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ukmla 2026

Cholesteatoma

Destructive keratinising squamous epithelium in the middle ear — foul-smelling discharge + conductive hearing loss. NOT a tumour. Requires surgical excision (mastoidectomy)

Review date
reviewed 2026-04-05
Reading time
5 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
ENTless-commonchronic
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Condition details
ENT
less-common
5 min read
reviewed 2026-04-05
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About This Page

This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

  • NOT a tumour — destructive keratinising squamous epithelium in the middle ear/mastoid
  • Most commonly acquired: retraction pocket in pars flaccida (attic) draws in squamous epithelium
  • Symptoms: persistent foul-smelling discharge (offensive otorrhoea), conductive hearing loss
  • Otoscopy: attic crust/retraction pocket or pearly white mass, granulation tissue
  • CT temporal bone: erosion of ossicles, tegmen, semicircular canal
  • Treatment: SURGICAL — mastoidectomy (canal wall up or down). No medical cure
  • Complications: facial nerve palsy, labyrinthine fistula, intracranial abscess, meningitis

Overview

Cholesteatoma is a destructive, non-neoplastic lesion of keratinising stratified squamous epithelium trapped in the middle ear or mastoid. Despite the name, it contains no cholesterol. Acquired cholesteatoma develops from a pars flaccida retraction pocket due to chronic Eustachian tube dysfunction. Trapped skin accumulates keratin which erodes bone through enzymatic activity, progressively destroying the ossicular chain and bony walls. Congenital cholesteatoma (rare) presents as a pearly white mass behind an intact TM in a child.

Epidemiology

Annual incidence: 3–6 per 100,000 (children), 9–12 per 100,000 (adults). More common in males. Risk factors: chronic OM, ET dysfunction, recurrent infections, cleft palate. Bilateral in ~10%. Most common indication for mastoid surgery.

Clinical Features

Symptoms
Persistent foul-smelling ear discharge — hallmark. Unresponsive to topical antibiotics
Hearing loss — conductive, from ossicular erosion
Ear pain if secondary infection
Vertigo/dizziness — lateral semicircular canal erosion (labyrinthine fistula)
Facial weakness — facial nerve involvement
Headache, fever, neck stiffness — intracranial complication
Signs
Attic crust (keratinous debris in pars flaccida) — classic finding
Deep retraction pocket in posterosuperior TM
Pearly white mass visible behind/within TM
Granulation tissue at margins
Positive fistula test (vertigo on tragal pressure) — labyrinthine fistula
Facial nerve palsy (LMN)

Investigations

First-line
Otoscopy + aural microsuctionENT microscope examination — assess retraction pocket extent
Pure tone audiometryConductive hearing loss from ossicular erosion
Second-line
CT temporal bone (high-resolution)Gold-standard — shows bony erosion, surgical planning
Specialist
MRI (DWI non-EPI)Differentiates residual/recurrent cholesteatoma from granulation — post-surgical surveillance

Management

ENT UK and British Society of Otology
1
Conservative (limited role)
  • Microsuction + topical drops control infection but do NOT cure
  • Only for small self-cleaning retraction pockets or patients unfit for surgery
  • Definitive treatment is SURGERY
2
Surgery (definitive)
  • Canal wall up (combined approach): preserves canal wall — better hearing/cosmesis but higher recurrence. Requires second-look or MRI surveillance
  • Canal wall down (modified radical): removes canal wall — lower recurrence but lifelong cavity care
  • Ossiculoplasty: ossicular reconstruction (PORP/TORP) for hearing
  • Tympanoplasty: TM repair
3
Post-operative
  • Long-term ENT follow-up essential — recurrence 5–15%
  • MRI DWI at 12 months for residual/recurrent disease
  • Open cavity: lifelong microsuction every 6–12 months, water precautions
  • Hearing aids if residual CHL

Complications

  • Ossicular erosion: Long process of incus most commonly — conductive hearing loss
  • Labyrinthine fistula: Erosion into lateral SCC — vertigo on pressure (positive fistula test)
  • Facial nerve palsy: Erosion of fallopian canal — urgent surgery
  • Intracranial: Extradural abscess, subdural empyema, temporal lobe abscess, meningitis, sigmoid sinus thrombosis — all life-threatening
  • Subperiosteal abscess
UKMLA Exam Tips
  • 1Cholesteatoma is NOT a tumour and contains NO cholesterol
  • 2Foul-smelling discharge + CHL + attic crust = cholesteatoma
  • 3Only cure is SURGERY (mastoidectomy). Drops control infection only
  • 4Attic (pars flaccida) retraction = most common origin
  • 5Congenital: pearly white mass behind INTACT TM in child with no ear disease history
  • 6Key complications: facial nerve palsy, labyrinthine fistula, intracranial abscess/meningitis
  • 7Fistula test: tragal pressure → vertigo = lateral SCC erosion

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Verified Sources & References

ENT UK — Cholesteatoma
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