Cholesteatoma: Symptoms, Diagnosis, and Ear Surgery
Expert evaluation of chronic ear disease and cholesteatoma in Orange County
A cholesteatoma is a collection of trapped skin that grows in the middle ear or mastoid bone behind the eardrum. It is not cancer, but it can enlarge, become infected, erode bone, damage the hearing bones, and spread toward the inner ear, facial nerve, or structures around the brain. Cholesteatoma usually does not go away on its own, so persistent symptoms require evaluation by an ear specialist.
Early diagnosis can limit damage and may make treatment less extensive. Patients with chronic foul-smelling drainage, one-sided hearing loss, repeated infections, or a deep eardrum retraction should not assume the problem is simply swimmer’s ear.
What Causes a Cholesteatoma?
Most acquired cholesteatomas begin when poor middle-ear ventilation creates negative pressure and pulls part of the eardrum inward. The retraction pocket traps skin that normally moves out of the ear canal. Over time, keratin debris accumulates and the pocket can expand.
- Eustachian tube dysfunction and chronic negative middle-ear pressure
- Repeated or long-standing ear infections
- A perforated eardrum that allows skin to enter the middle ear
- Prior ear surgery or trauma that traps skin
- Congenital cholesteatoma, an uncommon form present behind an intact eardrum
Cholesteatoma Symptoms
- Persistent or recurrent ear drainage, sometimes with a strong odor
- Progressive hearing loss in one ear
- Ear pressure, fullness, or discomfort
- Repeated ear infections that improve only temporarily with drops or antibiotics
- Tinnitus
- Dizziness, imbalance, or sensitivity to pressure or sound
- Facial weakness, severe headache, fever, or increasing pain in advanced cases
Symptoms may be mild even when the disease is extensive. The absence of severe pain does not rule out a cholesteatoma.
When Cholesteatoma Symptoms Need Urgent Care
New facial weakness, severe vertigo, rapidly worsening hearing, swelling or redness behind the ear, high fever, confusion, severe headache, or neurologic symptoms require urgent medical assessment. These findings may indicate extension beyond the middle ear or another serious complication.
How Cholesteatoma Is Diagnosed
Microscopic or endoscopic ear examination
An otologist examines the ear canal and eardrum for a retraction pocket, keratin debris, granulation tissue, drainage, a perforation, or evidence of previous surgery. Gentle cleaning under magnification may be needed to see the full extent.
Hearing tests
An audiogram measures conductive and sensorineural hearing loss and evaluates speech understanding. Tympanometry may provide additional information about eardrum and middle-ear function.
Temporal-bone CT scan
CT imaging shows the mastoid and middle-ear anatomy, bone erosion, ossicular damage, and the relationship of disease to important structures. CT is helpful for surgical planning but may not always distinguish cholesteatoma from fluid or scar tissue.
Diffusion-weighted MRI
A specialized diffusion-weighted MRI can help identify cholesteatoma in selected patients, particularly when evaluating possible residual or recurrent disease after surgery. The need for imaging depends on the examination, symptoms, and prior treatment.
Why Cholesteatoma Can Damage Hearing and Balance
The trapped skin produces inflammation and enzymes that can erode nearby bone. The incus and stapes are commonly affected, producing conductive hearing loss. Extension into the inner ear can cause sensorineural hearing loss, dizziness, or a fistula. Disease near the facial nerve can lead to weakness, and rare spread beyond the ear can cause serious intracranial complications.
Cholesteatoma Treatment
Ear cleaning, topical medication, and treatment of infection can control drainage, but they usually do not eliminate the underlying cholesteatoma. Definitive treatment is commonly surgical because the goal is to remove disease, create a safe and dry ear, prevent complications, and preserve or restore hearing when possible.
Types of Cholesteatoma Surgery
Tympanoplasty
The eardrum is repaired and retraction-prone areas may be reinforced with cartilage. Tympanoplasty is often combined with removal of disease from the middle ear. This procedure can generally be performed through the ear canal without large incisions behind the ear.
Mastoidectomy
A mastoidectomy removes cholesteatoma from the air pockets behind the ear. The extent depends on how far the disease has spread and whether anatomy can be safely preserved.
Canal-wall-up and canal-wall-down surgery
In canal-wall-up surgery, the posterior ear-canal wall is preserved. In canal-wall-down surgery, part of the wall is removed to create a more open cavity. Each approach has advantages and tradeoffs involving recurrence surveillance, water precautions, future cleaning, and hearing reconstruction.
Partial canal-wall removal with canal reconstruction and mastoid obliteration surgery
In this surgical technique pioneered by Dr. Djalilian, a small part of the canal wall that is blocking the view of the cholesteatoma is removed. After the full removal of the cholesteatoma, that portion of the ear canal and the area of the mastoid that the cholesteatoma occupied is obliterated (filled and reconstructed) with your own bone and cartilage. This procedure has the advantages of the canal wall down surgery because it allows full visualization and removal of the cholesteatoma, but it does not lead to a large open cavity in the ear as the mastoid is obliterated (filled) and the ear canal wall is reconstructed. This leaves the patient with a normal sized ear canal without the lifelong cleaning needs and water precautions.
