The Laryngoscope

C 2015 The American Laryngological,

V

Rhinological and Otological Society, Inc.

TRIOLOGICAL SOCIETY
CANDIDATE THESIS

A New Theory on the Pathogenesis of Acquired Cholesteatoma:

Mucosal Traction
Robert K. Jackler, MD; Peter L. Santa Maria, MBBS, PhD; Yasin K. Varsak, MD; Anh Nguyen, MD, PhD;
Nikolas H. Blevins, MD
Objectives/Hypothesis: Although the migration of its squamous outer surface of the tympanic membrane has been well
characterized, there is a paucity of data available concerning the migratory behavior of its medial mucosal surface. Existing
theories of primary acquired cholesteatoma pathogenesis do not adequately explain the observed characteristics of the disease. We propose a new hypothesis, based upon a conjecture that mucosal membrane interactions are the driving force in
cholesteatoma.
Study Design: A retrospective chart review and a prospective observational cohort study in rats.
Methods: After developing the new theory, it was tested through both clinical and experimental observations. To evaluate whether impairment of middle ear mucociliary migration would influence cholesteatoma formation, a retrospective chart
review evaluating cholesteatoma occurrence in a sizable population of patients with either primary ciliary dyskinesia (PCD)
or cystic fibrosis (CF) was performed. To study mucosal migration on the medial aspect of the tympanic membrane, ink
tattoos were monitored over time in a rat model.
Results: No cholesteatomas were identified in either PCD patients (470) or in CF patients (1,910). In the rat model,
mucosa of the posterior pars tensa migrated toward the posterior superior quadrant, whereas the mucosa of the anterior
pars tensa migrated radially toward the annulus.
Conclusion: Mucosal coupling with traction generated by interaction of migrating opposing surfaces provides the first
comprehensive theory that explains the observed characteristics of primary acquired cholesteatoma. The somewhat counterintuitive hypothesis that cholesteatoma is fundamentally a mucosal disease has numerous therapeutic implications.
Key Words: Cholesteatoma, pathogenesis, mucosa, migration.
Level of Evidence: 4.
Laryngoscope, 125:S1S14, 2015

INTRODUCTION
In the broadest sense, there are two types of aural
cholesteatoma: congenital and acquired. Congenital cholesteatoma appears to originate from an ectopic rest of
squamous epithelium, which was dubbed the epidermoid
formation by Michaels.1 Acquired cholesteatoma has a
more diverse pathophysiology. Secondary acquired cholesteatoma, which is not very common, results from the
implantation of squamous epithelial fragments from the
implosion of the membrane in explosion injury or penetrating trauma. It may also be iatrogenic when fragments
of squamous epithelium are displaced into the tympanum
during ear microsurgery.2 Another cause is entrapment of
squamous epithelium due to stenosis of the ear canal assoFrom the Department of OtolaryngologyHead and Neck Surgery,
Stanford University School of Medicine (R.K.J., P.L.S.M., K.Y.V., N.H.B.), Stanford, California; and the Department of OtolaryngologyHead and Neck
Surgery, Oregon Health and Science University (A.N.), Portland, Oregon,
U.S.A.
Editors Note: This Manuscript was accepted for publication
February 20, 2015. The Triological Thesis by Robert K. Jackler, MD2
was accepted in 2015.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Robert K. Jackler, MD, Otolaryngology
Head & Neck Surgery, Stanford University School of Medicine, 801
Welch Rd, Stanford CA 94305. E-mail: jackler@stanford.edu
DOI: 10.1002/lary.25261

Laryngoscope 125: August 2015

ciated with trauma, osseous dysplasia, or congenital atresia3 However, such mechanisms are relatively rare.
The vast majority of acquired cholesteatomas arise
when a pouch of the tympanic membrane (TM) draws
into the attic and/or posterior mesotympanum (Figs. 14).
Over the last century, numerous otologists have offered
theories to explain the mechanism by which these socalled primary acquired cholesteatomas form.4 Existing
theories emphasize the role of the squamous layer and
aggressive keratinocyte behavior. The purpose of the
present thesis is to present an alternative theory concerning the pathogenesis of cholesteatoma based upon the
novel postulate that primary acquired cholesteatoma is
primarily driven by activities and interactions of tympanic mucosal surfaces.

MATERIALS AND METHODS

Animal Study: Mucosal Migration in the Rat
To assess mucosal migration on the medial surface of the
TM, 15 adult male Sprague Dawley rats underwent mucosal
tattooing. Using a sterile technique, the tympanic bulla was
approached after a midline incision and retraction of the cervical musculature. The bulla was opened using a 0.5-mm diamond
burr exposing the medial surface of the tympanic membrane. To
allow for maximum contact of the tattooing ink (MGI-6 from
Dragonhawk Hebei, China) to the mucosal layer in the middle
ear, acetyl cysteine 100mg/ml was applied by a cotton ball

Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

S1

Fig. 1. The most common type of

acquired cholesteatoma originates in
the posterior tympanum. The pouch
develops an intimate relationship to
the long process and body of the
incus.
within the middle ear before being removed with a separate dry
cotton ball. After the middle ear was dried of fluid, the tattoo
ink was placed using a blunt-tipped probed. One or more colors
were used to label separate areas of the tympanic membrane.
The tattoo ink was allowed to dry. Cervical fat was harvested
and placed over the bulla opening and fixed with tissue glue.
This was to prevent postoperative fluid in the neck dissection
from entering the tympanic cavity. Postoperatively, the rats
were photographed using an adapted Welch Allyn (Skaneateles
Falls, USA) video-otoscope (Digital Macroview) via their external ear canal. The tattoo ink and its changes in position on the
medial surface of the tympanic membrane were recorded daily
over 2 weeks. All procedures were approved by our universitys
administrative panel on laboratory animal care.

Human Study: Cholesteatoma Incidence in

Patients With Mucociliary Impairment
A retrospective chart review of patients with primary ciliary dyskinesia and cystic fibrosis coexisting with otitis media or
cholesteatoma was conducted after approval by our universitys
internal review board. All patients presenting to our adult and
childrens university hospital, between January 1994 and
November 2013, with primary ciliary dyskinesia or cystic fibrosis were identified. The charts were reviewed retrospectively for
the coexisting diagnoses of otitis media or cholesteatoma. A
search of our institutions database of clinical records, from
1994 to March 2011, was also performed to calculate the incidence of otitis media and cholesteatoma in all patients presenting to our hospitals.

Fig. 2. As cholesteatoma pouch

deepens, it travels along the lateral
surface of the body of the incus.

Laryngoscope 125: August 2015

S2

Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

Fig. 3. As the cholesteatoma matures,

it becomes filled with keratin debris
and gradually expands through the
aditus-ad-antrum to involve the
mastoid.

RESULTS
Animal Study: Mucosal Migration in the Rat
A summary of the observed mucosal migration
pathway observed is shown in Figure 5. The mucosal
migration on the pars tensa was able to be observed
from 3 days to 9 days, depending on the placement of
ink on the TM. After 9 days, no further ink could be
seen on the medial surface of the pars tensa. In the posterior half of the pars tensa, the mucosal migration pattern followed away from the umbo to the posterior
superior quadrant of the pars tensa. In the anterior half
of the pars tensa, the pattern appeared to move more
radially toward the tympanic annulus. There was slight

movement superiorly in the anterior quadrant, although

this was difficult to assess due to the difficulty in applying
ink to the anterior superior quadrant of the pars tensa.
Inferior to the umbo, in the anterior or posterior half, the
pattern extended radially to the tympanic annulus.

