To determine the markers associated with Cholesteatoma like Attic perforation / retraction pocket or posterior marginal perforation, presence of aural polyp or granulation tissue and chronic ear discharge not resolving with antibiotics.
Material &Methods 100 patients of both sexes were selected from out patients department. Patients were operated for mastoid exploration. All patients were evaluated examined in usually way with otoscope and under microscope. Patients were evaluated for hearing loss by tuning fork test and pure tone audiometry. In Radiology investigations plain x-ray mastoid lateral oblique view done in all patients and CT scan was done in patients where needed. Operative findings were noted, all the granulation, polypoidal tissue and Cholestetoma matrix material were sent for histopathology
Out of 100 patients 48 were female and 52 male. Cholestetoma was seen in 45-cases, 1 patient had Tuberculosis while rest of 54 patients had non-specific chronic inflammation.
In 28 patients aural polyp was present, out of which 14 had Cholestetoma (50%), one had T.B (3.2%), 13 patients had posterior-superior marginal perforation in which 03 had Cholesteatoma (23.07%), 13 patients had attic perforation / retraction pocket in which 08 had Cholestetoma (61.5%), There were 26 patients who had central perforation with chronic discharging ear that was not resolving medical treatment in which 12 had Cholestetoma (46.15%), Granulation tissue was seen in 20 patients out of which 07 had Cholesteatoma (35%).
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In this study patients presented with chronic discharging ears with markers had a significant proportion of Cholestetoma was seen, is over all about 45%.
In view of this study patients with these markers should under go for mastoid exploration to avoid intra and extra cranial complication.
Key words: Cholesteatoma, aural polyp, granulation tissue, posterior superior marginal perforation/retraction pocket, and attic perforation/retraction pocket, CSOM.
Cholesteatoma is a cystic structure lined by keratinizing stratified squamous epithelium, resting on fibrous stroma of variable thickness, which may be having some element of original mucous lining.1
According to another definition cholesteatoma is an abnormal collection of viable and desquamated squamous epithelium in the middle ear or mastoid air space.2
Traditionally, the cholesteatoma has been divided into either acquired or congenital disease.
Acquired cholesteatoma may be subdivided into primary and secondary types. Primary acquired cholesteatoma presents without evidence of pre-existing perforation or infection. Secondary acquired disease includes cholesteatoma that forms as a result of traumatic (or iatrogenic) perforation or infection.
Congenital cholesteatoma is defined as an epidermal inclusion cyst behind an intact tympanic membrane.3
The inflammatory cells may actively participate in the aberrant functioning of cholesteatoma epithelium because of the release of various cytokines (tumor necrosis factor-a[TNF-a], tumor growth factor-b[TGF-b], tumor growth factor-a[TGF-a] and others). 4
Better diagnostic methods like CT and MRI and good antibiotics have greatly decreased the serious complications (intracranial) and thus the mortality of patients with CSOM with Cholesteatoma.5
Facial nerve palsy in association with cholesteatoma is well recognized.6
Cholesteatoma are histologically benign, though biologically invasive lesions that arise from the migration of squamous epithelium of the ear.7
The Propensity of cholesteatoma to erode and spread locally is unremarkable.
It is generally considered that activation of osteoclast is the main cause of erosion.8
Patients and Methods:
100 patients of chronic discharging ears irrespective of age and sex were selected from out patientââ‚¬â„¢s department of ENT at Liaquat National Hospital Karachi from June 2003 to July 2005. All patients were examined and evaluated by detailed history, examination of ear, nose and throat. Aural toilet done by suctioning and dry mopping where required. In all patients ears examined by otocsope as well as under microscope. All the findings were noted on Proforma, besides routine examination culture & sensitivity of aural pus and audio logical assessment done in all cases by tunning fork test and pure tone audiometry and X-ray mastoid done in all cases. CT scan or MRI done where needed.
Inclusion criteria in this study was presence of granulation tissue/polyps arising from middle ear cleft, attic perforation/retraction pocket or posterior marginal perforation. Patients with chronic suppurative otitis media not responded on medical treatment for more than three month.
Exclusion criteria was ear discharge < 3 months and dry central/subtotal perforations. Out of 100 patients 92 were operated for mastoid exploration
Always on Time
Marked to Standard
and operative findings were noted on proforma. All the granulation, polypoidal tissue and Cholestetoma matrix material were sent for histopathology.
Data analyzed by using SPSS version 10.0 Descriptive statistics like frequency and percentage was computed for data presentation. For this descriptive study no any statistical test was used. In all variables as mentioned above percentage according to frequency of the disease was calculated. Percentage of cholesteatoma was calculated in different clinical findings and on histopathological reports.
Out of 100 patients 48 were female (48%) and 52 male (52%). Cholestetoma was seen in 45 cases 45%, Table-1, followed by non-specific chronic inflammation in 54 patients (54%) and in one patient T.B was diagnosed on histopathology report.
The most common age group affected was between 25-35 yrs i.e. 40% , 2nd most common 15-25 yrs i.e. 35 %, above 35 yrs of age (13%) followed by 8% of cases between 8-14 years of age (08 cases) Table- 2.
In 28 patients aural polyp was present, out of which 14 had Cholestetoma (50%) Graph-3, one had T.B (3.2%), 13 patients had posterior-superior marginal perforation in which 03 had Cholesteatoma (23.07%) Graph-4, 13 patients had attic perforation / retraction pocket in which 08 had Cholestetoma (61.5%) Graph-1, There were 26 patients who had central perforation with chronic discharging ear that was not resolving medical treatment in which 12 had Cholestetoma (46.15%) Graph-2, Granulation tissue was seen in 20 patients out of whom 07 had Cholesteatoma (35%) Graph-3.
Two patients had extra cranial complications when presented in OPD and both were presented with facial palsy on the affected side, out of which one patient had central perforation with chronic discharging ear that was not resolving medical treatment and other had aural polyp arising from middle ear.
Otalgia was seen in only two patients and they both had chronic ear discharge with foul smell.
Chronic suppurative otitis media is a chronic discharge from ear in the presence of a perforation in the tympanic membrane.9 CSOM remained a prime infection of middle ear and mastoid cavity, in our region.10Cholestetoma may vary in size from a small sac limited to attic or posterior tympanum to wide spread disease involving the entire mastoid bowl. Occasionally the cholestetoma may extend medially into petrous apex or into the entire middle ear cavity including the eustachian tube opening inferiorly.11 Cholestetoma is notorious to cause more damage Potentially it is dangerous because of its capacity to destroy the bone.12
Overall incidence in different markers of cholesteatoma our study was about 45 %, which is alarming and these conditions should investigated and treated properly.
54 % of the results obtained from histopathology showed non-specific chronic inflammatory disease
This study also reveals the incidence is higher in adults than children. Compare these figures with a local literature, which also supports that the cholesteatoma was higher in adults between 20 ââ‚¬" 30 yrs13
The incidence of cholesteatoma was 24.3% in Attic perforation14 and 82.2% with Attic ââ‚¬"Retraction pockets.15 In our study Attic perforation/Retraction pockets with foul smell discharge was seen in 13 patients (13%), In this group cholesteatoma was seen in 08 patients i.e. out of 13 patients (61.5%).
The association of aural polyp with cholestetoma is well known and requires appropriate surgical treatment. The incidence of cholestetoma in ears presenting with polyps varies from 25% to 45 percent 16 in children incidence could be as high as 60 percent17
These figures were also supported by Prasannaraj, De NS, Narasimhan study of aural polyp reveals that out of 31 patients, who underwent mastoid exploration, 52% had extensive disease of the mastoid air cell system and 35% had an underlying cholesteatoma.18
In another study on aural polyp to identify predictive factors for underlying cholesteatoma, the presence of cholesteatoma underlying the polyp is 52% of cases indicate the importance of the polyp location and radiological signs as predictive factors for the diagnosis of cholesteatoma.19
In our study incidence of cholesteatoma in Aural Polyp was (50 %). Out of 28 cases 14 had cholestetoma. The presence of aural polyp had high percentage of cholestetoma, it signifies well established disease of the middle ear cleft with a greater potential for complication and often obscure an underlying cholesteatoma.
Cholestetoma was found in 24.6 percent of 65 ears under going polypectomy, how ever this figure rise to 39 percent if only the polyp arising from attic and postero-superior perforation are considered (no cholestetoma was found with tubotymapnic perforation). 20
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We found high incidence of cholestetoma in tubo tympanic type seen in 12 cases out of 26 cases, i.e. in 46.15% if we compare these results with the local literature the cholesteatoma was seen in 8.16% patients with CSOM not resolving with antibiotics i.e. cholesteatoma seen in 299 cases out of 2,804 patients.21
Malignant aural polyps either primary or secondary are very rare, in our study no neoplastic lesion was seen but one case of tuberculosis was detected on histology, it is there fore important to obtain histological diagnosis in all aural polyps to exclude neoplasm and other chronic inflammatory diseases to exclude neoplasm second avoid inappropriate surgical exploration.
In our study granulation tissue was seen in 20% of cases out of which only 7% of patients had cholesteatoma (35%).
Posterosuperior marginal perforation was seen in 13% of cases in which the cholesteatoma was seen in 03% of cases; if we compared these results with the literature the percentage of cholesteatoma with marginal postero superior perforation was 75.7%, which is significant.21
In view of the above results this is proposed that all cases of aural polyp, marginal perforation, attic perforation/retraction pockets, granulation tissue and CSOM not resolving with the antibiotics are strong markers predicting high incidence of underling cholestetoma. All these markers should be considered as unsafe disease and proper management could avoid Intracranial and extra-cranial complication.
Table-1 Percentage of sex Distribution (n=100)
Number of Patients
Percentage of cholesteatoma in Attic perforation/retraction pocket (n=13)
Percentage of Cholesteatoma in Patients with Chronic Suppurative Otitis Media (n=26)
Percentage of Cholesteatoma in patients presented with Aural Polyp (n=28)
Percentage of age Range (in years) [n=100]
Number of Patients
Percentage of clinical fiudings on examination (n=100)
Number Of Patients
Attic Perforation / Retraction Pockets
Postero superior marginal Perforation/retraction pocket
Percentage of Cholesteatoma in Patients with Postero superior perforation (n=13)
Percentage of cholesteatoma in Patients with Granulation tissue (n=20)