Cholesteatoma

The middle ear is normally lined by a delicate pink mucosal membrane, similar to the lining of your nose, mouth and sinuses. In contrast, the external ear canal is lined by skin, which constantly sheds and renews. If skin becomes trapped within the middle ear — for example, through a retraction pocket or a defect in the eardrum — it continues to shed, but has nowhere to escape. This leads to the formation of a destructive growth called a cholesteatoma.

Although not cancerous, cholesteatomas behave aggressively: they expand over time, eroding the small bones of hearing, causing infections, and potentially affecting the balance system, facial nerve, or even the brain if left untreated.

Cholesteatoma can be silent in its early stages, but common symptoms include:

• Persistent or smelly discharge from the ear
• Gradual hearing loss - this is due to the condition dissolving the bones of hearing
• A feeling of pressure or fullness in the ear
• Recurrent ear infections
• Dizziness or imbalance (in some cases)
• Rarely, facial weakness, headaches, or meningitis if complications arise

Cholesteatoma can occur in both adults and children. It may be:

• Acquired – most commonly due to chronic ear infections or a pressure imbalance between the outer ear and middle ear, which causes the eardrum to retract inwards and trap skin
• Congenital – where skin is trapped in the middle ear from birth, although this is rare

Diagnosis is usually made during an ear examination using a microscope or endoscope. Further investigations may include:

• Audiogram – to assess hearing
• CT scan – to evaluate the extent of disease and its relationship to nearby structures
• MRI – in some cases, to rule out recurrence or assess for complications

Surgery

Surgery is the only effective treatment for cholesteatoma. The goals are to:

• Remove all diseased tissue
• Create a safe, dry ear
• Preserve or reconstruct hearing where possible

Cholesteatoma surgery demands precision, adaptability, and long-term planning. Mr Patel has been formally trained in all recognised surgical techniques, including microscopic and endoscopic approaches, as well as both canal wall up (back-to-front) and canal wall down (front-to-back) techniques. This means he can offer each patient a bespoke procedure tailored to the extent of disease, their anatomy, and personal priorities.

As one of a limited number of ENT surgeons in the UK routinely performing endoscopic ear surgery, Mr Patel is able to offer significant advantages when managing cholesteatoma. The endoscope provides an unparalleled view of complex and hidden areas of the middle ear — such as the sinus tympani, sinus subtympanicus, and facial recess — which are common sites of residual disease.

His approach includes:

• Primary ossiculoplasty using a range of prostheses to maximise hearing outcomes where reconstruction is possible.
  Note: In the context of active inflammation and general anaesthesia, hearing results from primary ossiculoplasty are often less predictable than when reconstruction is done in a separate, staged procedure. However, if hearing remains significantly reduced following cholesteatoma removal, a tailored revision ossiculoplasty can often be performed later under local anaesthetic, offering a high chance of further improvement.
• Use of laser technology to sterilise the surgical bed, reducing the risk of regrowth from residual skin cells
• The ‘Patel Pressure Test’ – a clinical manoeuvre developed by Mr Patel and routinely perform at the end of surgery. This allows him to confirm that the ear drum reconstruction is intact and pressure-resistant, giving added confidence that the repair will withstand changes in air pressure from flying, train travel, or nose-blowing. This test enhances the likelihood of long-term graft success

The goal is not only to remove the disease, but to preserve or restore hearing, reduce the chance of recurrence, and support a smoother, more confident recovery..

Long-term outcomes in cholesteatoma surgery are best assessed at five years or more, as the condition carries a recognised risk of late recurrence. As Mr Patel has not yet been a consultant for five years, his personal outcome data should be interpreted with that context in mind.

However, published studies report:

• Complete disease clearance in approximately 85–95% of cases at five-year follow-up.

In my own practice to date:

• 70% of patients undergo primary ossiculoplasty (hearing reconstruction) at the time of cholesteatoma surgery.
• Of those, 66% achieve a good hearing result, defined as a post-operative air-bone gap of less than 20 dB.
• Over 80% of patients have had stable or improved hearing following surgery overall.

Risks

All surgery carries some risk. For cholesteatoma surgery, the most important risks include:

• Hearing loss – while the aim is to preserve or improve hearing, there is a small risk of deterioration, especially in advanced cases. In my practice to date, over 80% of patients have had stable or improved hearing following surgery. None of our patients have experienced complete hearing loss, though the published risk remains around 1%.
• Tinnitus – may persist or occasionally develop post-operatively
• Dizziness or imbalance – usually temporary and resolves within days to weeks
• Taste disturbance – due to the proximity of the chorda tympani nerve; which often needs to be sacrificed. The taste disturbance is usually transient
• Facial nerve weakness – a rare but serious complication; to date, we have had no cases of  facial weakness following cholesteatoma surgery
• Recurrence of disease – as discussed above, even with meticulous surgery, a small risk of recurrence remains This is why long-term follow-up is essential.