Human Study: Primary Ciliary Dyskinesia and

Cystic Fibrosis Coexisting With Otitis Media or
Cholesteatoma
A total of 470 patients with primary cilia dyskinesia
(PCD) were identified. Of these, 55.3% (n 5 260) were
found to have presentations for otitis media. No cases of
cholesteatoma were found. A total of 1,910 patients with

Fig. 4. (A) Typical sites of origin of

acquired cholesteatoma: posterior
epitympanic (1), posterior mesotympanic (2), and anterior epitympanic
(3). (B) Note that the segments of the
TM from which acquired cholesteatomas arise overlie the ossicles, suggesting that the ossicles play a
central
role
in
cholesteatoma
formation.

Laryngoscope 125: August 2015

Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

S3

toma being of ectodermal origin.11,12 In the great

majority of acquired cholesteatoma, this theory is difficult to reconcile with the observation that the generative
membrane is demonstrably composed of a pouch derived
from invagination of the TM.

Squamous Immigration Theory/Invasion Theory

In the squamous immigration theory, the epithelium of the lateral surface migrates through a perforation at the margin of the TM to enter the middle ear
cavity. In animal models, squamous epithelium can be
made to migrate medially through a marginal perforation.13,14 An essential difficulty with this theory is that,
given the incidence of TM perforation, cholesteatomas
are relatively rare. The great majority of cholesteatomas
are also seen developing from an intact TM.

Squamous Basal Hyperplasia/Papillary

Ingrowth Theory
Fig. 5. A summary of the mucosal migration pathway of the pars
tensa of the tympanic membrane in rats. In the anterior half of the
TM, the ink dots migrated radially from the umbo to the annulus.
In the posterior part of the drum, there was radial migration but
also migration in the posterior superior direction.

cystic fibrosis were identified, of which 16.8% (n 5 320)

had presentations for otitis media and no cases of cholesteatoma. A database search of a total of 1,951,145
patient records was used to calculate our hospitals incidence of cholesteatoma, which was 0.17% (n 5 3,350).

Existing Theories of Acquired Cholesteatoma

Formation
A number of comprehensive reviews have been published in recent years cataloging the existing pathogenic
theories on the development of primary acquired cholesteatoma.58 All current theories hypothesize that the
driving force in the development of acquired cholesteatoma is the outer squamous layer of the TM. These
include: 1) squamous metaplasia, 2) squamous immigration, 3) squamous basal hyperplasia, and 4) obstruction
vacuumretraction (Fig. 6). The latter is the most widely
quoted theory cited by contemporary otologists. These
theories differ in their explanations as to how the squamous epithelium initially penetrates the middle ear and
mastoid. All agree that, once a deep pouch with a constricted orifice has become established, the pressure
from the impacted keratin (with or without associated
infection) sustains further cholesteatoma expansion.

Squamous Metaplasia Theory

In the squamous metaplasia theory, inflammation
in the middle ear leads to transformation of the middle
ear mucosal lining. Squamous metaplasia from middle
ear mucosa has been observed in animal models.9,10
There is no histological or experimental evidence that
metaplasia results in cholesteatoma, and all current evidence points to the squamous epithelium in cholesteaLaryngoscope 125: August 2015

S4

Migration of keratinocytes in epithelial layers

occurs from deep to superficial. In the basilar hyperplasia theory, basal keratinocytes are thought to proliferate
and penetrate the basement membrane and extend elongated pseudopodia into the subepithelial space. These
features can be induced in animal models and have been
seen histopathological specimens of human cholesteatoma.15,16 Although inflammation can drive proliferation, there is no supporting evidence for what drives
these basal cells to migrate medially rather than laterally. Another requirement for pathogenesis of cholesteatoma in this setting would be the weakening of the
supporting structures and inward traction exerted on
these basal cells.

Squamous ObstructionVacuumRetraction (Ex

Vacuo)/Retraction Pocket Theory
The most widely accepted theory today is that dysfunction of the Eustachian tube leads to formation of a
vacuum in the tympanic cavity, which draws in a segment of the TM (most often the pars flaccida) as a
pouch. Most of the support for this theory lies behind a
gerbil model of Eustachian tube ligation, which induced
cholesteatomas in 75%; the observation of greatly
increased incidence of cholesteatoma in cleft palate
patients; and the occurrence of retraction pockets in the
epitympanum.8,17,18 On the surface, this theory has
much intuitive appeal; but upon closer inspection, it has
a number of serious shortcomings. There are numerous
animal models of Eustachian tube dysfunction that did
not induce cholesteatoma.1928 Repairing cleft palates or
placing pressure equalization tubes in cleft palate
patients does not reduce the incidence of cholesteatoma.2932 Although middle ear vacuum could initiate
TM retraction, it cannot credibly be the sustaining force
for progressive growth of the cholesteatoma pouch. The
reason for this is that the epitympanum, aditus, and
antrum become blocked early in the course of the disease
and thus fill with mucous and/or inflammatory tissues
(such as granulation and polyps). Vacuum due to gas
Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

Fig. 6. Established theories on the pathogenesis of acquired cholesteatoma.

reabsorption is impossible under these circumstances.

Clinically, even wide-mouthed cholesteatoma pockets,
empty of keratin debris, can progressively invaginate
into a nonaerated epitympanum and mastoid. Further
evidence against hypo aeration-mediated vacuum in cholesteatomatous ears is the observation that endoscopy of
the Eustachian tube shows a surprising lack of pathological changes.33 In many cases, the mucosa of the anterior position of the middle ear cavity (the protympanum)
in the vicinity of the tubal orifice is healthy. Indeed, it
has been suggested that hyperpatency, rather than the
more common cited hypopatency of the Eustachian tube,
coupled with habitual sniffing, may contribute to cholesteatoma generation.34,35 Under the obstructionvacuum
retraction theory anatomical obstruction of the Eustachian tube, such as from obliteration after surgery for
infratemporal fossa tumor or nasopharyngeal carcinoma,
should be a potent stimulus for cholesteatoma formation.
But ears with actual tubal occlusion rarely develop cholesteatomas.3638 It has long been maintained that the
Laryngoscope 125: August 2015

pars flaccida, the most common segment of the TM to

generate a cholesteatoma, is thinner than pas tensa
when the opposite is actually true.39 Additional evidence
against the vacuum theory comes from the observation
that tympanostomy tubes do not prevent cholesteatoma
formation.40 Furthermore, following intact canal wall
tympanomastoidectomy for cholesteatoma, epitympanic
reretraction is often observed despite a functioning tympanostomy tube effectively ventilating the middle ear
space.

A Comprehensive Theory for the Pathogenesis of

Primary Acquired Cholesteatoma Needs To
Explain All Aspects of Its Observed Behavior
(Table I)
Characteristics of an Ideal Theory. Given that
gas absorption-mediated vacuum cannot plausibly sustain cholesteatoma growth, any new theory must explain
the mechanism that underlies the progressive pouch-like
Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

S5

TABLE I.
A Comprehensive Theory for the Pathogenesis of Primary
Acquired Cholesteatoma Needs to Explain:
Why cholesteatomas arise from the superior and posterior quadrants of the tympanic membrane and not anteriorly or inferiorly
How cholesteatoma growth can be driven into nonaerated spaces
such as a disease filled epitympanum and antrum
Why some ears develop stable atelectasis and others develop
cholesteatoma
The frequent lack of abnormality of the Eustachian tube and
tubotympanum
Why anatomical obstruction of the Eustachian tube does not routinely lead to cholesteatoma formation
Why functioning tympanostomy tubes do not prevent cholesteatoma recurrence
Why cholesteatomas arise in older children and young adults, but
not in infants and seldom in young children.
Why cholesteatoma is strongly associated with mastoid
hypopneumatization

invagination of the TM into the middle ear and mastoid.

