GPAtlas🧭 When to suspect
A cholesteatoma is an abnormal collection of keratinising squamous epithelium (skin) within the middle ear and/or mastoid.
Despite the name it is neither a cancer nor made of cholesterol – but it grows relentlessly and erodes bone.
The working concept that matters in primary care is the "unsafe ear".
The hallmark presentation is chronic, often foul-smelling ear discharge (otorrhoea) that fails to settle with repeated topical treatment for "otitis externa" or "otitis media", accompanied by a progressive, usually unilateral conductive hearing loss.
It is frequently painless, so a comfortable ear is not reassuring.
The danger lies in silent local erosion into:
• The ossicles
• The facial nerve
• The labyrinth
• The mastoid
• Rarely, intracranially
To protect the ear:
• Recognise the pattern
• Look carefully at the attic
• Resist the urge to keep prescribing drops
• Refer urgently to ENT
Suspect it particularly in anyone with:
• Recurrent childhood "glue ear"
• A previous tympanic membrane perforation
• Previous ear surgery
| Type | Key features |
|---|---|
| Primary acquired (~80%) | Arises from a retraction pocket in the attic or pars flaccida, driven by Eustachian tube dysfunction – the commonest form. |
| Secondary acquired (~18%) | Follows a perforation or insult (infection, trauma or surgery) that implants squamous epithelium into the middle ear. |
| Congenital (~2%) | A pearly-white mass behind an intact drum, usually in a child (6 months–5 years), with no history of ear infection or surgery. |
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