Clinical profile of patients with cholesteatoma at tertiary care hospital

 

 

Abstract              Background: Cholesteatoma is the most serious form of chronic ear infection. Cholesteatoma may remain clinically silent for a significant period of time until the disease has become quite extensive. Hearing loss and otorrhea are common manifestations, but other more serious intratemporal and intracranial complications may arise. Aim: To study the clinical profile of patients with cholesteatoma at our tertiary care hospital. Material and Methods: The 50 patients diagnosed with cholesteatoma were taken for clinical evaluation, investigations and surgical treatment. All the patients underwent complete history taking and clinical examination with otoscope and examination under microscope. Pure tone audiometry was performed by a calibrated audiometer in a sound-proof room and narrow band masking was used when appropriate. Results: Adults were most commonly affected (80%) as compared to children (0-15 yrs) (20%). Otorrhea was the most common presentation (98%) followed by hearing loss (72%) post auricular abscesses and fistulae were seen frequently (16%). Facial palsy was seen in 4% of pre-operative patients. Conclusion: Cholesteatoma was more common in adults than children with slight male preponderance. Otorrhea is the most common presentation followed by hearing loss in cholesteatoma cases. These are important anatomic considerations in the management of cholesteatoma.

Key Words: Cholesteatoma, otorrhea, hearing loss, tympanic membrane

 

INTRODUCTION

Cholesteatoma is a progressive destructive middle ear disease. Most cases occur in children and young adults, but it can affect any age. It causes partial deafness, sometimes with unpleasant smelling discharge and pain. If the disease progresses, it can erode the inner ear causing total and permanent deafness and tinnitus. The inner ear also contains the balance organ. If cholesteatoma erodes into the balance organ, vertigo, a severe form of dizziness, results. Cholesteatoma can also attack the facial nerve causing facial paralysis. In rare cases the disease erodes upwards. The roof of the ear is the floor of the brain. If this thin plate of bone is breached, meningitis, brain abscess and death can result.^1,2Cholesteatoma may remain clinically silent for a significant period of time until the disease has become quite extensive. Hearing loss and otorrhea are common manifestations, but other more serious intratemporal and intracranial complications may arise. Cholesteatoma is the most serious form of chronic ear infection. The progression of the disease process is usually insidious but may be quite variable depending on the clinical circumstances. Signs and symptoms are dependent on the location and extent of disease. The aim of the present study was to study the clinical profile of patients with cholesteatoma at tertiary care hospital.

 

MATERIAL AND METHODS

The patients attending outpatient Department of ENT with complaints of ear discharge, earache and hearing loss were taken up for study. These cases of cholesteatoma were taken for clinical evaluation, investigations and surgical treatment. After discharge patients advised to come for regular follow up. Informed written consent is obtained from all the patients undergoing surgery.

Inclusion criteria

• Ear with discharge which may be blood stained, foul smelling (pungent / fishy odor).
• Cases with attic and posterosuperior quadrant pathology.
• Cases with evident intracranial complications.
• Congenital cholesteatoma with intact tympanic membrane.
• Patients giving informed and written consent.

Exclusion criteria

•  All cases with central perforation.
•  Safe dry ear.

               Being an observational study and usage of standard technique of surgery there were no additional risks other than the documented complications that may arise out of the surgery. All the patients underwent complete history taking and clinical examination with otoscope. Pure tone audiometry was performed by a calibrated audiometer in a sound-proof room and narrow band masking was used when appropriate. The hearing of the patient was assessed by pure tone audiogram. Hearing loss up to 15 dB was considered normal, 15-25 as minimal hearing loss, 25-40 dB as mild, 40-55 dB as moderate, 55-70 dB as moderately severe, 70-90 dB as severe and above 90 as profound. Routine blood and urine examination, pure tone audiometry, tympanogram, X-ray mastoid and CT scan temporal bone was performed.

 

RESULTS

Adults were most commonly affected (80%) as compared to children (0-15 yrs) (20%). Ages were dispersed over a wide range of age groups with a mean age of 24 years. The median age was 22 years (range, 5 years to 55 years). There was a slight male preponderance (54%) (Male vs. Female was 54% vs. 46%). Our study showed that the majority of the cases 34 (68%) belonged to the poor class followed by 11 (22%) to middle class and 5 (10%) to upper class.

Table 1: Distribution in different age groups

 

Our study revealed otorrhea as the most common presentation (98%) followed by hearing loss (72%) post auricular abscesses and fistulae were seen frequently (16%) Facial palsy was seen in 4% of pre-operative patients. Otorrhea was foul smelling in 96% of cases in our study.

Table 2: Different modes of presentation

Our study revealed posterosuperior retraction (56%) to be the most common type in our cholesteatoma series followed by attic retraction (40%).

