BackTable / ENT / Podcast / Transcript #120

Podcast Transcript: Evaluation and Management of Cholesteatoma

with Dr. Gauri Mankekar

In this episode of BackTable ENT, Dr. Shah and Dr. Gauri Mankekar, assistant professor of Otolaryngology at LSU Health Shreveport, discuss cholesteatoma workup and surgical management. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Cholesteatoma Classifications

(2) Acquired Cholesteatoma Risk Factors

(3) Diagnosing Cholesteatomas

(4) Treating Cholesteatoma: Ear Drops, Antibiotics & Steroids

(5) Surgical Treatment for Cholesteatoma

(6) Preoperative Patient Discussions

(7) Expert Advice for Cholesteatoma Surgery

(8) Cholesteatoma Surgery Complications

(9) Post-operative Cholesteatoma Care

(10) Managing Cholesteatoma Recurrence

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[Dr. Gopi Shah]
Hello, everyone, and welcome to the BackTable ENT Podcast where we discuss all things ENT. We bring you the best and brightest in our field with a hope that you can take something from our show to your practice. Now, a quick word from our sponsor.

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Now, back to the show. My name is Gopi Shah, and I'm a pediatric ENT. Today I have a very special guest. It's my pleasure to introduce Dr. Gauri Mankekar. She's an assistant professor of Otolaryngology Head Neck Surgery and Neurotology at Louisiana State University in Shreveport. She completed her medical school and residency at Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India, and also received her PhD at the University of Augsburg in Germany. She completed her fellowship in advanced otology and skull-based surgery at Louisiana State University at LSUHSC. She's here today to talk to us about Cholesteatoma. Welcome to the show, Gauri, How are you?

[Dr. Gauri Mankekar]

I'm good, Gopi. Thank you for having me on the show.
[Dr. Gopi Shah]
Thank you for coming on. Can you first tell our listeners a little bit about yourself and your practice?

[Dr. Gauri Mankekar]
Sure. I'm faculty, as you mentioned, at the ENT department at LSU Health Shreveport and Ochsner Medical Center, and my practice includes adults and pediatric patients with chronic ear disease, cholesteatoma, hearing loss, and vestibular disorders.

(1) Cholesteatoma Classifications

[Dr. Gopi Shah]
We're going to talk today about a pretty big topic. We're going to talk about cholesteatoma, but before we get into the clinical nuts and bolts, can you go over the different types of cholesteatoma when you're discussing it with a family or maybe a medical student?

[Dr. Gauri Mankekar]
Yes. Cholesteatoma is traditionally classified as congenital cholesteatoma and acquired cholesteatoma. Congenital cholesteatoma is typically seen in children, and accounts for about 2% of all cholesteatomas, and they develop from the embryonic rest of the squamous cell, and in the middle ear. They're typically found in the front or the anterior superior part of the middle ear. Acquired cholesteatomas have traditionally been further divided into primary cholesteatoma and secondary types. The primary cholesteatoma develops in the attic or the pars flaccida, and are associated with perforations of that part, whereas the secondary cholesteatomas typically develop in the middle ear through the pars tensor retractions or perforations.

[Dr. Gopi Shah]
As we now talk about how patients present to you, we think of traditionally cholesteatoma as a painless, chronic draining ear. Are those some of the most common symptoms that you see, and does the type of cholesteatoma present differently in your experience?

[Dr. Gauri Mankekar]
Yes. I have seen in practice and in my experience, they present a little differently. For example, congenital cholesteatomas are incidental findings. So either a pediatric or otolaryngologist will notice it when they take up a child for either your microscopic or serum removal, or even the myringotomy, and they're seen as just white masses behind an intact eardrum. On the other hand, the cholesteatomas which are typically seen in adults, sometimes also in children, they present as chronic draining ears, and foul smelling drainage from the ears, hearing loss, and the drainage can wax and wane.

Sometimes it's a lot, and sometimes it's canty, and so that's typically the presentation, although sometimes there could be an acute inflammatory phase where they present with some bleeding from the ear, and there could be pain associated. Hearing loss is the main issue with the drainage.

[Dr. Gopi Shah]
I wanted to ask you, how often do you see your patients with cholesteatoma that present with tinnitus or vertigo?

[Dr. Gauri Mankekar]
So with children, they typically cannot tell you about tinnitus or vertigo, but the adults, they do present, often they will not mention it. It's only on inquiry that they will talk about the tinnitus. The vertigo though if there are complications, then, yes, some of them do present with vertigo, and they will talk about it.

