A cholesteatoma is an abnormal collection of skin cells that develops in the middle ear or mastoid and can slowly erode bone and surrounding structures. Despite the name, a cholesteatoma is not a cancer. It behaves more like a destructive ‘skin cyst’ that traps dead squamous epithelium and skin cells, harbours bacteria, and expands over time. As a result, an ear cholesteatoma can persist despite recurrent ear infections until the disease is surgically removed. This is also why early detection of cholesteatoma is important, even when the symptoms appear mild.
Most acquired cholesteatomas arise behind the eardrum due to long-term Eustachian tube dysfunction and eardrum retraction pockets caused by negative pressure, or they follow chronic ear infections and a tympanic membrane perforation. Less commonly, it can arise in the ear canal itself. When it occurs in the ear canal, it may be described as a cholesteatoma of the external ear canal and requires slightly different surgical planning from that for a typical middle ear cholesteatoma.
At Barrie Tan ENT Head & Neck Surgery, surgical management focuses on the safe and complete removal of cholesteatoma using an endoscopic ear surgery approach whenever appropriate, followed by a structured follow-up to reduce the risk of regrowth.
Cholesteatoma often starts with mild symptoms, but ongoing foul-smelling ear discharge and gradually worsening hearing loss are key warning signs. Many patients observe a cycle in which ear discharge improves briefly with ear drops or antibiotics, only to recur later. Ear pain may occur, but some individuals experience minimal pain. Adults with cholesteatoma symptoms require the same level of attention as children. Common symptoms:
Gradually worsening hearing loss in the affected ear
Tinnitus or a ringing in the ears
Recurrent ear infections
External ear canal cholesteatoma may present as a persistent ear canal infection, with crusting, debris accumulation, localised discomfort, and recurrent inflammation.
Complications arise when a cholesteatoma erodes bone, thereby allowing an infection to spread. Possible serious complications include worsening hearing loss from damaged hearing bones, inner ear problems causing vertigo or a sudden hearing decline, facial nerve weakness, mastoid bone infection, and, rarely, a brain abscess or intracranial complications. Seek urgent assessment if you develop dizziness, vertigo or facial weakness, as these may indicate serious complications of cholesteatoma.
When to See an ENT Specialist
You should see an ENT specialist if ear discharge lasts more than two weeks, smells foul, recurs, or is accompanied by hearing loss, dizziness or facial weakness.
Do not wait if you develop facial nerve paralysis, severe vertigo, severe headache, confusion, or a sudden hearing change, as these can indicate complications involving the inner ear or deeper structures with lateral sinus thrombosis risk.
It is also worth seeking a physical examination assessment if you have a:
These patterns do not, on their own, confirm the diagnosis of cholesteatoma, but an early review will make cholesteatoma treatment safer and simpler.
A cholesteatoma diagnosis is made by combining your symptom pattern with a careful ear examination, including microscope cholesteatoma otoscopy and targeted imaging tests as needed.
Otoscopy of the cholesteatoma is the initial step in diagnosis. Under the microscope with ear endoscopy, an ENT specialist looks for:
Early cholesteatoma refers to a condition in which it is still localised and has not yet caused significant bone erosion or serious complications. This makes mastoidectomy for cholesteatoma surgery more straightforward and hearing outcomes more favourable. That is why tracking symptoms and early diagnosis are important for cholesteatoma.
A hearing test helps quantify the degree and type of hearing loss. Cholesteatoma commonly causes conductive hearing loss by damaging the eardrum and middle ear bones. Over time, mixed or sensorineural hearing loss can develop when inner-ear structures are affected.
A computed tomography (CT) scan of the temporal bone is commonly performed if the results alter surgical management. It also helps map the extent of the cholesteatoma and assess for bone erosion. In select cases, an MRI can be used to detect residual or recurrent cholesteatoma, particularly during follow-up.
Cholesteatoma treatment is primarily surgical because the disease does not reliably resolve with ear drops or antibiotics alone; surgery is the only definitive treatment.
This is because though drops and antibiotics can suppress active infection and reduce ear discharge, they do not remove the underlying trapped skin cells that sustain the condition. Persistent infection can recur until definitive cholesteatoma removal is performed. That said, non-surgical steps still matter as they can reduce inflammation of the middle ear mucosa, control infection before surgery, and improve safety.
Non-surgical management aims to control infection and prepare the ear for initial surgery. It is not intended to ‘cure’ the cholesteatoma. This may include:
External canal disease may be an exception for treatment in carefully selected early cholesteatoma cases, in which local debridement and close monitoring may be considered. However, once bony bone erosion, persistent debris, or recurrent disease are present, surgical intervention is commonly recommended.
