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Ear drum cyst may cause hearing loss, other problems

If a child with repeated ear infections appears to have hearing loss or persistent earache, he or she may have developed a cholesteatoma.

A cholesteatoma is a skin growth that occurs in the middle ear behind the eardrum. It can be caused by chronic ear infections, trauma to the ear or an improperly functioning eustachian tube, said Victor Ejercito, M.D., an otolaryngologist, or ear, nose and throat specialist, at Marshfield Clinic.

A cholesteatoma is formed when negative pressure builds in the middle ear. The eustachian tube carries air from the back of the nose into the middle ear, equalizing pressure. That equilibrium function can be compromised in people with frequent ear infections, colds, sinusitis or allergies or those with improperly functioning eustachian tubes, Dr. Ejercito noted. Air in the middle ear is absorbed, causing a partial vacuum. Negative pressure creates a pearl-shaped sac or cyst lined with dead skin cells that build inside the ear. A cholesteatoma may grow over time and destroy the surrounding delicate bones of the middle ear.

“Early intervention and treatment are important,” he said. In addition to hearing loss, symptoms may include dizziness, ear drainage and foul odor.

Less commonly, a congenital form (present at birth) of cholesteatoma may occur in the middle ear or nearby skull bones and go unnoticed for years. Those with cleft palates are more likely to have chronic ear infections leading to cholesteatoma formation because muscles surrounding eustachian tubes are weak.

Left untreated, cholesteatoma can cause loss of balance, ear bone deterioration or facial muscle paralysis. It can be aggressive, spreading to bones or infecting the brain. Cholesteatoma may occur in both ears, potentially leading to hearing loss in both.

While serious, the condition is treatable in children and adults. Hearing and balance tests and CAT scans of the mastoid – the skull bone next to the ear – are taken to determine the extent of destruction and hearing loss the cholesteatoma has caused.

Initial treatment may involve careful cleaning of the ear and antibiotics to control infection and stop drainage. A tiny, well-positioned cholesteatoma can be treated medically, Dr. Ejercito said, “if it’s small enough, accessible enough, open enough, shallow enough and the patient is reliable enough to come in on a regular basis for cleaning.”

Most cholesteatomas, however, are surgically removed. The goal is to rid the ear of infection and, he said, “to convert to a safe, healthy ear.” The anatomy of the ear may be changed during surgery, with the ear canal connecting to the mastoid. At least temporary hearing loss can occur.

“Surgery can be challenging,” Dr. Ejercito said. “You have to be sure you clean everything out. If there’s any residue, cholesteatoma can come back.” Surgery may be done in stages for optimum access around delicate hearing bones, he said. The otolaryngologist may take a second look several months after surgery to make sure no residue remains and the cholesteatoma is not recurring.

Hearing preservation or restoration is a secondary goal. The ear’s ability to conduct sound to the inner ear may decline because of the cholesteatoma and erosion of the hearing bones. In more than half of cases, hearing can be saved or reconstructed, Dr. Ejercito said, but hearing may not be restored to previous levels. Hearing aids may help if full restoration is not possible.

Hearing is reconstructed in a subsequent surgery after no trace of cholesteatoma remains and any anatomical change occurs. This is generally 6 to 12 months after the cholesteatoma is removed, Dr. Ejercito said. In children, who are more prone to ear infections, hearing reconstruction may be postponed until teen-age years. Ear infections, adenoids and tonsillitis can undo hearing restoration or affect cholesteatoma recurrence. “We wait until the ears are stable,” he said.

Also factoring into success of the treatment is whether the patient has allergies or nasal and sinus problems, which need to be treated as well. Smoking also affects the likelihood of success, Dr. Ejercito said. “We’re not as optimistic if they smoke.”

If hearing bones need to be removed, the patient may be a candidate for a bone-anchored hearing aid, he said. Marshfield Clinic is one of few medical facilities in the state to offer bone-anchored hearing aids.

Follow-up visits after surgery are important because cholesteatoma can recur. In cases where a cavity is created behind the eardrum, regular cleaning is needed every few months to prevent new infections, Dr. Ejercito noted. Patients may need to restrict activities such as swimming.

Cholesteatoma was more common years ago before ventilating tubes became widely used in children’s ears to prevent negative pressure, Dr. Ejercito said. Combined, ventilating tubes and antibiotics have helped prevent ear infections from becoming more serious problems. Cholesteatoma continues to occur in areas where access to medical care is limited or not sought.

Those who suspect a cholesteatoma should contact their primary care physician, he said. “Parents are very sensitive to hearing loss in children. If they notice any change in hearing or drainage, parents should ask their pediatrician to check it.”

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