[Dr. Gopi Shah]
In terms of risk factors, and it goes to the types of cholesteatomas, when I think of the primary acquired, I think of eustachian tube dysfunction, which could be due to different reasons, including craniofacial abnormalities with something more anatomic to what other risk factors for-- and we can just go through the risk factors for the acquired primary, acquired secondary. Are there any risk factors for congenital? I know sometimes, is it okay to say it's just bad luck?

[Dr. Gauri Mankekar]
Yes, I think so. With congenital cholesteatoma, it's quite often bad luck.

(2) Acquired Cholesteatoma Risk Factors

[Dr. Gopi Shah]
Can we go into some of the risk factors for the other acquired?

[Dr. Gauri Mankekar]
Yes, for the acquired cholesteatomas, it could be as you mentioned, eustachian tube dysfunction, but it's also cleft craniofacial malformations, turner syndrome, immune deficiencies with recurrent otitis media. Those are typically the risk factors for acquired cholesteatoma.

[Dr. Gopi Shah]
In terms of when the patient presents to you, or if it's a child with their parents on your history, what are some of the questions that are always on your checklist? Or let's say if you're with a resident or a medical student, you're like, "Oh, but make sure you always ask about this." What are some of those questions for you?

[Dr. Gauri Mankekar]
Well, I'll always ask them about the duration of symptoms, and I'll ask them, was it an acute onset, and whether they have had it for a long time? In children, I will definitely ask them about failed hearing screens in school, and the issue that they have communicating. Typically a parent will tell me that they're listening to the TV with the highest volume, and so nobody in the house likes it. That's one of the most important indicators to me that hearing loss is a big issue.

[Dr. Gopi Shah]
In terms of kids, what percent of your practice are cholesteatomas in children after a history of ear tubes? What percent do you think makes up that pie?

[Dr. Gauri Mankekar]
I would say about 5% or so.

[Dr. Gopi Shah]
Okay. You're a referral center, so you're going to get more, but it is something that you're seeing.

[Dr. Gauri Mankekar]
Yes. There is definitely a history of multiple sets of PE tubes, but when I typically see them, there is no tube in place, and I do see in growing squam through the perforations where the PE tube was, but it's difficult to associate that as being related to the PE tube. It could be just that the eardrum did not heal, and it's trying to heal, and that's how the squam is trying to grow, but it's not growing towards the edges, it's growing inwards.

[Dr. Gopi Shah]
In terms of differences in presentation in your children and adults, with kids, we think about school, we think about grades. Adults, I think about work, but tell me what you see as some of the big differences in presentation.

[Dr. Gauri Mankekar]
With children, typically they will present with acute presentations. Sometimes I have seen more mastoid abscesses in children compared to adults, and they can also present with meningitis and facial palsy in adults. I haven't seen as many presenting with those complications, although some of them could present with meningitis, and also with vertigo. So labyrinthitis, for example, which is rare. Labyrinthitis in children, I haven't seen many.

(3) Diagnosing Cholesteatomas

[Dr. Gopi Shah]
In terms of just getting into the history, I feel like cholesteatoma is something that we're taught that this is a physical exam, like you're going to see it on an exam, and it's a clinical diagnosis. I guess, first my question is-- and it might depend on the type, and you kind of talked about this with the congenital cholesteatomas behind the intact drum, anterior superior quadrant, the white pearl. What do you see with your acquired cholesteatomas depending on if it's primary or secondary?

[Dr. Gauri Mankekar]
First thing would be profuse drainage in the ear, and it's usually foul smelling. It could be greenish in color, and once I clear that drainage, then I might see squamous debris either in the middle ear through a perforation, or an attic perforation, or a pars flaccida perforation with a lot of debris. Sometimes I will see granulation inflammatory tissue, and that bleeds on touch, and it's somewhere along the bone, and there could be a marginal perforation associated with it. Then, sometimes through that perforation I can also see the incudostapedial joint if it's present. Sometimes just the stapes head, the eustachian tube opening, and very rarely even the round window membrane, or the niche.

[Dr. Gopi Shah]
Do you usually do the exam with microscopy? Is there ever a time where you're like, "Maybe I need to get a better look with auto endoscopy," or do you have a preference?

