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Clinical Summary

Despite their name, cholesteatomas are not composed of cholesterol, nor are they a form of a malignancy. Cholesteatomas are collections of desquamating stratified squamous epithelium found in the middle ear or mastoid air cells. Congenital cholesteatomas occur most frequently in children and young adults. Acquired cholesteatomas originate from perforation or retraction of the TM allowing migration of epithelium into the middle ear.

Injury may occur to middle ear ossicles through the production of collagenases and may erode into the temporal bone, inner ear structures, mastoid sinus, or posterior fossa dura. Treatment delays can lead to permanent conductive hearing loss or infectious complications.

Many cholesteatomas have an insidious progression without associated pain or symptoms. Computed tomography (CT) scans may reveal bony destruction.

Management and Disposition

Refer to otorhinolaryngology (ENT) upon initial diagnosis. No emergent medical or surgical management is required unless they become symptomatic.


  1. Persistent pain associated with headache, facial motor weakness, nystagmus, or vertigo suggests inner ear or intracranial involvement.

  2. Polyps found on the TM may indicate the presence of a cholesteatoma and require further evaluation to exclude its presence.


Congenital Cholesteatoma. A congenital cholesteatoma is seen behind an intact tympanic membrane. (Photo contributor: C. Bruce MacDonald, MD.)


Acquired Cholesteatoma. A large cholesteatoma is noted with significant distortion of the TM. Note the yellow epithelial debris from the cholesteatoma in the area of the pars flaccida. Often there is an effusion and debris, which can distort the anatomy on otoscopy. (Photo contributor: C. Bruce MacDonald, MD.)


Acquired Cholesteatoma. This is a left ear with an inferior perforation and granulation tissue present just below the tip of the malleus. A white mass is seen behind the eardrum in the posterosuperior quadrant, roughly 12-o’clock to 3-o’clock position. This patient had a history of pressure equalizer (PE) tubes placed several years ago with a resultant perforation allowing squamous epithelium access to the middle ear. (Photo contributor: David R. White, MD.)

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