It must also explain why cholesteatomas almost always
arise from the pars flaccida (epitympanum) or posterior
pars tensa but virtually never take origin from the anterior or inferior portions of the pars tensa41 (Fig. 4).
Importantly, the model also needs to account for the
strong association of cholesteatoma with the underdevelopment of the mastoid air cell system and explain why
some patients evolve simple atelectasis of the TM while
others develop a progressively expanding pouch. An
ideal theory would also elucidate the reason why cholesteatoma is often bilateral and occasionally familial.
Finally, a cogent theory must be verifiable by experimental analysis.
The Mucociliary System of the Middle Ear.
Given its importance to the newly proposed theory, it is
relevant to review what is known concerning the middle
ear mucociliary system.4246 The tympanum is lined by a
respiratory epithelium, which is low and cuboidal in
many areas, columnar in others, with a variable distribution of secretory (goblet) cells and cilia. Cilia are also
present on the mucosal undersurface of the tympanic
membrane.43 Sade described two concentrations of cilia,
which efficiently serve to clear the middle ear by directing the mucous blanket toward the Eustachian tube42
The most prominent is the hypotympanic pathway traversing the floor of the middle ear. The other pathways
are a tract along the anterior tympanic cavity, a tract
along the roof, and a tract over part of the promontory.42
Although numerous studies have characterized the pattern of epithelial migration of the lateral squamous surface of the TM, little has been described of the
movement on the mucosal undersurface of the drum.
The mucociliary apparatus consists of three functional
compartments: the cilia, a protective mucus layer, and
an airway surface liquid layer.47
Respiratory mucosal surfaces, such as those in the
nose and tracheobronchial tree, are well known to
migrate upon their basal laminae, and the current study
reveals that an ink dot migrates on the medial surface
but does not study whether it is the mucosa itself or its
Laryngoscope 125: August 2015

S6

mucous blanket that is responsible for the migration of

the ink. It would be believable to think the mucosal
surfaces in the middle ear behave similarly to other
respiratory mucosal surfaces, with mucosal epithelial
migration occurring. Mucosal migration in other respiratory surfaces is critical following injury, with
Interleukin-1beta mediating human airway epithelial
cell migration via NF-kappaB.48 This cytokine has
already been implicated in cholesteatoma pathogenesis,
with interleukin-1beta levels found to be raised in cholesteatoma.49,50 It is likely that the human mucosal
migration on the TM directs the secretion to join either
the upper or lower pathways described by Sade.42 The
mucosal migration pattern of the ossicles has also not
been well studied. It is most likely that the movement is
directed superiorly to join the superior mucosal pathway
toward eventual evacuation via the eustachian tube. The
mucous blanket presumably bridges to the floor of the
epitympanum via the mucosal surfaces of the suspensory
ligaments. The mucosal envelope of the middle ear has
been shown to have robust mucociliary clearance, which
rapidly expels secreted material from the tympanum.42
Our study confirms that ink tattooed to the mucosal surface of the tympanic membrane also migrates in a predictable pathway. Should the mucosa of the
undersurface of the TM lead to trapped mucosal elements, such as mucin or goblet cells, resulting inflammation occurs.

A Proposed New Theory for the Pathogenesis of

CholesteatomaMucosal Traction
Numerous investigators have demonstrated that
the outer epithelial surface of the TM is in constant
migration.51,52 Furthermore, the mucosal envelope of the
middle ear has been shown to have robust mucociliary
clearance, which rapidly expels secreted material from
the tympanum.42 Should the mucosa of the undersurface
of the TM come into contact with the mucosa of the lateral surface of the ossicles, the two mucosal surfaces
may become coupled. Once coupled, mucosal migratory
propulsion of the conjoined layers could drag the pliable
TM superiorly. Theoretically, upward traction of the
drum could be generated by a number of possible mechanisms (Fig. 7). The mucous blanket trapped between the
mucosal surfaces is propelled by ciliary action. Should
the mucosal secretion be tacky rather than slippery, an
upwardly flowing mucous blanket could gradually drag
the TM along the incus long process toward its body and
eventually traverse its suspensory ligaments onto the
mucosa of aditus and mastoid antrum. Another potential
driver would be net movement of the epithelial cell
layers themselves. Respiratory mucosal surfaces, such as
those in the nose and tracheobronchial tree, are well
known to migrate upon their basal laminae. Finally, it is
conceivable that the TM is drawn inward by sequential
adhesion of opposing mucosal surfaces by retraction of
bridging mucoid bands. We further break down the steps
in the pathogenesis of the mucosal traction theory below.
In our theory, primary acquired cholesteatoma formation involves the mucosal layer migrating and
Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

Fig. 7. Mucosal traction theory illustrating three potential types of mucosal interaction that drive cholesteatoma formation.

exerting traction on the TM. Proinflammatory mucosal

elements become trapped and cytokines are then
released, stimulating the second phase of growth, further keratinocyte proliferation, and migration. The third
stage of cholesteatoma growth occurs when impacted
keratin accumulates behind a constrained orifice and
exerts an expansile force, further accelerated by associated infection. It should be pointed out that such a
biphasic growth pattern (pouch first, then keratin accumulation) is implicit in all of the earlier cholesteatoma
pathogenic theories as well.
Phase I: The Role of Mucosal Traction. The natural history of cholesteatoma growth likely possesses a
precursor condition followed by two active phases of
growth. The precursor, which creates the necessary (but
not sufficient) condition for cholesteatoma formation, is
retraction of the drum in close proximity with the
ossicles. This is most likely due to middle ear under
pressure, resulting in medical deflection of the most pliant portions of the tympanic membrane. In the first
phase of cholesteatoma growth, our postulate is that net
migration of coapted mucosal leaves is the force that
drives invagination. Whereas the mucosal lining of the
TM is attached to a thin, pliable membrane, the mucosa
of the ossicles is fixed to their bony structure. If a net
force of movement is generated between them, it would
be expected to propel the more pliable TM. Supporting
this notion is the observation that entrapped islands of
mucosa have been identified in the vicinity of the leadLaryngoscope 125: August 2015

ing edge of cholesteatoma.53 It seems likely that, away

from the cholesteatoma leading edge, the mucosal
bilayer becomes reabsorbed, thus bringing the squamous
and fibrous layer of the TM directly into contact with
the periosteum of the ossicular chain.
Phase II: The Role of Mucins and Trapped
Mucosal Elements. Mucins are important glycoproteins
in the mucociliary transport process in the middle ear.54
Distinct mucin profiles are expressed in the middle ear,
and these change in disease states; in particular,
MUC5B and MUC4 are upregulated.54,55 Mucins found
in the phagocytes of the perimatrix and glandular cysts
found in the matrix also suggest that embedded mucosa
plays a crucial role in the pathogenesis of acquired cholesteatoma.56 A critical step is that mucin, which has
escaped from embedded mucosa, leads to the inflammation seen in the perimatrix, itself inducing keratinocyte
proliferation and migration and also bone destruction.57
Mucous glands are also increased in density in disease
states, but the density is diminished in cholesteatoma,
possibly because they have become broken down and
remnants embedded in the perimatrix.53,5862 Ongoing
coupled mucosal migration may lead to the trapping of
mucosa and mucosal elements, which in turn leads to
further inflammation and production of proinflammatory
cytokines. In the context of our proposed model of cholesteatoma, it is conceivable that cholesteatoma represents the end stage of increased mucosal migration,
trapped mucin, and mucosal elements. It may well be
Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