[Dr. Gauri Mankekar]
Right now in my practice, it's mainly a microscope in the clinic, and so, it's only in the OR that we are using endoscopes, but in the clinic, we are only using the microscope.

[Dr. Gopi Shah]
I find in kids, to get an exam, it can be pretty challenging. I could potentially hurt them more depending on the kid as well, but sometimes getting around the corners. Any tips or tricks in terms of getting a good exam? Because sometimes it's hard to tell, is it just wax on the drum? Is it a retraction pocket? Is the granulation I'm seeing? I touch it, it bleeds and that's it. Game over. I can't tell if there's a perf, how do you troubleshoot some of that? Every once in a while I've had to tell families like, "This is a pretty bad infection." The granulation tissue, and how long it's been going on for. These are the things I'm worried about, and I might include cholesteatoma differential, but I'm not 100% sure. What tips and tricks do you have for a good exam, or if you're not sure at what you're looking at?

[Dr. Gauri Mankekar]
Yes, children can be very challenging as you mentioned.

[Dr. Gopi Shah]
You have to gain their trust because it's going to be one of many exams.

[Dr. Gauri Mankekar]

Absolutely. If you hurt a child once, they will never trust you again. So, yes, it's very challenging. That's the first thing I try. I try to be friends with the child, and then see if they'll let me examine, if they don't, and if there's a lot of drainage that I have to clean out, sometimes I would wait until the second visit. So, because my first visit is just trying to get the child to know me and trust me. I would typically give them antibiotic ear drops, and see them maybe in a week or two weeks so I have gained their trust. Also, the drainage is a little less, and it helps me to clean out the ear. Very rarely I may have to profuse a kid, but kids are mini adults, and so, if you gain their trust, they do let you clean their ears, and it is easier to see inside.

As you mentioned, it's difficult to differentiate granulation tissue with an infected tube in place versus a cholesteatoma. It's very important to diagnose if there is a cholesteatoma hiding behind it. With kids who have craniofacial malformations, especially with Down syndrome kids, those are the kids that I would like to take under anesthesia and examine them. I do individualize the exam depending on the situation.

[Dr. Gopi Shah]
I'm glad you brought that up because, our children with Down syndrome, every once in a while it's a difficult exam. Sometimes a child with autism with a chronic draining ear, there's concerns of speech. Their hearing has been down for months now, we can't get it dry. Going to the OR, it happens, where it's an exam, and the exam though, if we don't get it right, we either aren't going to be able to treat it or missing the elephant, in the ear, in the room. That can cause more problems. I used to kick myself like, "I can't get the exam," but then it's like, "It's okay." There's going to be a handful of kids, and they don't all have to have Down syndrome or Autism. It might just be the four-year-old that just won't let you in their ear or whatnot.

I feel better about that now. Oh goodness. All right. In terms of, let's say you do see a cholesteatoma, let's say the ear is a little inflamed, that's your diagnosis. What are your next steps in terms of cooling it down, and then, your workup in terms of ideogram imaging, things like that?

[Dr. Gauri Mankekar]

I will typically get a culture from that drainage, and culture-directed antibiotics because most often the kids that I see have already been treated by their primary care pediatrician or a pediatric otolaryngologist. When I'm seeing the kid, I want to be sure it's culture-directed. That's what I start with. I do start with an antibiotic ear drop, and then the oral antibiotics as soon as I get the culture results back. But I will get an audiogram. If a child is older, then just a pure-tone audiogram, and then if I'm suspecting a CT scan, then I will get imaging studies. That would be my primary workup towards diagnosing the patient.

(4) Treating Cholesteatoma: Ear Drops, Antibiotics & Steroids

[Dr. Gopi Shah]
In terms of the ear drops, do you prefer just ciprofloxacin with dex? It's expensive sometimes. Do you end up switching? Is floxin just as okay, or how strongly do you feel about having the steroid combo?

[Dr. Gauri Mankekar]
My patients are typically Medicaid patients, and they can't afford the drops. I have found that compliance is better if I just have them use the Ofloxacin drops. I just go with that, and if I have to use steroids, then I would give them as a separate, so it would be a prednisone or dexamethasone separately. That works out much cheaper, and so, it's less about ideals versus what's practical.

[Dr. Gopi Shah]
In terms of the steroid, is that like an ophthalmic drop that you use?

[Dr. Gauri Mankekar]
Yes.

