Timely removal of “time bombs” in the ear
Otitis media is a familiar condition, but it is not generally considered to be a fatal one. Cholesteatoma otitis media, however, has the potential for intracranial and extracranial complications that can even threaten the life of the patient.
Having come into contact with a very large number of patients with cholesteatoma, and having encountered a variety of patients with different clinical manifestations of cholesteatoma in about 500 surgical cases a year, has given him a very deep understanding of cholesteatoma. Professor Chen told the reporter that he once asked a patient with a huge cholesteatoma how he felt about his condition during a room visit, but he didn’t expect that after talking to the patient for half a day, the patient didn’t say a word and didn’t pay any attention to him from the beginning to the end. A very large brain abscess, about four centimeters in size, had completely affected the patient’s speech function, and he could hear but could not speak (named aphasia), and his life was in danger at any time. The patient’s life was saved and he recovered completely after two months, for which the patient and his family were very grateful. On the other hand, it can be seen that the symptoms of brain abscess due to antibiotic abuse are not as typical as they used to be described in textbooks, but it is still important to realize that cholesteatoma-type otitis media complicated by brain abscess is not uncommon.
I also treated a 78-year-old woman who came to the emergency room with vertigo and facial palsy (commonly known as “crooked mouth and slanted eyes”), which turned out to be a result of two complications of cholesteatoma, one being labyrinthitis of the inner ear and the other facial palsy.
Cholesteatoma is like a time bomb in the ear canal, with unpredictable timing and unpredictable consequences, so once cholesteatoma otitis media is diagnosed, it should be treated as aggressively as possible.
Cholesteatoma otitis media should not be ignored
Cholesteatoma otitis media is one of the categories of otitis media, so let’s first look at what the classification of otitis media is. Professor Chen points out that the current classification of otitis media is very different from the past due to medical advances and a deeper understanding of it.
I. The past tense of otitis media classification –
1. Acute otitis media
(1) Acute non-suppurative otitis media
(2) Acute suppurative otitis media
2. Chronic otitis media
1) Simple otitis media.
2) otitis media with bone ulcer
3) cholesteatoma-type otitis media.
II. Present tense of otitis media classification –
1. Acute otitis media
(1) Acute purulent otitis media
(2) Acute non-suppurative otitis media (also called secretory otitis media or catarrhal otitis media)
2.Chronic otitis media
(1) Otitis media sequelae (adhesive otitis media, tympanic chamber sclerosis, non-tenderness)
(2) Middle ear cholesteatoma
From the above, it can be seen that cholesteatoma is a separate type of otitis media classification, both in the past and at present, which also shows that it has an aspect that cannot be ignored and needs to be taken seriously by patients and doctors.
Classification of cholesteatoma
Cholesteatoma is not a true tumor. It occurs clinically in adults, is unilateral, and can invade both ears. It is usually visible on CT as something that looks like a round ball, so we call it a cholesteatoma, and the contents look like something like bean curd.
There are two major types of cholesteatoma, “congenital cholesteatoma” and “acquired cholesteatoma”. Most congenital cholesteatomas are caused by the embryonic epithelium left behind during embryonic development. Acquired cholesteatoma is divided into acquired primary cholesteatoma and acquired secondary cholesteatoma. Acquired primary cholesteatoma usually does not have tympanic membrane perforation, the tympanic membrane is intact, and is often associated with superior tympanic chamber invagination; acquired secondary cholesteatoma is most often caused by acquired perforation of the tympanic membrane. In the beginning, it is not necessarily a cholesteatoma type otitis media, but may be a common otitis media. However, after repeated attacks, or after epithelium shed from the external auditory canal is shed to the middle ear through the tympanic membrane perforation, it snowballs and becomes a cholesteatoma.
Clinical manifestations of cholesteatoma
Acquired cholesteatoma has obvious symptoms and is easy to detect, while congenital cholesteatoma is more insidious.
