Cholesteatoma with intact tympanic membrane: a report of 41 cases

Congenital cholesteatoma clinical and surgical management

OBJECTIVES

Congenital cholesteatoma (CC) is accompanied by hearing loss and an intact tympanic membrane. However, the hearing loss is usually associated with otitis media, and the diagnosis of CC is frequently delayed in patients with an intact tympanic membrane. This study aimed to describe the clinical characteristics, management and outcomes of patients with CC.

METHODS

We reviewed patients with cholesteatoma from January 2011 to May 2020 and selected those meeting the congenital cholesteatoma criteria. The primary outcome measures included presenting symptoms, surgical findings, stage of disease, recurrence rate and hearing outcomes.

RESULTS

We reviewed 1646 medical files of cholesteatoma patients and identified 18 patients with congenital cholesteatoma, the mean age at operation was 8.13 ± 1.36 years (range 3-18). The unilateral hearing loss included moderate 13 patients (72.2%), severe 4 patients (22.2%), and slight 1 (5.6%). There were 14 cases of conductive hearing loss (77.8%) and 4 cases of mixed hearing loss (22.2%). The mean course of disease was 1.41 ± 0.05 years (range 0.4-3). The surgical management was oto-endoscope exploratory tympanotomy in 1（5.6%）, canal wall up mastoidectomy in 12 (66.7%) and canal wall down in 5 (27.8%), with 17 (94.4%) ossicular replacements. Seventeen (94.4%) patients presented with Potsic stage III-IV. Recurrence occurred in 5.6% of patients in stage III and 11.1% of patients in stage IV. After surgery, patients achieved normal voice tone hearing.

CONCLUSIONS

To diagnose it early, congenital cholesteatoma should be considered as a possible aetiology for hearing loss patients with an intact tympanic membrane. In our study, most patients were diagnosed at III and IV stage. This highlights the need to promote awareness of the disease among primary physicians in the community healthcare system. Surgical management with removal of the cholesteatoma and reconstruction of the tympanum and ossicular chain is an effective treatment.

Congenital Cholesteatoma in Adults-Interesting Presentations and Management

To report a series of adult patients diagnosed with congenital cholesteatoma (CC) with respect to symptoms, different varieties of presentation, surgical findings and approach used, complications and the postoperative results. A retrospective chart review of adult cases of CC who were treated in the period from January 2014-2017 was carried out in a tertiary care center. Levenson's criteria were used for diagnosis. Diagnosis was confirmed by imaging and intraoperatively. Postoperative results and complications were also analyzed. Six adult cases of CC were studied with a mean follow up of 10 months. Interesting presentations included otitis media with effusion, non-resolving facial nerve palsy, post aural discharge and meningitis. It included 3 cases of petrous apex cholesteatoma, 2 patients with cholesteatoma involving both the middle ear and mastoid and 1 patient with mastoid cholesteatoma. The operative procedures included canal wall up mastoidectomy (1 patient), atticotomy (1 patient), canal wall down mastoidectomy (1 patient), translabyrinthine and transotic excision of mass with blind sac closure (2 patients) and partial labyrinthectomy (1 patient). Complications encountered during surgery were cerebrospinal fluid leak and worsening of hearing in 2 patients and 1 patient respectively. CC can have variety of interesting presentations in adult population and they may or may not have the classical white mass behind the tympanic membrane. Appropriate individualized surgical planning and intervention gives good results.

Clinical Aspects and Surgical Outcomes of Congenital Cholesteatoma in 93 Children: Increasing Trends of Congenital Cholesteatoma from 1997 through 2012

BACKGROUND AND OBJECTIVES

The recent increase in the reported incidence of congenital cholesteatoma (CC) may be secondary to the widespread use of otoendoscopy as well as an increased awareness of these lesions among primary care physicians. However, little research about CC has been conducted in a large group of patients. This study aimed to analyze the clinical characteristics of CC including the annual number of patients, symptoms, age at diagnosis, stage and type of disease, surgical techniques, recurrence, and postoperative complications.