S7

that empty cholesteatoma pouches are capable of penetrating only preformed mucosal cavities (middle ear,
mastoid), which offer little resistance, but that bone erosion requires osteoclastic activity triggered by chronic
inflammation.
Phase III: The Role of Keratinocyte Hyperproliferation. Our theory proposes that the keratinocyte
migration in cholesteatoma is a secondary consequence
and not the driving factor in its pathogenesis. Keratinocytes in the tympanic membrane are in constant proliferation and migration. The keratinocyte layers are also
in constant migration from basal to superior layers and
outward from progenitor cell areas.63 Proliferation and
migration both increase in response to local cytokines
produced after injury or during inflammation.6466 One
of the main drivers for this is epidermal growth factor
receptor (EGFR) expression, which is upregulated in
injury and inflammation in the TM. Seventy-five per
cent of keratinocytes within cholesteatoma express
EGFR contrasting with 10% in normal canal skin.67 Its
inhibition can also prevent keratinocyte migration.66,68
Migration to deeper layers does not occur while there is
a robust supporting layer.63 In the TM, the fibrous and
mucosal layers act as this supporting layer. When this
supporting layer of mucosa migrates abnormally, the
underlying support is reduced. Without their supporting
structure, keratinocytes can then be found to migrate
medially.6
Hyperproliferation of keratinocytes in cholesteatoma
is well documented, including evidence of cytokeratin
markers of keratinocyte hyperproliferation (CK4,
CK34betaE12, CK10, CK14) being found in cholesteatoma
mucosal specimens.69 There are also a number of other
proepithelial proliferation cytokines associated with cholesteatoma, including IL1a and b, TNFa, ICAM1, LFA1,
IFNc, TGFa, and EGF.5 When keratinocytes undergoing
normal migration and proliferation are restricted in the
area into which they can migrate, such as in ligation of
the external ear canal in animal models,70 they can begin
to migrate into abnormal areas, leading to cholesteatoma.
Inflammation can also induce proliferation of cilia and
secretory cells, formulation of granulation tissue, and
bone turnover.9 In our proposed theory, the production of
proinflammatory cytokines results in increased proliferation and migration of keratinocytes. When combined with
the loss of the supporting layers of these migrating keratinocytes, the keratinocytes migrate into areas and become
trapped.
We believe it is the mucosal migration, with trapping of mucosal elements causing further inflammation
within the supporting layers, that leads to this loss of
supporting structure. When cholesteatoma is thought of
predominantly as a disease of the underlying supporting
tissuethat is, mucosawe can understand how it
relates to external auditory canal (EAC) cholesteatoma.
In the case of EAC cholesteatoma, bone is the underlying supporting tissue. Local osteitis develops with local
inflammatory cytokines, enhancing bone reabsorption
but also secondarily stimulating keratinocyte proliferation.3 Hence, in analogy to cholesteatoma arising from
the TM, EAC cholesteatoma may be driven primarily by
Laryngoscope 125: August 2015

S8

disease, which
epithelium.

damages

the

undersurface

of

the

What Can We Learn From Other Diseases of

Respiratory Mucosal Epithelium?
Because our new theory of pathogenesis depends on
the concept of mucosal migration, it is of interest to study
the occurrence of cholesteatoma in diseases of mucociliary
dysfunction. According to our theory, if mucosal migration
is impaired, then primary acquired cholesteatoma should
not evolve. Specifically, PCD and cystic fibrosis (CF) are
diseases of abnormal mucosal migration. In our retrospective cohort review of patients with these diseases, we
found no cases of cholesteatoma. In adults, we were
unable to find a report of cholesteatoma with PCD in the
literature (MEDLINE 1966). In children with PCD, two
studies report four cases of cholesteatoma, three of which
were bilateral.71,72 There is reason to question the accuracy of these reports. The cases of cholesteatoma were in
prior history and were not observed by the reporting
institution.73 In any case, it is more likely that a case of
bilateral cholesteatoma in a young child is of congenital
origin. There were no cases seen in any other large cohort
examining ear disease in PCD children.7478 According to
our hospitals own incidence of cholesteatoma (0.17%), we
should have identified 0.8 patients if PCD conferred no
immunity to the disease. Due to the very low incidences
of both PCD and cholesteatoma, it is hard to comment
about the relative risk of cholesteatoma in patients with
and without PCD.
Cystic fibrosis is a genetic disease with both
impaired cilia motility and abnormal mucosal migration.
We were unable to find (MEDLINE 1966) cases in the
literature of CF patients with cholesteatoma or cases in
our institutions cohort of 1,910 patients. If CF had no
effect on the incidence of cholesteatoma, according to our
hospitals own incidence of cholesteatoma (0.17%), we
should have identified 3.2 patients. The protective
effects of CF may lie in its impaired mucosal migration.
Following injury, regeneration of human CF airway surface epithelium is characterized by remodeling, delayed
differentiation, and altered proinflammatory and matrix
metalloproteinase responses.79 CF patients also have a
lower density of goblet cells.80 Migration and proliferation assays of CF airway epithelia demonstrate impaired
migration during healing.81 This direction of migration
can be controlled by wound currents in vitro. These currents are significantly reduced by blocking the cystic
fibrosis transmembrane conductance regulator (CFTR).82
Inhibition of CFTR, the defective channel in CF, impedes
mucosal migration.79,83 Impeded mucosal migration, as
seen in CF, is a logical explanation of the protective
effect of CF for cholesteatoma.

Association With Hypopneumatization

The strong correlation of hypopneumatization with
acquired cholesteatoma has led to extensive debates as to
whether it is a cause or effect of this disease84,85 An
intriguing possible explanation occurs to us, which closely
Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

links pneumatization to cholesteatoma formation. The

budding of mucosal tracts into the mastoid to form the
adult air cell system is a postnatal process that proceeds
roughly from infancy to adolescence. It is driven by invaginating mucosal pouches which, by epithelial proliferation, invade the marrow spaces of the mastoid.86 Mucosa
of the human ear is developmentally programmed to
undergo mucosal migration in early childhood to form the
mastoid antrum and peripheral air cell systems. Continuation of this process into later childhood and adolescence
may create more extensive pneumatization, extending
even into the apical petrous bone. Ultrastructural studies
show pneumatization occurs by the absorption of the mesenchymal tissue that occupied the space between epithelial layers and bone structures.87
An observation of interest is that the mastoid, like
the rest of the skull base early in life, is filled with
richly vascular, hematopoietically active red marrow.
With maturation, hematopoiesis moves predominantly to
the long bones and the skull base marrow becomes more
fatty yellow marrow.88 This phenomenon, together
with the deposition of more osteoid matrix and calcium,
may alter the potential for further mucosal ingrowth.
Suppose the normal process of mucosal migration were
delayed in its onset to a later stage during which the
mastoid, now more ossified and containing less vascular
yellow marrow, was no longer receptive to mucosal
ingrowth. Should the mucosal epithelium commence proliferation and make efforts at migration but be faced
with an impenetrable mastoid bone, this maladaptive
mucosal activity could then be most relevant to cholesteatoma formation. Vigorously proliferating epitympanic
mucosal surfaces, unable to fulfill their expected migratory intention, could constitute the dynamic engine that
propels cholesteatoma ingrowth. This developmentally
programmed mucosal migration of childhood, designed
to extend pneumatization deeper into the temporal bone,
could explain why acquired cholesteatoma primarily
evolves in older children and young adults and is virtually never seen in infants or toddlers.
Proctor has shown that the pneumatization process
follows the course taken by the embryological pouches,
derived from the first brachial pouch, which creates the
tympanum and antrum. The typical epitympanic cholesteatoma growth pattern follows these pathways while
traversing the epitympanic spaces into the mastoid via
Proctors superior and medical pouches.86 Interestingly,
mucous blanket movement throughout life tend to follow
the same pathways but in the reverse direction.86,89 Our
observations of mucosal migration of the TM suggest
there is a pathway of migration in the posterior half of
the TM toward the attic.
The postulated causal link between mastoid pneumatization and cholesteatoma formation should not lead
one to dismiss the importance of early childhood infection
in the evolution of disease. In pig models, which contain
mastoid systems resembling the human, the severity of
experimentally induced inflammation directly correlates
with the degree of inhibition of pneumatization.90,91
When a similar experiment was conducted, this time with
Eustachian tube dysfunction introduced, the pneumatizaLaryngoscope 125: August 2015

Fig. 8. In the mucosal traction theory, genesis of cholesteatoma

commences with coaptation of the mucosal lining of the undersurface of the tympanic membrane with that of the lateral surface of
the ossicles (incus depicted here).

