cholesteatoma is an abnormal sac of keratinizing squamous epithelium and accumulation of keratin within the middle ear or mastoid air cell spaces that can become infected and also erode neighbouring structures.  Cholesteatomas are usually acquired, but in rare cases they can be congenital

Acquired cholesteatomas are thought to arise when chronic negative middle ear pressure causes a weak area of the upper tympanic membrane to be sucked inwards and form a retraction pocket

Congenital cholesteatomas are thought to arise when squamous epithelium becomes trapped within the middle ear during embryogenesis and then expands, obstructing the Eustachian tube or surrounding the ossicles, causing a conductive hearing loss



NOTE Cholesteatoma may be asymptomatic in its early stages and when symptoms develop they are non-specific

Cholesteatoma most commonly presents with a persistent or recurrent ear discharge that is often foul smelling


The diagnosis requires clear visualisation of the tympanic membrane to identify the characteristic appearance of a cholesteatoma that may include:

  • A deep retraction pocket in the tympanic membrane, with or without granulation tissue and skin debris
  • A crust-like lesion, often yellow or brown in colour, usually in the upper part of the tympanic membrane, often surrounded by pus, and sometimes associated with a perforation of the adjacent tympanic membrane
  • A pearly white mass behind an intact tympanic membrane if a congenital cholesteatoma is present (although these are very rare)


If the tympanic membrane cannot be clearly seen because the external auditory canal is occluded by purulent discharge, treat for presumed infection and bring the person back for re-examination after treatment has been completed

If the tympanic membrane cannot be clearly seen after treatment, arrange referral to an ENT specialist. Do not delay referral for repeated courses of treatment if the discharge persists


Differential diagnosis

Other conditions which may present like cholesteatoma are:


Management and referral

Arrange routine referral to an ENT specialist for people who have:


Arrange emergency admission for people who also have:

  • A facial nerve palsy or vertigo
  • Other neurological symptoms (including pain) or signs that could be associated with the development of an intracranial abscess or meningitis


Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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