[Dr. Gopi Shah]
What's the percentage? Is it just dexamethasone? Is there a certain percentage for that?

[Dr. Gauri Mankekar]
I think it's 0.01, but I may have to look it up.

[Dr. Gopi Shah]
No, that's a good trick, because I know we used to sometimes use Xylocaine, which I think was the ophthalmic Ciprodex, which is a little bit cheaper as well. Then there was the Otovel, the one with the ampules. The cost is cost prohibitive whether it's Medicaid or commercial, and obviously uninsured, and it can range, but we can get into that on a different podcast.

[Dr. Gauri Mankekar]
Yes. One of my residents found out he was prescribing Ciprodex, and I said, "Okay, check out the prices, and then you'll know."

[Dr. Gopi Shah]
In terms of oral antibiotics, when I saw granulation tissue, it definitely do some orals, but I wasn't culturing just with the hopes that if I could clear it with the suction, or every once in a while if it was significant thick drainage and I couldn't suction the ear, I'd have the families-- you know the baby blue bulb syringe that flares out for the nose?

[Dr. Gauri Mankekar]
Yes.

[Dr. Gopi Shah]
Because it flares out, I don't think they're going to be able to push it far deep. I would say, "Hey, you have about five to seven millimeters, and you can try to clear your ear and get the drops in hopefully." In terms of culture-directed antibiotics, what would be common microorganisms that you would find in your culture?

[Dr. Gauri Mankekar]
Sometimes it is pseudomonas, and especially if they have an infected PE tube, I do get pseudomonas, and then often it is just a staphylococcus, or corynebacterium. If it's just corynebacterium, the antibiotic sensitivity doesn't matter as much. Anything works, but, yes. If it turns out to be pseudomonas, then I have to be more vigilant about giving the culture-directed antibiotics, and for a longer duration.

[Dr. Gopi Shah]
Do you like oral cipro, or what do you normally do? What's the five antibiotics you end up having?

[Dr. Gauri Mankekar]
For pseudomonas, it could be ciprofloxacin or levofloxacin versus augmentin or amoxicillin and clavulanic acid.

[Dr. Gopi Shah]
In terms of the audiogram, every once in a while, and especially, and maybe the congenital cholesteatomas that are caught relatively early, sometimes the audiograms look pretty good, like normal. Do you find that too in cholesteatoma? It's maybe a mild PTA of 26 to 30?

[Dr. Gauri Mankekar]
Yes.

[Dr. Gopi Shah]
Then you do surgery, and it's like, "Ugh." How often do you see where the hearing is? It's maybe a little lost but it doesn't look too bad?

[Dr. Gauri Mankekar]
Yes. That is so amazing about cholesteatoma, because they are disruptive, but sometimes they creep around the ossicles, and so they don't destroy the ossicles. You may find, especially in congenital cholesteatoma, you might find intact ossicles, and that's why the hearing is almost near normal. The other thing about cholesteatomas is that they transmit sound. That's what causes us to believe there is no hearing loss. I will advise parents in these situations, families as well, that clearing the disease may worsen the hearing loss. There is an informed discussion before I recommend surgery discussing that the surgery and clearing the disease may worsen the hearing loss because the disease is what is helping them to hear. That's a difficult discussion.

(5) Surgical Treatment for Cholesteatoma

[Dr. Gopi Shah]
Yes. We're going to get into surgery because you're right, the goals of surgery, the expectations, how may looks, and for me, obviously, I have a soft spot for kids, but having one side of your hearing all of a sudden now moderate, whatever it is, post-op, depending on what you're able to do in the first surgery, it's a whole school year. That's six months of a school year. Grades. But going back to the audio, are there any other red flags that you see, whether it's tympanometry, although sometimes, again, a congenital, it's going to be type A temp, or with the word discrim. Anything else that you've noticed on audios that you're like, "Oh, cholesteatomas also can show this?"

[Dr. Gauri Mankekar]
On tympanometry, I might say an Ad curve, which might indicate ossicular discontinuity, speech discrim on that side may be lower. Yes, if the child, especially, this is important in children, if they are able to do an entire audiogram with speech discrim, we may be able to get all that data, but sometimes it's difficult to get all that in a child, but in adults, for sure. In adults, we would get the speech audiometry, and the temps, and that would help us to come to a decision.

