In cases where cholesteatoma is evident, surgery will normally be recommended. There is no effective medical treatment for this condition and the only way to remove the disease is by surgery. Whilst this condition may not seem common, I would personally expect to operate for this condition most weeks and this had been the case over the past fifteen years as a consultant.
Prior to the operation a CT scan will have been performed along with a recent hearing test. The CT scan is not used to diagnose the condition but rather to assess the anatomy of the ear, potentially assess the extent of disease and identify any areas that will need special care due to bone erosion from the disease. The CT scan also assists in planning the surgical approach. The operation is performed as a day case under general surgery. The operation typically takes two-three hours as this is delicate surgery. No hair is shaved for the operation although in the past this was common practice.
There are two common approaches in surgery for this condition and there are merits to both. The best approach for the individual circumstances will be discussed at time of consultation, as the operation is planned to address the particular situation and patient preferences rather than a single type of operation fitting all cases. Below is a brief description of both although there are variations of these and other approaches which may be discussed at time of consultation.
"On- demand Surgery"
In this procedure a small cut is made at the front ot the ear in the natural skin crease typically two-three centimetres in length. Dissolving sutures are used to close the cut. Thereafter bone is removed from the ear canal until the full extent of the disease has been exposed which is then removed. If the disease and consequently bone drilling is limited then the area is rebuilt with natural body materials from the ear (cartilage, fascia). In this case it may be necessary to schedule a second operation usually anywhere between 6 and 24 months after the original operation. This second operation is to ensure that there is no further disease as it is not possible to see if disease has come back because the area rebuilt is opaque. If the disease is extensive then the inside of the ear is widened to create a cavity. In this case no further surgery is usually needed but long-term care of the cavity is typical. This is because the natural cleaning mechanism of the ear is disrupted and debris can accumulate. This cleaning is performed in the clinic and would typically be every six months- this is lifelong. The opening of the ear is usually widened a little to allow ventilation and cleaning.
Canal wall up Surgery
In this procedure a cut is made behind the ear. The bone behind the ear is drilled away to open the mastoid air cells and approach the disease. More drilling and bone removal is performed to allow removal of the disease. The aim of this operation is to keep the ear canal normal and prevent the need for a cavity. Typically a second operation will be needed anywhere between 6 and 24 months after the original operation to assess whether any further disease is present. This operation whilst having the advantage of avoiding a cavity is associated with a higher occurence of disease not being removed at first operation and of disease reforming as the cause of the cholesteatoma has not been addressed and may persist (as is the case if reconstructed in the on-demand operation above). This approach is generally the preferred approach in children. Overall the chance of cholesteatoma being discovered at time of further surgery or developing/recurring over time is approximately 20-40% (c.f 5-10% with operations that create a cavity).
In both procedures a high powered microscope is used. Specially designed cameras (endoscopes) are available to allow visualisation should the need arise and a laser (KTP) is also available to assist with surgery if needed at Queen's Medical Centre and by arrangement at other sites.
Modern ear surgery is safe but with any surgery there will always be potential for complications despite all care being taken to minimise this.
Injury to the facial nerve
The facial nerve travels through the ear and is responsible for movement of the muscles on the same side of the face. If injured it may result in complete paralysis of that side of the face. Thankfully damage to this nerve in modern ear surgery is rare. The nerve is in a predictable place and a facial nerve monitor is routinely used to detect if the surgeon is close to the nerve. However, as it is such a serious complication all patients are warned of the potential risk.
In removing cholesteatoma it is often necessary to remove one or more of the little bones of hearing from the middle ear (the ossicles) which may result in reduction in hearing. These bones are often damaged by the disease prior to the surgery and the hearing test before surgery may give some indication of this. There may be the opportunity to improve the hearing at time of surgery or at a subsequent operation if this is the case. Much less commonly, hearing loss can occur at time of surgery due to damage to the inner ear hearing with potential to lose all hearing in that ear.
Dizziness may occur in the post-operative/ recovery phase. This is usually temporary
Tinnitus or noises in the ear can occur after surgery of if present can be made worse. This is usually temporary but can be permanent.
The plate of bone that separates the air spaces of the ear and the brain is very thin and may be absent. It is also not uncommonly eroded by disease. The brain is protected by a tough layer of material called the dura, but if this is injured leakage of CSF (brain fluid) will result. This results in a risk of meningitis. If identified at time of surgery this can usually be successfully repaired. Very rarely CSF leakage is identified post-operatively necessitating further surgery.
Meningits/ Brain abscess
Mastoid surgery is performed to prevent these complications from arising from the disease. Rarely they may occur after surgery as a result of the operation.
A wound infection can arise after any operation and wound be evidenced by increased pain/tenderness and swelling along with redness and possible pus discharge. This would be treated with antibiotics. Rarely if an abscess formed this would need to be drained.
Generally the wounds heal well but there is a risk of obvious scarring and of keloid formation- a raised widened unsightly scar.
Some numbness of the top half of the ear occurs when an incision is made behind the ear. This usually resolves completely in six months but on rare occasions can be permanent. It is not uncommon for patients during the healing process to notice altered sensation and there is pain associated with the wound, although this is not normally a particularly painful operation.
Bleeding or a blood clot may develop after surgery and may necessitate return to theatre although this would be a rare event after this surgery. With operations involving a wound at the front ot the ear the wound inside the ear is not fully closed and it is not unusual to note a little bleeding from the ear after the operation which may persist for two or three days. This prevents any clot form developing under the wound. When the wound is behind the ear a head bandage may be used to reduce the risk of bleeding/clot formation. This bandage is in place for less than 24 hours.
Post-operatively it is recommended that you take a week off work/schooling. During this period the wound should be kept dry and the dressing over the wound left undisturbed. After one week the wound will be healed and this dressing can be removed.
The inside of the ear should remain dry until you have been seen back in clinic usually three to four weeks after the operation where further advice will be given dependent on the healing of the ear at that stage. It is recommended that to keep the ear dry cotton wool with vaseline is place in the bowl part of the ear for showering/bathing and removed after. This should not be pushed down the ear canal as this may disrupt the healing of the ear. Ear plugs should not be used for the same reason. You will not be able to use any hearing aid during the healing process.
You should not fly for at least one month after the surgery and should also avoid strenuous activity and contact sports during this recovery phase.
You may be prescribed drops to use in the ear after the operation for two weeks dependent on whether dissolving packing has been used - see how to use ear drops. Initially little of the drops will go in the ear but some will still be absorbed by a wick action and as the packing dissolves more will penetrate into the ear.
The operated ear may protrude slightly after the operation. This usually settles back into the normal position over the following weeks to months
The ear hole (meatus) may have been deliberately enlarged after the operation dependent on the type of surgery to allow ventilation and clearing of the ear- typically when a cavity has been created.
If the inside of the ear has been deliberately enlarged to remove the disease (mastoid cavity) then the ear may not naturally clean itself. In these circumstances you will need to attend clinic on a regular basis typically every six months to have the ear cleaned using suction. This is lifelong. Some patients who have mastoid cavities never need to attend and their ear is self cleaning and another group find that they have problems with ongoing/recurrent infection and need to consider further surgery with the aim of achieving a dry trouble-free ear.
Most patients can swim normally after mastoid surgery when the ear has fully healed, but a minority have issues which prevent this. You may wish to consider keeping the ear dry with an ear plug (custom-made ear plugs are available through the audiology dept at a charge) or by using cotton-wool with vaseline mixed into a gooey ball and placed in the bowl of the ear and opening and discarded after use. In general, in cases where a cavity has been created around half will find they need to keep their ear dry when swimming to avoid discharge.
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