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Cholesteatoma
Cholesteatoma
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Cholesteatoma

  1. 1. CHOLESTEATOMA Moderator-Dr.Mohan Presenter-Dr.Razal
  2. 2. Definition • The term coined by Johannes Muller in 1838. • defined as a cystic structure filled with desquamated squamous debris lying on fibrous matrix.(skin in wrong place) Currently the Definition is,  A three dimensional epidermoid structure  Exhibiting independent growth  Replacing the middle ear mucosa and resorption of the underlying bone.
  3. 3. Histologically • Cystic Content o is composed of fully differentiated anucleate keratin squames. • Matrix o contains keratinizing squamous epithelium lining a cyst like structure. • Perimatrix o known as lamina propria o peripheral part of cholesteatoma consists of granulation tissue and cholesterol granules. o This layer is in contact with the bone. It is the granulation tissue which releases enzymes that cause bone destruction.
  4. 4. Cholesteatoma
  5. 5. Classification Can be classified as, • Congenital cholesteatoma • Acquired cholesteatoma. o Primary acquired cholesteatoma o Secondary acquired cholesteatoma
  6. 6. Primary acquired • Etiology unknown • there is no history of preexisting or previous episodes of otitis media or perforation. Lesions just arise from the attic region of the middle ear. • Various theories have been proposed to explain the pathophysiology
  7. 7. Pathophysiology Cawthrone theory: • suggested by Cawthrone in 1963 • that cholesteatoma always originated from congenital embryonic cell rests present in various areas of the temporal bone.
  8. 8. Pathophysiology Tumarkin’s theory: • cholesteatoma is derived by immigration of squamous epithelium from the deep portion of the external auditory canal into the middle ear cleft through a marginal perforation or a total perforation.
  9. 9. Pathophysiology Toss theory of invagination: • persistent negative pressure in the attic region causes invagination of pars flaccida causing a retraction pocket. • This retraction pocket becomes later filled with desquamated epithelial debris which forms a nidus for the infection to occur later. • Common organisms to infect this keratin debris are Psuedomonas, E. coli, Proteus etc.
  10. 10. Retraction pockets • A retraction pocket is an invagination of the tympanic membrane. The negative middle ear pressure, which is the cause of retraction pocket • Toss classified attic retraction pockets into 4 grades:
  11. 11. • Grade I: The pars flaccida is not in contact with the neck of the malleus. • Grade II: The retracted pars flaccida is in contact with the neck of the malleus and clothing it. • Grade III: Here in addition to grade II features there is minimal erosion of the outer attic wall • Grade IV: In this grade in addition to all the above said changes there is severe erosion of the outer attic wall or scutum.
  12. 12. Pathophysiology Metaplasia: • This theory was first suggested by Wendt in 1873. • The epithelium in the attic area of the middle ear undergoes metaplastic changes in response to subclinical infection. • This metaplastic mucosa is squamous in nature there by forming a nidus for cholesteatoma formation in the attic region.
  13. 13. Pathophysiology Habermann’s epithelial invasion theory: • This theory suggests that following perforation of the tympanic membrane, epithelium invades into the attic area.
  14. 14. Secondary acquired • This always follows active middle ear infection which destroy the tympanic membrane along with the annulus. • The destruction of annulus predisposes to epithelial migration from the external auditory canal into the attic region
  15. 15. Pathology • Necrosis of tympanic membrane tissue along with its annulus. caused due to the virulence of the organisms involved i.e. beta-hemolytic streptococci. • Necrosis starts to occur in those areas of ear drum which have the poorest blood supply.
  16. 16. Congenital Cholesteatoma • Are epidermoid tumors originating from the embryonic epidermoid rest located in the temporal bone or adjacent meningeal spaces. • It appears as whitish globular masses lying medial to an intact tympanic membrane.
  17. 17. Pathogenesis Teed’s epithelial cell rest theory: • Suggested by Teed in 1936 • the persistence of squamous epithelial cell rests in the temporal bone lead to the formation of congenital cholesteatoma.
  18. 18. Pathogenesis Implantation theory: • Friedberg suggested, viable squamous epithelial cells in the amniotic fluid present in the middle ears of neonates and hypothesized that this was a possible source of congenital cholesteatoma
  19. 19. Pathogenesis Ruedi's invagination theory: • This theory suggests that in utero infection of tympanic membrane causes invagination of ear drum into the middle ear cavity causing congenital cholesteatoma.
  20. 20. Post-traumatic cholesteatoma a/c Tertiary Acquired Mechanisms: • Epithelial entrapment in fracture line • In growth of epithelium through fracture line • Traumatic implantation of epithelium into middle ear
  21. 21. Causes of bone destruction • Hyperaemic decalcification • Osteoclastic bone resorption due to: o Acid phosphatase o Collagenase o Acid proteases o Proteolytic enzymes o Leukotrienes o Cytokines • Pressure necrosis: No role • Bacterial toxins: No role
  22. 22. Evaluation • History • Head and neck examination • Otologic examination • tuning fork examination-conductive hearing loss • Hearing evaluation (PTA) -conductive hearing loss • Tympanometry-Flat tympanograms • CT scan of temporal bones
  23. 23. Complications • Infection • Otorrhea • Bone destruction o Ossicles, tegmen • Hearing loss • Facial nerve paresis or paralysis • Labyrinthine fistula • Intracranial complications
  24. 24. Management • Aural toilet • Antibiotics • Grommet insertion (to manage early retraction pockets) • Canal wall down mastoidectomy
  25. 25. Aural toilet • Done only for active stage – Dry mopping with cotton swab – Suction clearance: best method – Gentle irrigation (wet mopping) Removes accumulated debris Acidic pH discourages bacterial growth

Notas del editor

  • ant. epitympanum), petrous apex, cerebello-pontine angle


    a portion of embryonic tissue that remains in the adult organism. Also called epithelial rest, fetal rest.
  • History

    Hearing loss Otorrhea Evaluation Otalgia Nasal obstruction Tinnitus Vertigo Previous history of middle ear disease: CSOM TM perforation Previous surgery

    The erosion of ossicles, most commonly in the incus, may result in conductive hearing loss

    Tympanometry is a technique used to look at the function of the middle ear.

    Middle ear pressure values ranging from +50 daPa to –200 daPa for children, and +50 daPa to –50 daPa for adults is generally considered normal.

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