Realistic View on Aeration Mechanism in Cholesteatoma Patients and its Influence on Management and Hearing Rehabilitation Decisions

Cholesteatoma is a destructive disease. If untreated – may lead to complications. It has a high recidivism rate, may require more than one surgery to achieve control, destructs the ossicular chain and invariably leads to conductive hearing loss with time. Often, also to a significant SNHL. The etiology in most cases is middle ear under-aeration. Cholesteatoma can be eradicated, but the tendency of an individual to develop middle ear under-aeration is not changed by surgical treatment (although it may improve spontaneously). Patients with controlled cholesteatoma are often left with a significant hearing loss, conductive or mixed. Ossiculoplasty (passive middle ear prosthesis), which is a seemingly straightforward procedure, often fails in patients with cholesteatoma. Re-development of negative ME pressure or accumulation of fluid in the ME cavity prevent from a properly placed prosthesis to function, and therefore does not offer a stable and predictable hearing solution. A non-physiologic external ear, re-development of tympanic membrane atelectasis (without being an indication for surgery by itself), blind sac obliteration of external ear canal or a radical cavity, prevent these patient from using conventional hearing aids. As long as bone conduction is good enough, bone conduction hearing aids, especially implanted, but not only, offer a good and especially predictable solution in these cases. When bone conduction is too poor, cochlear implantation preceded by partial petrosectomy with blind sac obliteration of external ear canal and middle ear cleft should be offered. When choosing an implantable hearing solution, the need for imaging follow up should be considered as well. Our current knowledge about middle ear physiology, medical outcomes of the different surgeries, sensitivity of imaging modalities and effectiveness of the various alternatives of hearing rehabilitation should always be used in combination when planning cholesteatoma management.