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Chapter 5
Primary Care Otolaryngology
The treatment for cholesteatoma is surgical removal. While excision gets
rid of the cholesteatoma, the underlying eustachian tube dysfunction is
still present. Thus, cholesteatoma has the propensity to recur. Once
patients have undergone surgery for removal of a cholesteatoma, they will
need continuous monitoring of their ears for the rest of their lives.
Another way cholesteatoma can develop is when squamous epithelium
migrates into the middle ear space through a hole in the eardrum. The
perforation can come from a previous otitis media infection, a PE tube
hole that did not heal, or trauma.
Marginal perforations, or holes along
the outer portion of the eardrum,
are more likely to allow migration of
epithelium than central perforations
.
Remember that the eardrum has
three layers: cuboidal epithelium in the middle ear, a fibrous layer in
the middle, and squamous epithelium on the outside.
When there is a
perforation, all three layers start to
proliferate
, but if the
squamous layer
and the cuboidal layer meet
, the
fibrous layer will stop
. This can lead to
a chronic perforation in which the middle ear is constantly being exposed
to the outside, and thus develops a low-grade inflammation.
Clinical Example
A 14-year-old boy comes to your office complaining of painless right ear
drainage. He is otherwise healthy, although he did have PE tubes in his
ears as a child. On examination, you find he has slightly turbid drainage
coming from a hole in his right eardrum. You diagnose chronic otitis
media and learn that he does not know he has a perforation. He has not
been trying to keep water out of his ear. You assume he has a
Pseudo-
monas aeruginosa
infection and prescribe ofloxacin otic solution (0.3%)
twice a day for 10 days. He returns in two weeks with a dry ear and a small
residual eardrum perforation. You next order an
audiogram
, a hearing
test that shows a 15-dB
conductive hearing loss with normal discrimina-
tion
(ability to understand words). You tell the patient to keep water out of
his ear. He comes back in four to six weeks and has not had any more
drainage, so you refer him for a
tympanoplasty
.
Tympanoplasty
Tympanoplasty
, an operation to
repair a hole in the eardrum
, is gener-
ally performed either
through the ear canal or from behind the ear
. The
surgeon freshens up the edges of the hole. Then, because the fibrous tissue
will not grow with squamous epithelium meeting cuboidal epithelium,
a piece of
fascia temporalis
(the fibrous connective tissue overlying the
temporalis muscle) or
tragal perichondrium
(the lining overlying the