 

Table 3: Type of tympanic membrane pathology seen

Out of the 38 cases with hearing loss, conductive hearing loss was the most common 31 (82%) type.

 

Table 4: Type of Hearing Loss

On X-ray mastoid, sclerotic mastoid was most commonly seen in 41 (82%) followed by diploc in 5 (10%) and pneumatic in 4 (8%) cases.

 

DISCUSSION

Our study regarding the distribution of cholesteatoma in different age groups revealed that adults were more commonly affected (80%) as compared to children (20%). There was a slight male preponderance (54%). Ages were dispersed over a wide range of age groups with a mean age of 24 years and median age of 22 years (range, 5-55 years.) In a similar study in Papua New Guinea patients Garap JP and Dubey SP³ found that adults were more commonly affected, and there was a male preponderance. The median age was 24 years (in our study =22 years). Our results are more or less consistent with this study probably because of the similar socio economic status of our patients. Another study in Ireland by Sheahan P et al.⁴ revealed a mean age of 34 years (our study= 24 years). This higher mean age in Irish people may indirectly be a result of better health consciousness, health care delivery system, better socio economic status leading to prompt diagnosis and treatment of predisposing factors for cholesteatoma development in children e.g. retraction pockets. Our study regarding the distribution of cholesteatoma in various socio-economic groups revealed that the majority of our cases were poor (68%). The study by Garap JP and Dubey SP³ in Papua New Guinean patients, too revealed that the majority of them were poor. In a study in Greenlanders, Homoe P⁵ found that children had an increased risk of chronic otitis media when living in very crowded households. This may be one the reasons why most of our patients are poor who have presented to us with cholesteatoma. The diagnosis of cholesteatoma is usually made on otologic examination.^6,7 Since the signs and symptoms of ear disease may be lacking, cholesteatoma may go undetected for many years in children and adults.⁸ Our study regarding the different modes of presentation of cholesteatoma revealed otorrhea as the most common presentation (98%) followed by hearing loss (72%), Postauricular abscesses and fistulae were seen frequently (16%). Facial palsy was seen in 4% of pre-operative patients. In a similar study to identify the common presentation(s) Garap JP and Dubey SP³ found otorrhea to be the most common presentation in all age groups. Postauricular abscesses and fistulae were seen frequently. 6% of patients had preoperative facial palsy. The results of our study are comparable with this study in Papua New Guinean patients. The reason may be that the socio-economic background of the poor Papua New Guinean patients correlates with the majority of poor patients (60%) in our study. In another study of clinical features by Sheahan et al.⁴ in Ireland revealed hearing loss (78%) to be the most common presenting symptom followed by otorrhea (60%). Among the results these two studies, our results correlate better with the former study probably because of the above mentioned reason.

 

CONCLUSION

Cholesteatoma was more common in adults than children with slight male preponderance. Otorrhea is the most common presentation followed by hearing loss in cholesteatoma cases. These are important anatomic considerations in the management of cholesteatoma.

 

REFERENCES

• Procter B, Chronic Otitis Media and Mastoiditis. Chapter 29. In: Paparella, Shumrick, Gluckman, Meyerhoff, Otolaryngology. Volume II Otology and Neuro-ototlogy, 3^rd Edition, W.B. Saunders Company, 1991;1349-1371.
• Youngs R. Chronic Suppurative Otitis Media - Cholesteatoma. Chapter 28, Harold Ludman, Tony Wright, Diseases of the ear, Sixth Edition, Arnold, 1998.
• Garap JP, Dubey SP, Canal Wall down mastoidectomy - experience in 81 cases. Otology Neurotology 2001; 22(4):451-456.
• Sheahan P, Donnelly M, Kane R., Clinical features of newly presenting cases of chronic otitis media. Journal of Laryngology and Otology 2001;115(12):962-966.
• Homoe P. Otitis media in Greenland, studies on historical, epidemiological, microbiological and immunological aspects. International Journal of Circumpolar health 2001;60 Supplement 2:1-54.
• Mafee MF, Levin BL, Applebaum EL, Campos CF. Cholesteatoma of the middle ear and mastoid. Otolaryngol Clin North Am. 1988; 21:265-268.
•  Buckingham RA, Vavassori GE. Tomographic evaluation of cholesteatoma of the middle ear and mastoid. Otolaryngol Clin North Am 1973; 6:363-377.
•  Bluestone Charles D, Klein JO. Intracranial complications and sequelae of Otitis media. In: Bluestone CD eds. Paediatric Otolaryngology. WB Saunders, Philadelphia, 1990. 2^nd ed. Vol 1. pp.738-740.

 

 

 

 

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