SUBJECTS AND METHODS

Retrospective chart review was performed for patients who met the inclusion criteria between January 1997 and June 2012.

RESULTS

Ninety-three patients underwent surgery for CC. The age at operation ranged from 12 months to 17 years (mean age, 6.1 years). The number of patients was less than 4 per year until 2005, but increased to more than 10 per year since 2008. CC was most commonly reported as an incidental finding (58.1%). The operative procedures included the transcanal myringotomy approach (46.2%), canal wall up mastoidectomy (37.6%), tympanoplasty (8.6%), and canal wall down mastoidectomy (7.5%). The recurrence rate was 20.4% and the complication rate was 12.9%. No patients with stage I CC had complications.

CONCLUSIONS

This study showed that the incidence of CC has recently increased notably. Most patients with stage I and II CC were completely cured by transtympanic surgery, and complication and recurrence rates increased according to the extent of disease. Early detection of CC is important to facilitate minimally invasive surgery and to reduce complication and recurrence rates.

A Review of Twenty Congenital Cholesteatomas of the Middle Ear in Children

Cholesteatomas, arising within the middle ear space behind an intact tympanic membrane, have been detected more frequently in recent years. This article reviews 19 children (with a mean age of 4.3 years) who underwent surgery over a 7-year period for removal of cholesteatomas from behind intact tympanic membranes. Most of these children were referred by pediatricians who had detected an asymptomatic whitish middle ear mass. Many had histories of treatment for otitis media. Patients with similar histories were excluded from the series if there had been a prior perforation, myringotomy, or otologic surgery. In the series, one fourth of the children had associated congenital malformations, and there were 3 times as many boys as girls. In two thirds of the cases, the cholesteatoma was manifested as an anterior-superior middle ear mass that seemed to arise from the processus cochlearlformis, undersurface of malleus area. Many could be removed via an extended anterior tympanotomy operative approach. The results of surgery are reviewed. The possible origins of these localized cholesteatomas are considered. Are they congenital defects that arise from misplaced keratinizing epithelium? Do they arise from mesenchymal cells whose differentiation is stimulated by inflammatory changes within the middle ear?

Congenital cholesteatoma localized to the tip of the mastoid bone: a case report and possible etiology

Congenital cholesteatomas of mastoid origin are extremely rare. We reported one in 2007 and experienced an additional case. A male presented with a 5-month history of right-sided ear discharge. Computed tomography of the temporal bone showed a soft tissue density occupying the mastoid tip. At surgery, the cholesteatoma sac was completely isolated from the mastoid antrum and lateral air cell in the mastoid tip area. We now doubt the rarity of this entity. With a brief literature review, we consider how the cholesteatoma localizes to the tip of the mastoid bone.

Congenital cholesteatoma in identical twins

OBJECTIVE

We present an extremely rare case of congenital cholesteatoma in identical twins.

METHOD

Case report of congenital cholesteatoma in identical twins, and a literature review, are presented.

RESULTS

Both cases presented to the ENT out-patient clinic, but with different clinical pictures. Both were managed surgically.

CONCLUSION

Congenital cholesteatoma presents as a whitish mass in the middle ear, with an intact tympanic membrane. It is a rare entity comprising between 3.7 and 24 per cent of total cholesteatoma cases. The key to its diagnosis is the absence of previous ear infection, ear surgery and local trauma. To our best knowledge, this paper represents the first report in the world literature of congenital cholesteatoma in identical twins.

Clinical experience of 71 cases of congenital middle ear cholesteatoma

CONCLUSIONS

As congenital middle ear cholesteatoma (CMC) is a different disease entity from acquired cholesteatoma, early diagnosis is important for good treatment results. Preoperative computed tomography (CT) imaging is a useful modality for both evaluation of the extent of the disease and selection of appropriate surgical methods. Some modification should be considered based on the findings of the actual operative field for complete removal of CMC.

OBJECTIVES

To present the results of surgical treatment of 71 cases of CMC and investigate the applicability of preoperative CT for the treatment of CMC.

PATIENTS AND METHODS

A retrospective study over an 11-year period was performed. The presenting symptoms, tympanic membrane findings, surgical findings, methods, and results were investigated retrospectively.

