Cholesteatoma

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 11 Aug 2025

Last updated: 10 Apr 2024

Cholesteatoma is an accumulation of squamous epithelium and keratin debris that usually involves the middle ear and mastoid.

Although benign, it may enlarge and invade adjacent bone.

Often presents with a malodorous ear discharge with associated hearing loss.

Diagnosis is clinical based on history and otoscopic findings. CT scan of the temporal bone, provides lesion definition and extent.

Treatment is surgical removal. Adjunctive topical antimicrobial treatment may help reduce acute symptoms preoperatively.

Complications include hearing loss, recurrence, meningitis, facial palsy, and a labyrinthine fistula.

Definition

Cholesteatoma is defined as the presence of keratinising squamous epithelium within the middle ear, or in other pneumatised areas of the temporal bone. This keratinising epithelium exhibits independent growth, leading to expansion and to resorption of underlying bone.[1] Focal erosion of external canal bone with accumulation of keratin is called external canal cholesteatoma.[2]

History and exam

Key diagnostic factors

presence of risk factors
hearing loss
ear discharge resistant to antibiotic therapy
attic crust in retraction pocket
white mass behind intact tympanic membrane

Full details

Other diagnostic factors

tinnitus
otalgia
altered taste
dizziness
facial nerve weakness

Full details

Risk factors

middle ear disease
eustachian tube dysfunction
otological surgery
traumatic blast injury to ear
congenital anomalies
family history

Full details

Diagnostic investigations

1st investigations to order

pure tone audiogram
CT scan of the petrous temporal bones

Full details

Investigations to consider

fistula test
MRI scan of the head and petrous temporal bones
bacterial culture

Full details

Treatment algorithm

ACUTE

all patients

Contributors

Authors

Susan A. Douglas, MBBS (Hons) UWI, FRCSEd, FRCS (ORL-HNS)

Consultant Otolaryngologist and Otologist

Rotherham NHS Foundation Trust

Rotherham

Disclosures

SAD declares that she has no competing interests.

Peer reviewers

Cliff Megerian, MD

Professor and Vice Chairman of Otolaryngology

Case Western Reserve University School of Medicine

Cleveland

Disclosures

CM is an author of a reference cited in this topic.

Iain Swan, MD, FRCS

Senior Lecturer in Otolaryngology

Honorary Consultant Otolaryngologist

Glasgow Royal Infirmary

Glasgow

Disclosures

IS declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Kuo CL, Shiao AS, Yung M, et al. Updates and knowledge gaps in cholesteatoma research. Biomed Res Int. 2015;2015:854024.Full text Abstract

Castle JT. Cholesteatoma pearls: practical points and update. Head Neck Pathol. 2018 Sep;12(3):419-29.Full text Abstract

Isaacson G. Diagnosis of pediatric cholesteatoma. Pediatrics. 2007 Sep;120(3):603-8. Abstract

Bhutta MF, Williamson IG, Sudhoff HH. Cholesteatoma. BMJ. 2011 Mar 3;342:d1088. Abstract

Ayache D, Darrouzet V, Dubrulle F, et al. Imaging of non-operated cholesteatoma: clinical practice guidelines. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Jun;129(3):148-52. Abstract

American College of Radiology. ACR appropriateness criteria: hearing loss and/or vertigo. 2018 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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Cholesteatoma

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

all patients

Contributors

Authors

Susan A. Douglas, MBBS (Hons) UWI, FRCSEd, FRCS (ORL-HNS)

Disclosures

Peer reviewers

Cliff Megerian, MD

Disclosures

Iain Swan, MD, FRCS

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice