Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon

Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

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Cholesteatoma and mastoid surgery

There are 3 layers to the eardrum. The inner is a mucosal layer, the middle a fibrous layer which gives the drum its strength and the outer a squamous or skin layer. Cells are shed from the surface of the skin and these move radially across the edge of the drum to the outside and then laterally along the skin of the ear canal, becoming part of wax. It is possible for a pocket of skin to grow inwards from the drum and, if this is in the form of a “cave with a narrow neck”, this can erode inwards. If left untreated in the long-term this can gradually become larger and also be associated with some bone erosion, due to enzymes secreted by the mass of cholesteatoma. The erosion is a very slow process but, in the longer term, complications can include meningitis, brain abscess, facial palsy, dead ear, dizziness and pressure effects on the brain. The risk of these is small but, overall, the safer option in the longer term is generally to consider surgery to exteriorise and remove the disease. This operation is termed a mastoid exploration.

The precise nature of the mastoid exploration can vary from case to case, depending on the amount of bone which needs to be removed. This area of disease can erode posteriorly into the honeycomb of bone just behind the ear, in the mastoid bone, and can also erode the ossicles or bones of the middle ear. The aim of surgery is to remove the disease and prevent long-term complications; this certainly means that hearing is likely to at the very least be worse after the operation. Occasionally it is possible for the hearing to be reconstructed, sometimes at a later stage, but the principle aim is to remove disease. Neither can a dry ear be guaranteed; sometimes the ear can discharge after the operation still although local treatment measures can help with this.

The skin approach used in the operation can vary; this may be done by an incision just in front of the ear, an endaural approach, or an incision behind the ear, a postaural approach, and the decision on the particular approach will depend on individual cases and the preference of the surgeon.

At the end of the operation there will be sutures and a head bandage is likely to need to be worn for 24 hours post-operatively. Occasionally there is a drain and there will be a dressing left in the ear which may need to be left there for up to 3 weeks. Typically, this operation requires a post-operative stay of 1 – 2 days.

There are certain complications and the most significant of these tends to be the consideration of the facial nerve. There is a risk of around 1 – 3 % of facial palsy, i.e. weakness of the movement of the face, due to damage of the nerve during the operation. Sometimes the disease itself can envelop the nerve and, indeed, the facial palsy can be a complication of an untreated case.

It is possible to get a little unsteadiness and tinnitus (a ringing noise in the ear) after the procedure, which usually settles soon.

There are smaller risks of losing the hearing completely, particularly if the disease has eroded the bone covering the vestibular structures so that during the removal of the disease inner ear components are exposed.

The chorda tympani is a nerve which supplies taste just at the lateral border of the tongue but in many cases this has already been damaged by disease anyway. If not, then it is possible that post-operatively a slight metallic taste may be noted along the side of the tongue; this usually settles but may be permanent.

Typically 1 – 2 weeks absence from work or school would be recommended following the procedure; it will be around 3 weeks before the dressing is removed and sometimes a further dressing may be put in to try to gain a better result with regard to the cavity.

In a small proportion of cases, further surgery can be required. Sometimes this is if there is any recurrence of disease but can also be required for minor adjustments to the cavity to promote aeration and to keep the cavity dry.


© Vincent Cumberworth 2005