RESULTS

CMC was found incidentally in 38 cases (53.5%). A whitish mass medial to the tympanic membrane was observed in 62 cases (87%). Postoperative air-bone gap changes were not statistically significant. There was no predominance of localized lesions of the middle ear. The recurrence rate was 9.9% (seven cases), and higher in open type. Staging by CT and surgical staging matched in 70.4%. Positive predictive value for mastoid involvement of CT staging was 72.7%, with sensitivity and specificity of 68.6% and 87.5%, respectively.

Congenital cholesteatoma of mastoid region manifesting as acute mastoiditis: case report and literature review

OBJECTIVES

We report an extremely rare case of congenital cholesteatoma of the mastoid region, presenting as acute mastoiditis. We also review the 16 previously reported cases of congenital cholesteatoma of the mastoid region.

CASE REPORT

A 65-year-old man presented with left-sided, post-auricular swelling and pain. Acute mastoiditis was diagnosed, with computed tomography demonstrating destruction of the bony plates of the posterior cranial fossa and sigmoid sinus. Initial surgery revealed a cholesteatoma in the mastoid, with no extension into the aditus ad antrum or attic. These findings were confirmed by pathological and immunohistochemical analysis of the surgical specimen, the latter using involucrin. The cholesteatoma matrix was completely removed in a second operation.

CONCLUSIONS

Including this case, only four of the 17 reported cases of congenital cholesteatoma of the mastoid region showed post-auricular pain or swelling, indicating acute mastoiditis. Clinicians should bear in mind that congenital cholesteatoma may be present in patients presenting with mastoiditis, particularly adults.

Congenital middle ear cholesteatoma in children; retrospective review of 35 cases

Congenital middle ear cholesteatoma (CMEC) is a rare disease entity in otolaryngology. However, we try to assess the characteristic features and recurrences of CMEC in pediatric patients according to stages, and to determine the value of preoperative computed tomography (CT) scan. Retrospective review of 35 cases of CMEC under the age of 15 yr that had been treated at the tertiary referral center from 1995 through 2006. The main outcome measures were CT findings, surgical findings, recurrence rate and hearing assessment. Preoperative CT scan accurately predicted the extent of the cholesteatoma seen during surgery in 30/35 (85.7%). The recurrence rate of CMEC was 5.7% (2/35) and all of recurred cases were stage IV. In recurred cases, cholesteatomas were extended to sinus tympani and facial recess at revisional operation as well as initial operation. So we concluded that preoperative CT scan is essential in defining the extent of existing pathology. The intraoperative CMEC extension and location influence the outcome of surgery. In the higher stages, careful eradication of disease, particularly in the region of sinus tympani and facial recess is recommended.

Congenital Cholesteatoma of the Mastoid Temporal Bone

OBJECTIVE

Congenital mastoid cholesteatomas are rare lesions of the temporal bone. The clinical presentation of these lesions is variable, making them difficult to identify preoperatively. We evaluated our series of mastoid congenital cholesteatomas (CCs) in an effort to better define the clinical presentation, imaging characteristics, and surgical challenges specific to this lesion.

STUDY DESIGN

Retrospective chart and radiologic study review.

METHODS

The medical records of patients with the diagnosis of mastoid CC on radiologic imaging over a 15-year period were reviewed. All had surgical and pathologic confirmation. Eight patients underwent preoperative computed tomography (CT). Six also underwent magnetic resonance (MR) scanning. Demographic information, clinical presentation, imaging results, and operative findings were recorded.

RESULTS

Nine patients with the diagnosis of mastoid CC satisfying the inclusion criteria were found. Clinical findings were variable, with the most common presentation being an incidental finding. Imaging findings were more uniform. All CT scans demonstrated an expansile, well-circumscribed mass centered within the mastoid portion of the temporal bone. All MR scans showed a well-circumscribed mass with high intensity on T2-weighted images with precontrasted T1 sequences showing the lesion to be isointense or slightly hyperintense to cerebrospinal fluid (CSF). Operative findings included lateral mastoid cortex erosion, sigmoid sinus exposure, ossicular destruction, facial nerve exposure, and associated postauricular abscess. Management of these lesions is reviewed.

