Cholesteatoma treatment in Bangalore

It is not the voice that commands the story; it is the ear…….
– Italo Calvino

The ear is the organ of hearing and balance which are vital to our human body. An ear infection is one of the commonest conditions that can lead to morbidity. Infection of the middle ear is called otitis media and if it persists for more than three months it is termed as chronic otitis media. The middle ear houses the three bones of hearing called the ossicles. It also contains important structures and lies close to the brain. Hence any infection in the ear if not treated has a chance of spreading to other areas such as brain.

Chronic otitis media can be either safe or unsafe type depending upon the disease process. The unsafe type is also called as cholesteatoma or squamous disease. Cholesteatoma is collection of epithelial debris in the middle ear due to persistent infection and negative middle ear pressure that can destroy the bones and has the propensity to spread beyond the confines of ear. Hence cholesteatoma is termed as unsafe type.

Persistent middle ear pressure can be due to abnormal Eustachian tube (tube that connects ear to back of the nose) function. This negative pressure pulls the weakest part of the ear drum (pars flaccida) resulting in the formation of sac like structure that leads to collection of epithelial debris resulting in the formation of cholesteatoma. The cholesteatoma contains inflammatory mediators and enzymes that has bone destruction capability. This results in erosion of bone leading to spread of cholesteatoma to the surrounding vital structures.

Cholesteatoma commonly presents as on and off pus discharge from ear that is foul smelling and can occasionally be blood stained. Decreased hearing is the next common symptom that results due destruction of hearing bones (ossicles). Sometimes cholesteatoma presents with signs of complications like giddiness, facial weakness, fever, neck rigidity, swelling behind the ear, etc depending upon the structure it has spread to.

If a person experiences any of these symptoms, they are advised to consult an ENT surgeon and undergo a complete examination. A thorough otoneurological examination along with cleaning the ear and examining the findings through microscope or endoscope is necessary. Audiological (hearing test) evaluation followed by CT scan should be done to know the site, extent of the disease, condition of the bones and to rule out any impending complications.

Surgical clearance of the cholesteatoma is the mainstay of treatment. It involves clearing the cholesteatoma from the middle ear and mastoid and can also accompany the reconstruction of the ossicles if needed. Conventionally this surgery is being performed with the help of microscopes. Skin incision is made behind the ear lobe (post-aural) and the surgical clearance mandates drilling of mastoid bone. Microscopes render a narrow view that makes it difficult to visualize and clear the disease process in the deep and hidden structures of the middle ear. This has resulted in high recurrence rates following microscopic techniques.

Due to recent advances in technology, endoscopes are being used in the field of otology due to its improved visualization and optics. Endoscopes were used as an adjunct to microscopic technique to visualize the hidden areas and to guide in the clearance of disease in these areas to minimize the residual or recurrence. At present endoscopes are being used as the primary modality in cases of middle ear cholesteatoma.

Endoscopic technique is performed via the ear canal and it does not require post-aural scar or extensive tissue dissection and bone drilling. This technique has reduced the recurrence of the disease as per literature. It provides similar hearing improvement as microscopic technique but improved quality of life outcomes like better cosmesis, less post-operative pain and discomfort and early return to work and activities. There is no need for mastoid bandage and patient can be discharged as day care basis.

SVASTII is the centre for advanced endoscopic ear surgeries and (Prof) Dr. Satish Nair has been performing the endoscopic technique for basic as well as advanced otological procedures which renders the patient a scarless surgery with reduced hospital stay but without any compromise in the disease clearance. Our results have been similar to that of the microscopic surgery and at par with international standards.

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