tion was still correlated with inflammation but was not

affected by Eustachian tube dysfunction.92 It is not the
under pressure in the middle ear spaces, as previously
suggested, but the coexisting inflammation that is the
most important factor. Thus, inflammation at a critical
period in the development of the mastoid causes a suppression of mastoid pneumatization.93 This may also
explain the link between cleft palate patients, who are
prone to early otitis, and cholesteatoma. This is supported
by the inability to prevent cholesteatoma in cleft palate
patients with pressure equalization tubes.29,30
When examining the relationship of otitis media
with cholesteatoma in PCD and CF, the association
seems to be more complex. In our retrospective review
and in the literature, PCD is associated with both
almost universal otitis media and mastoid hypopneumatization.9499 According to our theory, the occurrence of
otitis media leads to delayed pneumatization. In PCD
patients, who have otitis media with abnormal mucosal
migration, the usual delayed pneumatization does not
occur. In contrast to PCD, CF patients have a lower incidence of otitis media hyperpneumatization of the temporal bones.81,100104 Without the inhibitory effect of otitis
media in CF, delayed pneumatization does not occur.
Presumably, because CF shows slower mucosal migration, this pneumatization occurs slower than other children without CF. It would be useful to compare mastoid
pneumatization between age-matched patients with and
without CF to investigate this hypothesis.

Why Does Acquired Cholesteatoma Occur in the

Attic? The Unique Properties of the Pars
Flaccida
Clues to the pathogenesis of cholesteatoma are also
present when examining the unique properties of the
pars flaccida. As its name suggests, the pars flaccida
possess higher elastic properties, allowing it to be drawn
in more easily.105 It is composed of three layers, with
Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

S9

Fig. 9. Conjoined mucosal layers may adhere with varying degrees of intimacy: via the mucosal blanket alone (A), with interdigitation of cilia
(B), or by direct approximation of the epithelial cells themselves (C).

epithelial layers similar to the pars tensa but a thicker

and less organized connective tissue layer between.39,105
The pars flaccida is the only part of the TM that has
been shown to contain mast cells. Mast cells are known
to secrete a number of pro inflammatory cytokines and
proteinases.106 Mast cell migration into epithelium is
seen in cholesteatoma but has not been observed in normal skin from any other anatomic site.107,108 Compared
with the pars tensa, there are fewer cilia in the pars
flaccida mucosa in healthy ears; however, during disease
states expression of cilia increases.46,86,109,110 In sum-

mary, the pars flaccida is more pliant, contains mast

cells, and has increased cilia in diseased statesall factors that may predispose to cholesteatoma formation
according to our theory.

Why Does Acquired Cholesteatoma Occur in the

Attic? The Ossicles
Cholesteatomas arise in the epitympanum and posterior middle ear precisely because the ossicles are present to provide a nearby opposing mucosal surface (Fig.

Fig. 10. Pouch formation due to the propulsive effects of ciliary beat on the
entrapped mucous blanket.

Laryngoscope 125: August 2015

S10

Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

Fig. 11. Pouch formation resulting

from migration of the mucosal epithelium on the surface of the
ossicles.

8). One mechanism of trapping proposed is the contact

with the mucosa of the lateral surface of the ossicles,
leading to coupling of the two opposing mucosal surfaces
(Fig. 9). Once coupled, mucosal migratory propulsion of
the conjoined layers could drag the pliable TM superiorly in the predicted path of normal mucosal migration.

The mucous blanket becomes trapped between the mucosal surfaces, propelled by ciliary action, leading to trapping of mucosal elements (Fig. 10). Another potential
driver would be net movement of the epithelial cell
layers themselves (Fig. 11). Finally, it is conceivable that
the TM is drawn inward by sequential adhesion of

Fig. 12. Pouch development by sequential adhesion (AC) of the tympanic membrane to the ossicular surface through contraction of bridging mucous bands.

Laryngoscope 125: August 2015

Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

S11

opposing mucosal surfaces by retraction of bridging

mucoid bands (Fig. 12).

cartilage alone, eliminating the use of a reinforcing fascia graft, may be a superior strategy in avoiding generation of a recurrent pouch.

DISCUSSION
Therapeutic Implications of the Mucosal
Traction Theory
Once we make the assumption that cholesteatoma
is fundamentally a mucosal disease, a number of
observed properties of cholesteatoma, which were not
easily explained by earlier theories, appear to have plausible explanations. The second insight of fundamental
importance is the independence of the proposed mechanism from Eustachian tube dysfunction, other than the
initial stages that bring the opposing mucosal surfaces
into contact. The theory also explains why some patients
develop atelectasis whereas others develop a pouch. Variation must exist in the vigor mucosal migration and/or
in the pattern of its movement. It is also easy to imagine
that some individuals have thinner, more lubricating
mucous, which enables opposing surfaces to glide by,
rather a more viscous mucous, which adheres and
thereby couple the migration of adjacent surfaces.54 It is
conceivable that variation in the composition and concentration of surfactant may be relevant.111
Should our hypothesis prove correct that cholesteatoma is fundamentally a mucosal disease, a number of
novel therapeutic strategies may be then explored. The
first would be to undertake measures that inhibit the
adhesion of abutting mucosal surfaces. Medications that
reduce the viscosity of mucous in order to lubricate the
interface of opposing surfaces would allow the mucous
blanket to glide without placing traction on the TM.
Intervention to separate adhered mucosal surfaces
before migration, perhaps by interposition of a slippery
biomembrane to separate opposing surfaces, may theoretically inhibit pouch formation. Therapies that reduce
the presence of cilia on the medial side of the drum and/
or the lateral aspect of the ossicles may also theoretically diminish the tendency to form cholesteatoma.
Selective depopulation of ciliated cells on the medical
aspect of the TM using a laser or pharmacological agent
may reduce the migratory vigor. Conceivably, measures
that reorient the pattern of mucous blanket flow away
from the epitympanum might have a beneficial effect.
In the near term, the most likely successful therapy
is to render the TM nonpliable, or to increase the support in that region through obliteration making the attic
resistant to migration. In recent years, otologists have
become increasingly aggressive with the use of autologous cartilage to reconstruct the TM.112,113 For many
years, cartilage discs have been placed to reconstruct
the epitympanum. These fail fairly often over time by
retraction of the TM around its margin. According to the
present theory, such recurrences result from mucosal
migration onto the undersurface of the scutum and cartilage graft, a postulate in line with clinical observation.
Hermetic cartilage replacement of the posterosuperior
TM, leaving no pliable membrane in this region, may
well have a higher rate of success in reducing recurrent
cholesteatoma. It could be speculated that utilization of
Laryngoscope 125: August 2015

S12

Future Strategies for Experimental Testing of

the Mucosal Migration Theory
Although a great deal is known about the migratory
behavior of the outer surface of the TM, little is known of
about the in vivo behavior of the undersurface of the TM
or the lateral aspect of the ossicles in man. This could be
studied in vivo with relative ease utilizing one of various
kinds of labeling substances available and placed, for
example, during tympanostomy tube placement or cochlear implant surgery. The variability of migratory vigor in
cholesteatomatous versus healthy ears would be of central interest. Explanted tympanic mucosa could be studied in vitro in organ or tissue culture to better elucidate
its migratory properties. Histologically, greater scrutiny
should be given to the leading-edge mucosal interface of
surgically resected cholesteatomas.
It is uncertain whether any animal model is relevant
to retraction pocket cholesteatoma in man. Most involve
either entrapment of squamous epithelium through ligature of the ear canal or induction of mucosal metaplasia
through exposure to caustic substances.14,114 Clearly
these models have little analogy to how acquired cholesteatomas typically arise in man. Perhaps detailed study
of mucosal interactions in the Mongolian gerbil, which
has been shown to have a high spontaneous rate of cholesteatoma formation, will provide useful insights.115 It is
not too difficult to conceive of an animal model in which
tympanic mucosal surfaces could be brought into juxtaposition in order to study their interaction.
Although it is the scientific equivalent of the cart
before the horse, it is a time-honored tradition in otology (although perhaps not an especially admirable one)
to test a hypothesis by implementing therapeutic strategies and assessing their effectiveness. For example, stapedectomy for otosclerosis was introduced and
progressively refined over 4 decades in the absence of a
clear understanding of the pathophysiology of the underlying disease process. Because our current therapeutic
strategies for acquired cholesteatoma are associated
with a disappointingly high incidence of recurrence,
novel strategies that entail little or no risk to the patient
are justifiable when their theoretical underpinnings are
strong.