CONCLUSION

Congenital mastoid cholesteatomas have a variable and nonspecific clinical presentation. Surgical challenges arise from the indolent nature of this clinical entity, which belies the extent of otologic involvement. Imaging with CT and magnetic resonance imaging are diagnostic, defines the extent of these lesions, and facilitates preoperative surgical planning.

Congenital cholesteatoma: theories, facts, and 53 patients

Congenital cholesteatoma has a different pathophysiology than acquired cholesteatoma in that these patients rarely have eustachian tube dysfunction. This likely accounts for their reasonable preoperative hearing and their lack of complications or recurrences postoperatively. The most important factor is early detection. Treatment remains surgical removal.

Congenital cholesteatoma: 20 years' experience at The Children's Hospital of Philadelphia

OBJECTIVE

We report our experience with congenital cholesteatoma over a span of 20 years with an emphasis on presenting characteristics and predictors of outcome.

METHODS

We conducted a retrospective review from 1981 through 2000.

RESULTS

One hundred seventy-two congenital cases were identified in 167 patients. Five patients had bilateral disease. The majority (72%) were found in boys, with an average age of 5.0 years. Hearing loss was slight to moderate. When confined to 1 quadrant, cholesteatoma was anterosuperior in 82% of cases; 47% had cholesteatoma in 2 or more quadrants. Ossicular chain involvement was found in 43% of all cases, and mastoid extension was evident in 23%. The rate of recurrent disease was directly related to the extent and number of quadrants involved.

CONCLUSION

To our knowledge, this is the largest series of congenital cholesteatomas to be reported. This review confirms the male predominance and predilection for the anterosuperior quadrant. The extent of cholesteatoma and its relation to residual disease should be used as a guide for planning a second-look procedure.

Congenital middle ear cholesteatomas in children: our experience in 34 cases

OBJECTIVES

To evaluate clinical data, extensions, residual disease rate, and functional results in cases of congenital cholesteatoma in pediatric patients compared with cases of acquired forms.

STUDY DESIGN AND SETTING

In a retrospective study conducted at a single tertiary care center over a decade, 34 congenital cholesteatomas (mean patient age, 6.6 years) isolated from a series of 215 cholesteatomas in children were treated surgically and followed up for an average of 83 months. Surgical treatment consisted of the closed technique (CT), open technique tympanoplasty in CT [TOT], radical mastoidectomy (RM), or Rambo's technique. The main outcome measures were surgical findings, residual lesion rate, and hearing assessment.

RESULTS

The first surgical procedure was CT in 85.3%, TOT in 8.8%, RM in 2.9%, and Rambo's technique in 2.9% of patients. Two, 3, and 4 operations were necessary in 76.5%, 11.4%, and 11.4% of children, respectively. Residual lesions were observed in 34.6% of those multi-operated patients (7 CT and 2 TOT), 24.1% in those treated with CT, and 29.2% in those treated with CT with a planned second look. Mean postoperative pure tone average and air-bone gap were 26 and 21 dB, respectively. A speech reception threshold of less than 30 dB HL was achieved in 66% of patients. A total of 26 ossiculoplasties had to be performed (8 partial and 18 total); the mean postoperative air-bone gap was lower after the former (15 dB) than after the latter (22 dB). A high-frequency pure-tone hearing loss of more than 10 dB was uncommon (5.8%). Unsurprisingly, the residual lesion rate seems to be higher for congenital than for acquired cholesteatomas, but hearing results are significantly better.

CONCLUSION

In most cases, staged CT appears to be the best technique to treat these lesions, which often develop in a well-pneumatized mastoid.

[Giant cholesteatoma with intact tympanic membrane]

The cholesteatoma is characterized by Epidermic Keratinizated tissue in the middle ear and mastoid with capacity of migration and erosion of near-by structures. Commonly cholesteatoma is associated with chronic medium otitis, but in a few cases, tympanic membrana is integry and the diagnosis is made when appear complications. We report a case of giant cholesteatoma with intact tympanic membrana. The extension, silent period and evolution are evaluate.

