Cholesteatoma A cholesteatoma is an ingrowth of the skin of the external layer of the eardrum in the middle ear.

It is generally caused by a chronic retraction pocket of tympanic membrane, creating persistently high negative pressure of the middle ear. the skin forms a sac that fills with degenerated skin and sebaceous materials. The sac can attach to the structures of the middle ear or mastoid or both.

Normal

Cholesteatoma

Chronic otitis media can cause chronic mastoiditis and lead to the formation of cholesteatoma. It can occur in the middle ear, mastoid cavity, or both, often dictating the type of surgery to be performed. Cholesteatomas are common benign tumors of the inner ear. They usually do no cause pain, however, if treatment or surgery is delayed, they may destroy structures of the temporal bone. These fast growing benign tumors may cause severe sequelae such as hearing loss or neurologic disorder. Cholesteatomas may be asymptomatic or they may cause hearing loss, facial pain and paralysis, tinnitus, or vertigo. Audiometric tests often show a conductive or mixed hearing loss. Based on presenting symptoms, diagnosis may be made by visual examination or by computed tomography or MRI. Therapy includes treatment of the acute infection and surgical removal of the mass to restore hearing. Medical Management Local treatment of chronic otitis media consists of careful suctioning of the ear under otoscopic guidance. Instillation of antibiotic drops or application of antibiotic powder is used to treat purulent discharge. Systemic antibiotics are prescribed only in cases of acute infection. Surgical Procedures: Surgery can be performed either through the ear canal or in combination with an incision behind the ear. Tympanoplasty

With a cholesteatoma limited to the tympanic membrane or with a small congenital cholesteatoma or with a limited cholesteatoma forming through an eardrum perforation, the procedure can be done through the ear canal. Incisions are made within the ear canal and the ear canal skin along with the eardrum are lifted to inspect the middle ear. Frequently the chorda tympani nerve (taste nerve) may need to be moved aside to allow adequate inspection. This may cause a temporary taste disturbance from the front part of the tongue on that side. If the nerve becomes overly stretched, the patient can have a permanent metallic taste. In order to avoid this the nerve is divided. Eventually the taste buds on that side usually become reinnervated from taste fibers from the opposite side of the tongue. Occasionally the cholesteatoma may invade this nerve and it may be necessary to resect the nerve anyway. In order to allow clear visualization of the cholesteatoma, frequently it is necessary to remove the incus bone. Inner ear trauma leading to temporary dysquilibrium from overmanipulation of the stapes bone while dissecting the cholesteatoma from the surrounding structures can occur. The cholesteatoma and/or retracted portion of the eardrum is then dissected and removed. The eardrum is repaired using the covering (fascia) of the chewing muscle (temporalis) as a template for tympanic membrane growth. The continuity of the ossicles is then restored using either the patients own incus or an artificial prosthesis. Ossiculoplasty Ossiculoplasty is the surgical reconstruction of the middle ear bones to restore hearing. Prostheses made of materials such as Teflon, stainless steel, and hydroxyapatite are used to reconnect the ossicles, thereby reestablishing the sound conduction mechanism. However, the greater the damage, the lower the success rate or restoring normal hearing. Mastoidectomy The objectives of the mastoid surgery are to remove the cholesteatoma, gain access to diseased structures, and create dry and healthy ear. If possible, the ossicles are reconstructed during the initial surgical procedure. A mastoidectomy is usually performed through a postauricular incision. Infection is eliminated by removing the mastoid air cells. A second mastoidectomy my be necessary to check for recurrent or residual cholesteatoma. Nursing Intervention Reducing Anxiety

The nurse reinforces the information discussed by otologic surgeon with the patient, including the anesthesia, the location of incision, and expected surgical result. The patient also encourage to discuss any anxieties and concerns about the surgery.

Relieving Pain Although most patient complain very little about incisional pain after mastoid surgery, they do have some ear discomfort. Aural fullness or pressure after surgery is caused by residual blood or fluid in the middle ear. The prescribed analgesic medication may taken for the first 24 hours. Preventing Infection Measures are initiated to prevent infection in the operated ear. The external auditory canal wick, or packing, may impregnated with an antibiotic solution before instillation. Prophylactic antibiotics are administered as prescribed, and the patient is instructed to prevent water from entering the external auditory canal for 6 weeks. Improving Hearing and Communication Hearing in the operated ear may be reduce for several weeks because of edema, accumulation of blood and tissue fluid in middle ear and dressings or packing. measures are initiated to improve hearing and communication, such as reducing environmental noise, facing the patient when speaking, speaking clearly and distinctly without shouting, providing good lighting if the patient relies on speech reading, usually non-verbal clues(eg, facial expression, pointing, gestures). Preventing Injury Vertigo may occur after mastoid surgery if the semicircular canals or other areas of the inner ear are traumatized. Antiemetic or antivertiginous medication(eg, antihistamine) can be prescribed if a balance disturbance or vertigo occurs. Safety measures such as assisted ambulation are implemented to prevent falls and injury. Preventing Altered sensory Perception Facial nerve injury is a potential, although rare, complication of mastoid surgery. The patient is instructed to report immediately any evidence of facial nerve( cranial nerve VII) weakness, such as drooping of the mouth on the operated side, slurred speech, decreased sensation, and difficulty swallowing.