Endoscopic ear surgery
An endoscope can provide angled views into hidden spaces of the middle ear and may be used alone in selected limited disease or together with microscopic surgery. The approach is chosen according to disease extent and safety.
Lasers in Cholesteatoma surgery
Dr. Djalilian pioneered the use of the curved adjustable laser for cholesteatoma surgery. This form of laser can be used with endoscopes and can be used around crevices and corners in the ear. Lasers allow safer removal of disease around very sensitive structures of the inner ear and hearing bones (ossicles). In addition, we use lasers to destroy any potential residual cholesteatoma cells to prevent recurrence.
Ossicular reconstruction
If the hearing bones have been eroded, they may be repaired or replaced with a prosthesis during the first operation or a later staged procedure. Hearing restoration is secondary to complete and safe disease removal.
Mesna
Mesna is a drug that is used for treatment of certain conditions in the body. Mesna has been found to help reduce the adherence of cholesteatoma to the surrounding tissues. This allows the cholesteatoma to be removed more easily with a lower likelihood of recurrence. Dr. Djalilian is one of a handful of surgeons in the world at the forefront of cholesteatoma surgery using Mesna in surgical removal of cholesteatoma.
What to Expect After Cholesteatoma Surgery
Recovery depends on the extent of disease and the operation performed. Temporary ear pressure, drainage, muffled hearing, mild dizziness, and soreness around the ear may occur. Patients typically receive instructions about keeping the ear dry and using drops for the first few weeks. We prefer the patients to not participate in strenuous physical activity for one week. Our out of the area patients usually fly home 1-2 days after surgery after removing the dressing.
Follow-up is essential. Cholesteatoma can remain hidden in difficult areas or recur because of ongoing eardrum retraction. Surveillance may include office examinations, hearing tests, or diffusion-weighted MRI.
Can Cholesteatoma Come Back?
Yes. Recurrence risk varies with the type and extent of disease, Eustachian tube function, age, anatomy, and surgical approach. Long-term follow-up is important even when the ear feels normal and drainage has stopped. Generally, the likelihood of recurrence after surgery with Dr. Djalilian is 5%, which is significantly lower than the 30-50% recurrence rate with traditional approaches.
Why Choose a Cholesteatoma and Ear-Surgery Specialist?
Cholesteatoma surgery requires removal of disease from narrow spaces near the facial nerve, inner ear, brain covering, and major blood vessels. Hamid R. Djalilian, MD, is a board-certified, fellowship-trained otologist and neurotologist, professor of otolaryngology and biomedical engineering at UC Irvine, and director of UCI Health Otology, Neurotology and Skull Base Surgery Services. He has extensive experience treating cholesteatoma and has patients who travel from out of state for surgery. In the past few years, he has performed surgery on patients from Nevada, Arizona, New Mexico, Colorado, Utah, Wyoming, Illinois, Oregon, and Washington.
Dr. Djalilian evaluates primary, recurrent, and complex cholesteatoma; chronic ear infections; ossicular damage; and hearing reconstruction. Patients in Orange County, throughout California, and those seeking a second opinion may request review of their examination, hearing tests, CT or MRI, and prior operative records.
Frequently Asked Questions
No. It is trapped skin and keratin, not a malignant tumor. It can still behave aggressively by expanding, eroding bone, and causing infection.
Antibiotics and ear drops may control infection and drainage, but they usually do not remove the trapped skin. Surgery is commonly recommended for definitive treatment.
Yes. It can damage the eardrum, hearing bones, or inner ear. Early treatment may reduce the risk, but hearing cannot always be fully restored.
Very rarely. Dr. Djalilian has performed close to 800 cholesteatoma surgeries using his novel PCWDwO where a small portion of the obstructing canal is removed to expose the cholesteatoma and that portion is reconstructed and mastoid obliterated with your bone and cartilage. This allows the surgery to be done in one stage without the need for a second surgery.
Selected limited cases may be treated through the ear canal with endoscopic or microscopic techniques. More extensive mastoid disease may require an incision behind the ear. The safest approach depends on the disease, not cosmetic preference alone.
Schedule a Cholesteatoma Consultation
Persistent drainage, one-sided hearing loss, recurrent infections, or a suspected cholesteatoma should be evaluated promptly. To schedule an appointment with Dr. Hamid R. Djalilian, call UCI Health at 714-456-7017. Bring prior audiograms, CT or MRI images, and operative reports when available.
Written and medically reviewed by Hamid R. Djalilian, MD. Last reviewed July 2026.