Congenital cholesteatoma and malformations of the facial nerve: rare manifestations of the BOR syndrome

We describe a 14-month-old girl with unilateral congenital cholesteatoma and anomalies of the facial nerve in addition to the more common branchial arch, otic, and renal malformations comprising the branchio-oto-renal (BOR) syndrome. Her mother also has the BOR syndrome and unilateral duplication of the facial nerve. This is the first study of a BOR patient with congenital cholesteatoma and the second family in which cholesteatoma and anomalies of the facial nerve are described in patients with the BO/BOR syndrome. We review the congenital cholesteatoma literature and discuss hypotheses for the pathogenesis of this entity in light of this new report.

Congenital cholesteatomas in the tympanic membrane

The etiology of congenital middle ear (ME) cholesteatomas is unclear. One etiologic possibility of ME cholesteatoma may be progression of a congenital tympanic membrane (TM) cholesteatoma. We recently have encountered three cases of congenital tympanic membrane cholesteatoma. Each child, ages 1, 3, and 14 years, presented with cholesteatoma of the tympanic membrane extending into the middle ear. These children have not had previous otologic surgery including myringotomy, nor had they had repeated middle ear infections, perforation, or trauma. Neither the 3-year-old nor 14-year-old child complained of hearing loss. Audiograms demonstrated only a mild conductive loss. Each child underwent excision with tympanoplasty. Although the middle ear component of the cholesteatoma was always more extensive than the pearl seen, the point of attachment was the TM and not the middle ear. This demonstrates one possible source for congenital cholesteatomas.

Cholesteatoma in children

Cholesteatoma in children falls into two main categories: congenital and acquired. Though they present in different ways, both are potentially destructive lesions that are managed surgically. The goals of treatment are to eradicate keratinizing squamous epithelium from the temporal bone and to preserve or restore hearing. These children need to be followed closely by the pediatric otolaryngologist to prevent and control recurrent disease.

Congenital cholesteatoma with spontaneous epidural abscess, sinus thrombosis and cutaneous fistula

A congenital cholesteatoma or epidermoid is a benign mass that causes devastating effects if left untreated. An unusual case with a congenital cholesteatoma located in the mastoid region complicated by epidural abscess, sinus thrombosis, and cutaneous fistula is presented. The patient had normal otologic findings and had no neurologic deficit. A review of the literature found no report of a similar case.

Congenital aural cholesteatoma: results of surgery in 60 cases

From 1978 to 1993, 59 patients (60 ears) with congenital middle ear cholesteatoma were treated at the House Ear Clinic. The median patient age at presentation was 5 years, and the period of postoperative follow-up was 4.8 years. An intact canal wall was maintained in 58 of 60 cases and a closed middle ear space in all cases. In 12 operations, lateral graft tympanoplasty eradicated the cholesteatoma in one stage; 32 patients required a second-stage surgery to rule out recurrence, and the remaining 16 cases required three or more operations to eradicate disease and reconstruct the hearing mechanism. Thirty-five (63%) of 56 patients had a postoperative air-conduction threshold pure-tone average (PTA) within 10 dB of the best bone-conduction PTA; 91% were within 20 dB. Average speech reception threshold improved from 32 dB hearing level (HL) preoperatively to 20 dB HL postoperatively.

Chronic suppurative otitis media

OBJECTIVE

To review various aspects of chronic suppurative otitis media (CSOM).

DATA SOURCES

A MEDLINE search and extensive review of articles provided the information for this review.

DATA EXTRACTION

Studies describing the epidemiology, microbiology, risk factors, pathology, diagnosis, treatment, complications, and recurrence of CSOM were included.

DATA SYNTHESIS

Pseudomonas aeruginosa and anaerobes are the most predominant bacteria found in CSOM. Treatment with otic, oral, or parenteral drugs (e.g., neomycin/polymyxin B/hydrocortisone otic, ciprofloxacin, ceftazidime, or aminoglycosides) should be guided by ear fluid culture results. Prompt treatment with effective and safe antibiotics may prevent complications of CSOM.

