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, so 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. Crucially 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 and, rarely, intracranially.
The key primary-care skills are simple but decisive: recognise the pattern, look carefully at the attic, resist the urge to keep prescribing drops, and refer urgently to ENT. Suspect it particularly in anyone with recurrent childhood "glue ear", a previous tympanic membrane perforation, or previous ear surgery.
| Type | Key features |
|---|---|
| Primary acquired (~80%) | Arises from a retraction pocket in the attic / 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. |
Source: ENT UK · NICE NG98
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