The symptoms of acquired cholesteatoma are as follows
1. Long-term recurrent pus flow, and the pus has a special odor, like the smell of stinky tofu or rotten eggs.
In the early stage, cholesteatoma is relatively small and patients cannot feel the hearing loss, but cholesteatoma itself has osteolytic effect, which may lead to destruction of surrounding bone and damage the auditory tuberosity, thus leading to hearing loss. Some patients may experience tinnitus, and cholesteatoma can release some toxins, making it a more dangerous form of otitis media.
Symptoms of congenital cholesteatoma.
Congenital cholesteatoma has no special manifestations in the early stage, no symptoms of pus flow or recurrent infections, and is not quite the same as the acquired secondary ones, so it is not easy to detect. However, after the cholesteatoma grows to a certain extent, the patient may suffer from facial palsy or lose hearing in one ear, and then come back to the doctor. Hearing loss and facial palsy.
Complications of cholesteatoma
The complications of cholesteatoma do not only affect the ear, but can affect the head and face of the person. Cholesteatoma can cause many complications, some of which can be fatal.
So why can cholesteatoma cause serious complications? It starts with the structure of our middle ear.
The mastoid process of the middle ear is like a “ceiling” above what is known medically as the “brain plate” or “tympanic ventricle and sinus ceiling”. The posterior aspect of the mastoid process is adjacent to the cerebellum and the sigmoid sinus, a large intracranial blood vessel. The interior of the temporal bone also includes organs of the balancer such as the semicircular canal, which is in charge of body balance, and the facial nerve, hidden within the temporal bone, which is in charge of facial muscle movement. Damage to any of these structures can lead to complications, such as facial palsy, commonly known as a crooked mouth and slanted eyes. Complication of vaginitis leading to vertigo. Meningitis and, in severe cases, brain abscess. Complication of sigmoid sinus thrombophlebitis. In children, it may be complicated by a subperiosteal abscess behind the ear.
Treatment of cholesteatoma
Once diagnosed, cholesteatoma otitis media is best treated surgically. However, some patients who cannot tolerate surgery can be treated conservatively.
Conservative treatment – mainly for older, frail patients who cannot tolerate surgery. For example, patients with severe heart disease, high blood pressure, diabetes, or those who are too weak to tolerate surgery. Patients with active tuberculosis should not undergo surgery, which is a contraindication to surgery.
Conservative treatment: patients with fever and vertigo can be treated with appropriate medication, and localized ear drops can be used.
Surgical treatment – Almost all cholesteatoma-type otitis media can be treated surgically, except for the above-mentioned groups. The surgical treatment of cholesteatoma is now a very mature ear microsurgery technique called tympanoplasty, I should say. In some formal medical institutions, microsurgery has been carried out for many years, and the surgeons in microsurgery have undergone formal training in temporal bone anatomy and have extensive clinical experience, which should guarantee the safety of the surgery and keep the risks to a minimum. However, there are risks associated with any surgery, and natural tympanoplasty also carries certain risks, such as facial paralysis after surgery, which can lead to medically induced facial paralysis or other complications if the technique is not skilled. However, even after facial palsy occurs, it is not very scary and can be repaired by other methods.
Purpose of surgery: to completely remove the lesion, obtain a dry ear, reconstruct the patient’s hearing, and prevent intracranial and extracranial complications.
The probability of recovery: The probability of resolving pus infection is about 95%, and only a small percentage of patients will have a recurrence, and the probability of hearing improvement can reach about 70%.
The post-operative follow-up is still important, as routine surgery is usually hospitalized for three days, the first day for pre-operative preparation, the second day for opening, and the third day for discharge, followed by recovery at home. After 4-5 dressing changes, the stitches are usually removed in about a week and the growth of the tympanic membrane can be seen at one and a half months. It is important to have regular annual follow-ups and not to be negligent.
Finally, once a patient is clearly diagnosed with cholesteatoma otitis media, he or she should not hesitate to go to a regular hospital for active treatment, preferably with surgery to completely remove the lesion and prevent complications.