Cholesteatoma surgery is planned to safely remove all disease, reduce the risk of regrowth, and, when possible, restore the ear’s structure and hearing. The success rate of cholesteatoma surgery is typically very high for controlling the disease long-term and preserving hearing; however, the condition can recur, especially in children, particularly in congenital cholesteatoma. The success of the surgery depends on the extent of disease, whether any hard-to-see areas, such as the sinus tympani, are affected, and whether there is infection or scarring.
At Barrie Tan ENT, the planned approach to treat ear cholesteatoma is endoscopic ear surgery, typically a tympanomastoidectomy. A mastoidectomy for cholesteatoma is the surgical removal of the disease from both the middle ear (tympanum) and the mastoid air cells behind the ear. Depending on the extent of the procedure, the operation can be performed with an endoscope, a microscope, or both.
Some ears are best managed with additional reconstruction to reduce the risk of long-term complications of the mastoid cavity and to facilitate ear maintenance. This is where mastoid cavity obliteration and soft tissue reconstruction may be considered.
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These steps are not required for every patient. They are selected when they improve access to care, healing, long-term ear health, and surveillance.
Hearing reconstruction is considered once the cholesteatoma is removed and the ear is stable. Ossiculoplasty refers to reconstructing the damaged middle ear bones using your own tissue, prostheses, or a combination of both.
Ossiculoplasty may be done in the same operation or as a staged procedure, depending on:
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If a patient is suitable, ossiculoplasty can improve hearing; however, outcomes may vary. Scar tissue and inflammation can limit the hearing outcome even after careful reconstruction.
At Barrie Tan ENT at Gleneagles Hospital in Singapore, our team can help you understand the expected range of cholesteatoma surgery costs, once the likely surgical plan is clearer.
ENT Specialist for Cholesteatoma
If you have mild to moderate symptoms of cholesteatoma and your hearing loss is progressively worsening, it is advisable to book an appointment with Dr Barrie Tan. Early diagnosis helps improve patient outcomes.Â
After cholesteatoma surgery, expect a staged healing process: early recovery followed by long-term follow-up to monitor for cholesteatoma regrowth. While every ear is different, most patients can expect:
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Cholesteatoma surgery recovery time varies with the extent of disease and the reconstruction performed. Many patients can return to desk work within about a week, but precautions and activity modifications may be advised for longer, especially if there is packing or a reconstructed eardrum.
If ossiculoplasty is performed, hearing improvement may not be immediate. Some patients require staged hearing reconstruction, in which hearing outcomes are measured over months rather than weeks.
Complications of cholesteatoma surgery are uncommon in experienced hands. However, you should understand the key risk factors associated with the middle ear and mastoid before proceeding. Risks can include:
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Recovery is also a commitment. Good outcomes depend on keeping follow-up appointments, protecting the ear while it heals, and reporting any recurrent ear discharge or sudden change in hearing. If left untreated, complications of cholesteatoma can worsen.
Cholesteatoma can recur in two ways: either small fragments of the original growth were left behind and regrows as residual cholesteatoma, or a new one forms later due to a new skin pocket (called true recurrent cholesteatoma). This difference is why regular follow-up examinations are a required component of cholesteatoma treatment.
Doctors typically detect recurrent cholesteatoma during follow-up examination, although imaging may be used. Catching it early often means the second operation can be smaller and less risky.
Preventing recurrence involves follow-up, management of the Eustachian tube dysfunction with negative-pressure control, and the treatment of chronic inflammation to prevent tympanic membrane retraction pockets. While not always preventable, good surveillance is key. Long-term stability may be supported by keeping the ear dry, conducting regular reviews, and treating nasal allergies or chronic sinusitis.
For cholesteatoma of the external ear or ear canal, prevention also means avoiding repeated trauma and addressing narrowing or debris trapping, sometimes with meatoplasty.
Dr Barrie Tan employs advanced techniques, including endoscopic ear surgery for precise cholesteatoma removal, as well as other procedures as indicated. The goal is to clear the infection, prevent serious complications, prevent cholesteatoma regrowth, and improve hearing.
If you have persistent ear discharge, hearing loss, or frequent ear infections, seek medical attention immediately. Cholesteatoma can be fixed. Treating it sooner makes surgery simpler and protects your hearing long-term. If left untreated, serious complications can develop. Contact Barrie Tan ENT Head & Neck Surgery, for an evaluation.
MBBS, MRCS (Edinburgh), MMed (Otorhinolaryngology), FAMS
Dr Barrie Tan is an ENT specialist at Gleneagles Hospital, Singapore, with more than 20 years of clinical and surgical experience. He previously served as Head of ENT and Director of the Centre for Hearing and Ear Implants at Singapore General Hospital. The information provided is not intended as medical advice. More about our medical experts.
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