Figure 16.

10 Demonstration of a superior retraction pocket, the depths of which can still be

appreciated. 1retraction of the tympanic membrane onto the long process of the incus.

Figure 16.11 Demonstration of a superior retraction pocket, the depths of which can no longer
be
appreciated (short arrows), with development of cholesteatoma pearl (long arrow).

DIFFERENTIAL DIAGNOSIS
Otitis media, otitis externa, tympanic membrane perforation, malignant neoplasm.

WORKUP
Initial workup of cholesteatoma includes physical examination, audiogram, and CT scan of the
temporal bone. The senior author (MDS) rarely obtains CT scans for chronic ear issues, reserving the
use for some revision procedures, or if the patient has symptoms suggestive of inner ear or facial
nerve involvement (i.e., lateral canal fistula, dizziness, or facial paresis). Typical imaging findings
include blunting of the scutum, bony erosion of the lateral attic wall, superior external auditory canal,
and ossicles. In the case of advanced cholesteatoma, nonenhancing mass with smooth borders can be

appreciated eroding surrounding bone.

Surgical management of cholesteatoma with mastoidectomy is the mainstay of treatment. In the event
that a canal wall up mastoidectomy is performed, a second-look procedure may be performed in 9
12 months to evaluate for recurrence of the disease. Generally speaking, the past teaching is that
cholesteatoma recurs in approximately 40% of patients; however, in the senior authors experience
TREATMENT