CONCLUSION
A novel theory of cholesteatoma pathogenesis is
presented, which is based upon the premise that the
squamous pouch is drawn inward by the interaction of
opposing motile surfaces of middle ear mucosa. Conceptually, this putative mechanism is more closely aligned
with the observed characteristics of the disease than earlier theories.

Acknowledgment
Artist Christine
illustrations.

Gralapp

produced

the

original

Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

BIBLIOGRAPHY
1. Lee TS, Liang JN, Michaels L, Wright A. The epidermoid formation and
its affinity to congenital cholesteatoma. Clin Otolaryngol Allied Sci
1998;23:449454.
2. Pulec JL, Deguine C. Iatrogenic cholesteatoma. Ear Nose Throat J 2004;
83:445.
3. Vrabec JT, Chaljub G. External canal cholesteatoma. Am J Otol 2000;21:
608614.
4. Soldati D, Mudry A. Knowledge about cholesteatoma, from the first
description to the modern histopathology. Otol Neurotol 2001;22:723
730.
5. Olszewska E, Wagner M, Bernal-Sprekelsen M, et al. Etiopathogenesis of
cholesteatoma. Eur Arch Otorhinolaryngol 2004;261:624.
6. Sudhoff H, Tos M. Pathogenesis of sinus cholesteatoma. Eur Arch Otorhinolaryngol 2007;264:11371143.
7. Goycoolea MV, Hueb MM, Muchow D, Paparella MM. The theory of the
trigger, the bridge and the transmigration in the pathogenesis of
acquired cholesteatoma. Acta Otolaryngol 1999;119:244248.
8. Persaud R, Hajioff D, Trinidade A, et al. Evidence-based review of aetiopathogenic theories of congenital and acquired cholesteatoma. J Laryngol
Otol 2007; 121:10131019.
9. Wright CG, Meyerhoff WL, Burns DK. Middle ear cholesteatoma: an animal model. Am J Otolaryngol 1985;6:327341.
10. Kuijpers W, Vennix PP, Peters TA, Ramaekers FC. Squamous metaplasia
of the middle ear epithelium. Acta Otolaryngol 1996;116:293298.
11. Broekaert D, Coucke P, Leperque S, et al. Immunohistochemical analysis
of the cytokeratin expression in middle ear cholesteatoma and related
epithelial tissues. Ann Otol Rhinol Laryngol 1992;101:931938.
12. Youngs R, Rowles P. The spatial organisation of keratinocytes in acquired
middle ear cholesteatoma resembles that of external auditory canal skin
and pars flaccida. Acta Otolaryngol 1990;110:115119.
13. Friedmann I. The comparative pathology of otitis media, experimental and
human. II. The histopathology of experimental otitis of the guinea-pig
with particular reference to experimental cholesteatoma. J Laryngol
Otol 1955;69:588601.
14. Masaki M, Wright CG, Lee DH, Meyerhoff WL. Experimental cholesteatoma. Epidermal ingrowth through tympanic membrane following middle ear application of propylene glycol. Acta Otolaryngol 1989;108:113
121.
15. Sudhoff H, Bujia J, Borkowshi G, et al. Basement membrane in middle
ear cholesteatoma. Immunohistochemical and ultrastructural observations. Ann Otol Rhinol Laryngol 1996;105:804810.
16. Broekaert D. The problem of middle ear cholesteatoma: etiology, genesis
and pathobiology. A review. Acta Otorhinolaryngol Belg 1991;45:355367.
17. Wolfman DE, Chole RA. Experimental retraction pocket cholesteatoma.
Ann Otol Rhinol Laryngol 1986;95:639644.
18. Dominguez S, Harker LA. Incidence of cholesteatoma with cleft palate.
Ann Otol Rhinol Laryngol 1988;97:659660.
19. Piltcher OB, Swarts JD, Magnuson K, Alper CM, Doyle WJ, Hebda PA. A
rat model of otitis media with effusion caused by eustachian tube
obstruction with and without Streptococcus pneumoniae infection: methods and disease course. Otolaryngol Head Neck Surg 2002;126:490498.
20. Johnson MD, Contrino A, Contrino J, Maxwell K, Leonard G, Kreutzer D.
Murine model of otitis media with effusion: immunohistochemical demonstration of IL-1 alpha antigen expression. Laryngoscope 1994;104:11431149.
21. Khan JA, Campbell JC. Studies on the production of middle-ear effusion
in the experimental animal. J Laryngol Otol 1981;95:987993.
22. Hebda PA, Piltcher OB, Swarts JD, Alper CM, Zeevi A, Doyle WJ. Cytokine profiles in a rat model of otitis media with effusion caused by
eustachian tube obstruction with and without Streptococcus pneumoniae
infection. Laryngoscope 2002;112:16571662.
23. Kuijpers W, van der Beek JM, Willart EC. The effect of experimental tubal
obstruction on the middle ear. Preliminary report. Acta Otolaryngol
1979;87:345352.
24. Doyle WJ. Functional eustachian tube obstruction and otitis media in a
primate model. A review. Acta Otolaryngol Suppl 1984;414:5257.
25. Hellstrom S, Salen B, Stenfors LE, Soderberg O. Appearance of effusion
material in the attic space correlated to an impaired Eustachian tube
function. Int J Pediatr Otorhinolaryngol 1983;6:127134.
26. Ebert CS, Jr., Pollock HW, Dubin MG, et al. Effect of intranasal histamine
challenge on Eustachian tube function. Int J Pediatr Otorhinolaryngol
2002;63:189198.
27. Downs BW, Butehorn HF, 3rd, Prazma J, Rose AS, Stamat JC, Pillsbury
HC, 3rd. Action of histamine on eustachian tube function. Otolaryngol
Head Neck Surg 2001;124:414420.
28. Heavner SB, Hardy SM, White DR, McQueen CT, Prazma J, Pillsbury
HC, 3rd. Function of the eustachian tube after weekly exposure to pepsin/hydrochloric acid. Otolaryngol Head Neck Surg 2001;125:123129.
29. Reiter R, Haase S, Brosch S. Repaired cleft palate and ventilation tubes
and their associations with cholesteatoma in children and adults. Cleft
Palate Craniofac J 2009;46:598602.
30. Hornigold R, Morley A, Glore RJ, Boorman J, Sergeant R. The long-term
effect of unilateral t-tube insertion in patients undergoing cleft palate
repair: 20-year follow-up of a randomised controlled trial. Clin Otolaryngol 2008;33:265268.
31. Spilsbury K, Ha JF, Semmens JB, Lannigan F. Cholesteatoma in cleft lip
and palate: a population-based follow-up study of children after ventilation tubes. Laryngoscope 2013;123:20242029.