CONCLUSIONS

Treatment of CSOM has improved as a result of availability of effective otic and oral antibiotics. Treatment of the anaerobic infection with antibiotics should be studied further.

Congenital cholesteatoma

Since the late 1970s, the author has had the opportunity to prospectively study, document, and surgically manage 40 cases of congenital cholesteatoma. All cases met strict criteria for inclusion in the study, all were surgically and pathologically confirmed, and were definitively followed. During that same period, 38 cases were managed by other members of the otolaryngology department. It is the purpose of this thesis to critically study this personal and institutional experience, and to validate the rationale for early diagnosis and prompt and effective surgical intervention.

Congenital cholesteatoma presenting as a post-auricular mass

Congenital cholesteatoma usually presents as either a conductive deafness or as a facial palsy. We report a case which presented as a post-auricular mass. It is important to recognize the possibility that the disease may present in this way when considering the management of such a mass.

Primary cholesteatoma of the mastoid presenting as cervical abscess

Primary cholesteatoma has been described in a number of sites within the temporal bone. We report an unusual case of primary cholesteatoma, confined to the mastoid, presenting with Bezold's abscess of the anterior cervical triangle, in an otherwise asymptomatic elderly man with normal hearing.

Experimental induction of middle ear cholesteatoma in rats

We induced cholesteatoma in two groups of rats by instilling different concentrations of propylene glycol into the middle ear cavity. Fifteen rats were exposed to 50% propylene glycol (group I), while pure propylene glycol was applied to six others (group II). The group I rats were killed 1 month after instillation. Seven of the 15 showed cholesteatoma in the middle ear with accumulation of keratin debris. The group II rats were killed 3 months after instillation. All six animals showed inflammation in the experimental ears, and five of the six experimental ears showed cholesteatoma in the middle ear cavity. Six experimental ears in group I and five in group II revealed retraction of the tympanic membrane, possibly due to eustachian tube obstruction. Bone resorption was seen along with cholesteatoma and inflammatory cells and osteoclasts in the middle ear of all 11 of these rats. The seventh cholesteatoma of group I can be classified as a microcholesteatoma, a pearl-like cyst within the tympanic membrane. The microcholesteatoma was formed by an invasion of basal cells from the tympanic epidermis and the proliferation of these cells in the fibrous layer of the tympanic membrane. Our findings suggest that cholesteatoma in the middle ear cavity is a response to the inflammation produced by high concentrations of propyleme glycol.

Origin of congenital cholesteatoma from a normally occurring epidermoid rest in the developing middle ear

The sites of involvement of congenital cholesteatoma, a lesion which has recently become more frequently recognized, are reviewed from literature sources. There is a propensity for its occurrence, especially when small, in the anterior superior part of the middle ear. The same situation is the precise location of an epidermoid cell rest, the epidermoid formation (EF). This is seen in most fetal ears at the junction of the Eustachian tube with the middle ear near the anterior limb of the tympanic ring, until 33 weeks gestation, when it disappears. Its origin is traced to early fetal life from the ectoderm of the first branchial groove. In embryonic and early in fetal life it seems to act as an organizer in the development of the tympanic membrane and middle ear. It is likely that congenital cholesteatoma is derived from the EF by its continued growth instead of regression. Congenital cholesteatomas show a thinner and flatter matrix than acquired cholesteatomas, probably because the former are most frequently 'closed' and therefore subject to pressure effects from the keratin within the cyst. 'Open' forms also occur in smaller numbers. It is possible that a screening program for congenital cholesteatoma in infants might reduce the incidence of the severe, extended form of the disease.

Double intratemporal congenital cholesteatomas combined with ossicular anomalies

A 15-year-old patient had unilateral double congenital cholesteatomas, one isolated to the mastoid and the other located in the petrous pyramid. The presenting symptoms were facial palsy and a conductive hearing loss on the affected side. The case is interesting, not only in that there were two isolated cholesteatomas in the same temporal bone, but also because of the combination of ossicular anomalies. The unusually early detection and surgical intervention in this instance suggest that similar cases of multicentric cholesteatomas may have occurred, but may have been concealed because of the later detection and possible linkage of the cholesteatomas. I would therefore emphasize Sheehy's recommendation that temporal bone radiography never be omitted where idiopathic facial nerve palsy exists.

A review of twenty congenital cholesteatomas of the middle ear in children

Cholesteatomas, arising within the middle ear space behind an intact tympanic membrane, have been detected more frequently in recent years. This article reviews 19 children (with a mean age of 4.3 years) who underwent surgery over a 7-year period for removal of cholesteatomas from behind intact tympanic membranes. Most of these children were referred by pediatricians who had detected an asymptomatic whitish middle ear mass. Many had histories of treatment for otitis media. Patients with similar histories were excluded from the series if there had been a prior perforation, myringotomy, or otologic surgery. In the series, one fourth of the children had associated congenital malformations, and there were 3 times as many boys as girls. In two thirds of the cases, the cholesteatoma was manifested as an anterior-superior middle ear mass that seemed to arise from the processus cochleariformis, undersurface of malleus area. Many could be removed via an extended anterior tympanotomy operative approach. The results of surgery are reviewed. The possible origins of these localized cholesteatomas are considered. Are they congenital defects that arise from misplaced keratinizing epithelium? Do they arise from mesenchymal cells whose differentiation is stimulated by inflammatory changes within the middle ear?

Congenital cholesteatoma of the ear

Congenital cholesteatoma of the ear is a capricious and challenging problem for the otologist. We present 21 cases managed at the Mayo Clinic from 1961 to 1983. In all but one unusual case, the cholesteatoma developed behind an intact tympanic membrane and there was no history of aural infections. Preoperative symptoms and signs were predominantly conductive deafness with either a normal tympanic membrane or an opaque, whitish appearance to the drum. Disease was located in the middle ear or in the middle ear and mastoid, except in one patient who had cholesteatoma extending into the petrous apex. Surgical management depended on the extent of the lesion, and recurrences were unusual, suggesting that congenital cholesteatoma may not be as aggressive as acquired cholesteatoma.

The sleeve autograft in congenital cholesteatoma

An epithelial cyst behind an intact tympanic membrane with no previous history of ear infections is an unusual but not infrequent finding in children. If it is recognized early and completely removed, a permanent cure is obtained. However, if it is unrecognized or poorly treated, there may be far-reaching complications. The conventional technique of creating a tympanomeatal flap to remove the congenital cholesteatoma is often unsatisfactory. This is because the cyst may be located in the anterior-superior quadrant and extend beneath the malleus. It therefore becomes impossible to accomplish a complete removal and still preserve auditory function. This leads to incomplete removal with recurrence and subsequent radical removal with loss of auditory function and alteration of normal anatomy. A technique is presented whereby the canal skin, malleus, and cholesteatoma are removed en bloc. Once outside the confines of the bony ear canal, the tympanic membrane is inverted and the epithelial cyst removed under direct vision. The eardrum-malleus-canal skin autograft is then replaced in anatomical position and the hearing reconstructed with a homograft notched incus. This technique has been utilized in nine cases over the past 10 years. Case reports demonstrate the anatomical and functional results.

Intramembranous and mesotympanic cholesteatomas associated with an intact tympanic membrane in children

A series of 15 intramembranous (IMTC) and mesotympanic (MTC) cholesteatomas associated with intact tympanic membranes in children is presented. Clinical observations, audiometric and radiographic data, and surgical findings are correlated. A history of recurrent otitis media was obtained in 85% (13/15) of the cases, differentiating them from the usual congenital cholesteatomas. The possibility that many of these are indeed "acquired" lesions is emphasized. Hypothetical pathogenetic mechanisms are discussed. The basal cell papillary proliferation theory is considered the most attractive explanation of the development of both IMTCs and MTCs. The need for careful, prolonged, follow-up otoscopic examination of children with recurrent otitis media is stressed, if more of these lesions are to be recognized early.