Cholesteatoma (NHS patient and clinical overview, symptoms, complications, CT referral, surgery and long-term follow-up; page last reviewed 20 February 2025.)Updated 20 Feb 2025
  2. Royal United Hospitals Bath: Surgery for Cholesteatoma (NHS ENT information on trapped skin, bony destruction, surgical rationale and complications; accessed 4 August 2026.)
  3. NHS Greater Glasgow and Clyde Right Decisions: Otorrhoea without pain and cholesteatoma referral guidance (ENT-authored NHS referral guidance on chronic squamous ear disease, conservative aural care, cholesteatoma referral and emergency facial/vestibular complications; last reviewed 7 May 2025.)Updated 7 May 2025
  4. British National Formulary (BNF) (Current UK prescribing information for otic anti-infectives and corticosteroid preparations; check tympanic-membrane status, product licence, ototoxicity, dose and duration at prescribing; accessed 4 August 2026.)
  5. NICE NG98: Hearing loss in adults: assessment and management (Current NICE referral and audiology recommendations for persistent otorrhoea, abnormal tympanic membrane, hearing loss and urgent associated signs; last updated 2 October 2023.)Updated 2 Oct 2023
  6. Pai et al.: Growth and Late Detection of Post-Operative Cholesteatoma on Long Term Follow-Up With DWI MRI (UK tertiary-centre postoperative study supporting long-term diffusion-weighted MRI surveillance for residual or recurrent disease; published 2019.)Updated 1 May 2019

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.