Laryngoscope 125: August 2015

32. Muntz HR. An overview of middle ear disease in cleft palate children.
Facial Plast Surg 1993;9:177180.
33. Sasaki C, Yamashita K, Miyazaki T, Y S. Etiological significance of tubal
dysfunction in pediatric cholesteatoma. In: Tos M, Thomsen J, Peitersen
E, eds. Cholesteatoma and Mastoid Surgery. Amsterdam, The Netherlands: Kugler; 1989:481484.
34. Sakagami M, Tsuji K, Sone M. Importance of habitual sniffing in the
pathogenesis of bilateral cholesteatoma. In: Magnan J, Chays A, eds.
Proceedings of the Sixth International Conference on Cholesteatoma
and Ear Surgery. Cannes, France: Label Production; 2000:6770.
35. Magnuson B. Tubal closing failure in retraction type cholesteatoma and
adhesive middle ear lesions. Acta Otolaryngol 1978;86:408417.
36. Coker NJ, Jenkins HA, Fisch U. Obliteration of the middle ear and mastoid cleft in subtotal petrosectomy: indications, technique, and results.
Ann Otol Rhinol Laryngol 1986;95:511.
37. Chen CY, Young YH, Hsu WC, Hsu MM. Failure of grommet insertion in
post-irradiation otitis media with effusion. Ann Otol Rhinol Laryngol
2001;110:746748.
38. Low WK, Fong KW. Long-term post-irradiation middle ear effusion in
nasopharyngeal carcinoma. Auris Nasus Larynx 1998;25:319321.
39. Lim DJ. Tympanic membrane. II. Pars flaccida. Acta Otolaryngol 1968;66:
515532.
40. Roland NJ, Phillips DE, Rogers JH, Singh SD. The use of ventilation
tubes and the incidence of cholesteatoma surgery in the paediatric population of Liverpool. Clin Otolaryngol Allied Sci 1992;17:437439.
41. Jackler RK. The surgical anatomy of cholesteatoma. Otolaryngol Clin
North Am 1989;22:883896.
42. Sade J. Middle ear mucosa. Arch Otolaryngol 1966;84:137143.
43. Lim DJ, Hussl B. Human middle ear epithelium. An ultrastructural and
cytochemical study. Arch Otolaryngol 1969;89:835849.
44. Kawabata I, Paparella MM. Ultrastructure of normal human middle ear
mucosa. Preliminary report. Ann Otol Rhinol Laryngol 1969;78:125137.
45. Shimada T, Lim DJ. Distribution of ciliated cells in the human middle ear.
Electron and light microscopic observations. Ann Otol Rhinol Laryngol
1972;81:203211.
46. Albiin N, Hellstrom S, Stenfors LE, Cerne A. Middle ear mucosa in rats
and humans. Ann Otol Rhinol Laryngol Suppl 1986;126:215.
47. Mall MA. Role of cilia, mucus, and airway surface liquid in mucociliary
dysfunction: lessons from mouse models. J Aerosol Med Pulm Drug
Deliv 2008;21:1324.
48. White SR, Fischer BM, Marroquin BA, Stern R. Interleukin-1beta mediates human airway epithelial cell migration via NF-kappaB. Am J Physiol Lung Cell Mol Physiol 2008;295:L1018L1027.
49. Kim CS, Lee CH, Chung JW, Kim CD. Interleukin-1 alpha, interleukin-1
beta and interleukin-8 gene expression in human aural cholesteatomas.
Acta Otolaryngol 1996;116:302306.
50. Schilling V, Negri B, Bujia J, Schulz P, Kastenbauer E. Possible role of
interleukin 1 alpha and interleukin 1 beta in the pathogenesis of cholesteatoma of the middle ear. Am J Otol 1992;13:350355.
51. Boxall JD, Proops DW, Michaels L. Scanning electron microscopy of tympanic membrane epithelium during in vitro migration. J Otolaryngol
1990;19:5761.
52. Moriarty BG, Johnson AP, Patel P. Patterns of epithelial migration in the
unaffected ear in patients with a history of unilateral cholesteatoma.
Clin Otolaryngol Allied Sci 1991;16:4851.
53. Sudhoff H, Bujia J, Holly A, Kim C, Fisseler-Eckhoff A. Functional characterization of middle ear mucosa residues in cholesteatoma samples. Am
J Otol 1994;15:217221.
54. Lin J, Tsuprun V, Kawano H, et al. Characterization of mucins in human
middle ear and Eustachian tube. Am J Physiol Lung Cell Mol Physiol
2001;280:L1157L1167.
55. Schousboe LP, Rasmussen LM, Ovesen T. Induction of mucin and adhesion molecules in middle ear mucosa. Acta Otolaryngol 2001;121:596
601.
56. Nagai T, Suganuma T, Ide S. Mucosubstance histochemistry and pathogenesis of acquired cholesteatoma. Eur Arch Otorhinolaryngol 2007;264:
749753.
57. Nagai T, Suganuma T, Ide S, Shimoda H, Kato S. Confirmation of mucin
in lymphatic vessels of acquired cholesteatoma. Eur Arch Otorhinolaryngol 2006;263:361364.
58. Tos M, Caye-Thomasen P. Mucous glands in the middle earwhat is
known and what is not. ORL J Otorhinolaryngol Relat Spec 2002;64:86
94.
59. Tos M, Bak-Pedersen K. Density of mucous glands in chronic otitis media.
Arch Otolaryngol 1974;99:180184.
60. Sade J. Cellular differentiation of the middle ear lining. Ann Otol Rhinol
Laryngol 1971;80:376383.
61. Lim DJ, Saunders WH. Acquired cholesteatoma: light and electron microscopic observations. Ann Otol Rhinol Laryngol 1972;81:111.
62. Anniko M, Mendel L. Cholesteatoma. A clinical and morphological analysis. Acta Otolaryngol 1981;91:275283.
63. Knutsson J, von Unge M, Rask-Andersen H. Localization of progenitor/
stem cells in the human tympanic membrane. Audiol Neurootol 2011;16:
263269.
64. Alberti PW. Epithelial Migration on the tympanic membrane. J Laryngol
Otol 1964;78:808830.
65. Santa Maria PL, Redmond SL, Atlas MD, Ghassemifar R. Histology of the
healing tympanic membrane following perforation in rats. Laryngoscope
2010;120:20612070.

