Intended for healthcare professionals

Practice Easily Missed?


BMJ 2011; 342 doi: (Published 03 March 2011) Cite this as: BMJ 2011;342:d1088
  1. Mahmood F Bhutta, clinical research fellow1, visiting scientist2,
  2. Ian G Williamson, clinical senior lecturer3,
  3. Holger H Sudhoff, professor of otolaryngology/head and neck surgery4
  1. 1Nuffield Department of Surgical Sciences (University of Oxford), John Radcliffe Hospital, Oxford OX3 9DU, UK
  2. 2MRC Harwell, Harwell Science and Innovation Campus, UK
  3. 3School of Medicine, University of Southampton, Southampton, UK
  4. 4Bielefeld Academic Teaching Hospital, Münster University, D-33604 Bielefeld, Germany
  1. Correspondence to: M F Bhutta m.bhutta{at}
  • Accepted 25 November 2010

A cholesteatoma is a lesion of the ear, formed of a mass of stratified keratinising squamous epithelium (fig 1).1 Aetiology is debated,2 but cholesteatoma probably arises from the lateral epithelium of the tympanic membrane, and then grows as a self perpetuating mass into the middle ear. This may activate local osteoclasts,3 possibly as a result of infection of dead epithelium at the centre of the lesion, with potentially serious consequences from local tissue destruction.

Fig 1 Left: Cholesteatoma (red arrow) arising in the upper part (pars flaccida or “attic”) of left tympanic membrane. Note erosion of surrounding bone (blue arrow). Right: Normal tympanic membrane (left ear) for comparison

Case scenario

A 24 year old man presented to his general practitioner several times over a year with an intermittently discharging left ear and associated hearing loss. Visualisation of the tympanic membrane was not possible owing to otorrhoea and oedema in the external auditory canal. He was treated for presumed otitis externa with repeated courses of topical antibiotic drops, but as improvement was only temporary he was referred to a specialist. An otolaryngologist cleared the external auditory canal of debris (“aural toilet”) and discovered a cholesteatoma arising from the left tympanic membrane; this was successfully treated by surgical excision.

How common is cholesteatoma?

  • The estimated incidence of cholesteatoma in northern Europe is 9.2 per 100 000 population a year4

  • Therefore a general practitioner with a practice size of 2500 patients would be expected to see on average one new case every four to five years

  • The peak incidence is in the age range 5-15 years,5 but cholesteatoma can arise in any age group

  • Seven per cent of people diagnosed will subsequently develop cholesteatoma in the …

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