Jackler et al.: A New Theory of Cholesteatoma Pathogenesis

S13

66. Santa Maria PL, Redmond SL, McInnes RL, Atlas MD, Ghassemifar R.
Tympanic membrane wound healing in rats assessed by transcriptome
profiling. Laryngoscope 2011;121:21992213.
67. Bujia J, Kim C, Holly A, Sudhoff H, Ostos P, Kastenbauer E. Epidermal
growth factor receptor (EGF-R) in human middle ear cholesteatoma: an
analysis of protein production and gene expression. Am J Otol 1996;17:
203206.
68. Santa Maria PL, Redmond SL, Atlas MD, Ghassemifar R. The role of epidermal growth factor in the healing tympanic membrane following perforation in rats. J Mol Histol 2010;41:309314.
69. Olszewska E, Sudhoff H. Comparative cytokeratin distribution patterns in
cholesteatoma epithelium. Histol Histopathol 2007;22:3742.
70. Steinbach E, Gruninger G. Experimental production of cholesteatoma in
rabbits by using non-irritants (skin tolerants). J Laryngol Otol 1980;94:
269279.
71. Wolter NE, Dell SD, James AL, Campisi P. Middle ear ventilation in children with primary ciliary dyskinesia. Int J Pediatr Otorhinolaryngol
2012;76:15651568.
72. el-Sayed Y, al-Sarhani A, al-Essa AR. Otological manifestations of primary
ciliary dyskinesia. Clin Otolaryngol Allied Sci 1997;22:266270.
73. Lin V, Daniel S, James A, Friedberg J. Bilateral cholesteatomas: the hospital for sick children experience. J Otolaryngol 2004;33:145150.
74. Majithia A, Fong J, Hariri M, Harcourt J. Hearing outcomes in children
with primary ciliary dyskinesiaa longitudinal study. Int J Pediatr Otorhinolaryngol 2005;69:10611064.
75. Coren ME, Meeks M, Morrison I, Buchdahl RM, Bush A. Primary ciliary
dyskinesia: age at diagnosis and symptom history. Acta Paediatr 2002;
91:667669.
76. Hadfield PJ, Rowe-Jones JM, Bush A, Mackay IS. Treatment of otitis
media with effusion in children with primary ciliary dyskinesia. Clin
Otolaryngol Allied Sci 1997;22:302306.
77. Pedersen M, Mygind N. Rhinitis, sinusitis and otitis media in Kartageners syndrome (primary ciliary dyskinesia). Clin Otolaryngol Allied Sci
1982;7:373380.
78. Sommer JU, Schafer K, Omran H, et al. ENT manifestations in patients
with primary ciliary dyskinesia: prevalence and significance of otorhinolaryngologic co-morbidities. Eur Arch Otorhinolaryngol 2011;268:383
388.
79. Hajj R, Lesimple P, Nawrocki-Raby B, Birembaut P, Puchelle E, Coraux C.
Human airway surface epithelial regeneration is delayed and abnormal
in cystic fibrosis. J Pathol 2007;211:340350.
80. Yildirim N, Sone M, Mutlu C, Schachern PA, Paparella MM, Le CT. Histopathologic features of the temporal bone in patients with cystic fibrosis.
Arch Otolaryngol Head Neck Surg 2000;126:7578.
81. Trinh NT, Bardou O, Prive A, et al. Improvement of defective cystic fibrosis airway epithelial wound repair after CFTR rescue. Eur Respir J
2012;40:13901400.
82. Sun YH, Reid B, Fontaine JH, et al. Airway epithelial wounds in rhesus
monkey generate ionic currents that guide cell migration to promote
healing. J Appl Physiol (1985) 2011;111:10311041.
83. Schiller KR, Maniak PJ, OGrady SM. Cystic fibrosis transmembrane conductance regulator is involved in airway epithelial wound repair. Am J
Physiol Cell Physiol 2010;299:C912921.
84. Sade J, Fuchs C. A comparison of mastoid pneumatization in adults and children with cholesteatoma. Eur Arch Otorhinolaryngol 1994; 251:191195.
85. Sato Y, Nakano Y, Takahashi S, Ikarashi H. Suppressed mastoid pneumatization in cholesteatoma. Acta Otolaryngol Suppl 1990; 471:6265.
86. Proctor B. The development of the middle ear spaces and their surgical
significance. J Laryngol Otol 1964;78:631648.
87. Hilding DA, Szachowicz E, Larsen SA. Development of the epithelium of
the middle ear. Electron microscopic study of fine structure, including
junctional complexes and basal lamina. Am J Otolaryngol 1980;1:97108.
88. Okada Y, Aoki S, Barkovich AJ, et al. Cranial bone marrow in children:
assessment of normal development with MR imaging. Radiology 1989;
171:161164.
89. Michaels L. Biology of cholesteatoma. Otolaryngol Clin North Am 1989;22:
869881.

Laryngoscope 125: August 2015

S14

90. Ikarashi F, Nakano Y, Okura T. The relationship between the degree of

chronic middle ear inflammation and tympanic bulla pneumatization in
the pig as animal model. Eur Arch Otorhinolaryngol 1994;251:100104.
91. Okura T. [Mastoid pneumatization after blocking the aeration route
through the eustachian tube]. [Article in Japanese]. Nihon Jibiinkoka
Gakkai Kaiho 1994;97:16751682.
92. Ikarashi F, Nakano Y, Okura T. Pneumatization of the tympanic bulla
after blockage of the ventilation route through the eustachian tube in
the pig. Ann Otol Rhinol Laryngol 1996;105:784790.
93. Palva T, Ramsay H. Fate of the mesenchyme in the process of pneumatization. Otol Neurotol 2002;23:192199.
94. Rott HD. Kartageners syndrome and the syndrome of immotile cilia. Hum
Genet 1979;46:249261.
95. Eliasson R, Mossberg B, Camner P, Afzelius BA. The immotile-cilia syndrome. A congenital ciliary abnormality as an etiologic factor in chronic
airway infections and male sterility. N Engl J Med 1977;297:16.
96. Ernstson S, Afzelius BA, Mossberg B. Otologic manifestations of the
immotile-cilia syndrome. Acta Otolaryngol 1984;97:8392.
97. Greenstone M, Stanley P, Cole P, Mackay I. Upper airway manifestations
of primary ciliary dyskinesia. J Laryngol Otol 1985;99:985991.
98. Mygind N, Pedersen M. Nose-, sinus- and ear-symptoms in 27 patients
with primary ciliary dyskinesia. Eur J Respir Dis Suppl 1983;127:96
101.
99. Sethi BR. Kartageners syndrome and its otological manifestations.
J Laryngol Otol 1975;89:183188.
100. Martins L, Guimaraes RE, Becker HM, Bedran MB, Medeiros M,
Camargos P. Low prevalence of middle ear disease in cystic fibrosis
patients. J Pediatr (Rio J) 2011;87:8083.
101. Jorissen M, De Boeck K, Feenstra L. Middle ear disease in cystic fibrosis.
Int J Pediatr Otorhinolaryngol 1998;43:123128.
102. Cipolli M, Canciani M, Cavazzani M, Uras P, Zampieri P, Mastella G.
Ear disease is not a common complication in cystic fibrosis. Eur J
Pediatr 1993;152:265266.
103. Haddad J Jr, Gonzalez C, Kurland G, Orenstein DM, Casselbrant ML.
Ear disease in children with cystic fibrosis. Arch Otolaryngol Head Neck
Surg 1994;120:491493.
104. Berkhout MC, van Rooden CJ, Aalbers RC, et al. Temporal bone pneumatization in cystic fibrosis: a correlation with genotype? Laryngoscope
2014;124:16821686.
105. Stenfors LE, Bloom GD, Hellstrom S. The tympanic membrane. Acta Otolaryngol Suppl 1984;414:2830.
106. Harvima IT, Nilsson G. Mast cells as regulators of skin inflammation
and immunity. Acta Derm Venereol 2011;91:644650.
107. Albino AP, Kimmelman CP, Parisier SC. Cholesteatoma: a molecular and
cellular puzzle. Am J Otol 1998;19:719.
108. Albino AP, Reed JA, Bogdany JK, Sassoon J, Parisier SC. Increased numbers of mast cells in human middle ear cholesteatomas: implications for
treatment. Am J Otol 1998;19:266272.
109. Atef A, Ayad EE. Ciliary count in chronic suppurative otitis media: comparative quantitative study between mucosal and squamous types using
scanning electron microscopy and image analysis. J Laryngol Otol 2004;
118:343347.
110. Hermansson A, Prellner K, Hellstrom S. Persistent structural changes in
the middle ear mucosa of the rat, after an experimentally induced episode of pneumococcal otitis media. Acta Otolaryngol 1990;109:421430.
111. McGuire JF. Surfactant in the middle ear and eustachian tube: a review.
Int J Pediatr Otorhinolaryngol 2002;66:115.
112. Anderson J, Caye-Thomasen P, Tos M. A comparison of cartilage palisades and fascia in tympanoplasty after surgery for sinus or tensa
retraction cholesteatoma in children. Otol Neurotol 2004;25:856863.
113. Martin C, Timoshenko AP, Bertholon P, Prades JM. Cartilage and tympanoplasty. Acta Otorhinolaryngol Belg 2004;58:143149.
114. Kim HJ, Chole RA. Experimental models of aural cholesteatomas in Mongolian gerbils. Ann Otol Rhinol Laryngol 1998;107:129134.
115. Chole RA, Henry KR, McGinn MD. Cholesteatoma: spontaneous occurrence in the Mongolian gerbil Meriones unguiculatis. Am J Otol 1981;2:
204210.

Jackler et al.: A New Theory of Cholesteatoma Pathogenesis