[Dr. Gopi Shah]
If you have a child or a patient that you're not able to get a good hearing test on, let's say you just get a sound field, not even ear specific. But you can see the exam, do you consider an ABR preoperatively or maybe before the time of surgery to get a baseline or, I don't know. Is there a role for that?

[Dr. Gauri Mankekar]
I have and I do sometimes. Especially in children who need an ear examination under anesthesia to confirm cholesteatoma, I will get an ABR at the same time, and that gives me some baseline audiometric data before I go ahead with any kind of other intervention.

[Dr. Gopi Shah]
Yes. Again, I know we're about to talk about surgery in a second. Because we think of cholesteatoma traditionally as it's a surgical disease, there's no way around it. Do you ever tell the family like, listen, we don't have a great hearing test, but we're going to plan for an ABR for the first 30, 40 minutes, and then plan for surgery under the same anesthetic? Or do you ever have to do anything like that when you don't have good audiometric data, or how important is that preoperatively?

[Dr. Gauri Mankekar]
I think that's very important preoperatively just to have some baseline data, and when possible I have done that just so I know what amplification the child may need, and this is, as I said, more important in children.

[Dr. Gopi Shah]
In terms of imaging, when you consider getting a CT, is there ever a role for MRI or CT with contrast?

[Dr. Gauri Mankekar]
In my practice, I will get a CT scan if clinically I have confirmed there is cholesteatoma, I would recommend an MRI for patients where I see adhesions or attenuation of the tegmen, and I suspect an encephalocele. For revision cases, or where I want to know more about recurrence of cholesteatoma, I do get a DWI-MRI. I have not ordered a CT with contrast at any point. I don't think it has a role to play in cholesteatoma, and so I avoid that.

[Dr. Gopi Shah]:
In terms of CT, what are you looking for? Do you have a system that you use, like, "Okay, I'm suspecting cholesteatoma, so I'm going to look at tegmen, next, next, next?" How do you go through it?

[Dr. Gauri Mankekar]
On a CT scan, I would typically start with the ear canal. Is there any osteitis, and then go forward into the middle ear, if the middle ear shows any destruction of the scutum, ossicles, and then into the tegmen, look at the tegmen, and then move back and see what about the sigmoid plate, is it attenuated, is there any adhesions there?

Cellularity of the mastoid, is it a very cellular mastoid, is it not pneumatized? Then opacification, what's the extent of the opacification? I would also like to look at the lateral canal and the facial nerve. Is there a fistula on the lateral semicircular canal, or is the facial node adhesion, and at what point? It gives me a map to figure out which way to plan for the surgery itself, but also for the hurdles that we may face.

[Dr. Gopi Shah]
This is probably a silly question, but I always go from top superior to inferior on axials, A, do you look at coronal or axial first, or does it matter to you, and are there certain findings that are better on certain cuts? How do you like to do that?

[Dr. Gauri Mankekar]
I start with typically axial CT scans, and on an axial CT scan, I will start from below upwards, and then look at each slice, and examine each of those landmarks I mentioned. Then I will look at the coronals and figure out the level of the tegmen, and also if there is attenuation of the tegmen, and then also look at the lateral semicircular canal, and then the vertical facial, and then follow it into the tympanic segment, so, yes, I follow actual first, coronal second.

[Dr. Gopi Shah]
I think when I initially came out of my training in my early years, I was always looking at the axial first, but then I realized, wait a second, the skull base, the scutum, some of the big clues are on my coronals, that's actually I need to get better at that. Then I was like, okay, because initially coming out I was like, it's all about the lateral canal and the facial nerve, and so it took me some time to be like, actually the coronal's got a lot of information on it too.

[Dr. Gauri Mankekar]
You can correlate it. Sometimes the tegmen defects are seen on an actual, and you can correlate it with the coronal scan, and it's good to know at the level of it. Sometimes I will see them simultaneously.

[Dr. Gopi Shah]
Okay. Now we're planning for surgery. Do you do endoscopic and microscopic, and if so, how do you decide which technique you're going to use for the surgery?

[Dr. Gauri Mankekar]
The imaging will typically give me some idea about how to plan the surgery in addition to, of course, the clinical findings, but if it's a very pneumatized mastoid, and it's an extensive cholesteatoma, I just start with a microscope versus if it's a congenital cholesteatoma, then I will have the endoscope ready. It depends on the extent of disease clinically and on imaging. I do have an endoscope on standby because even in the cases where it's extensive, an endoscope is good to look around corners, and so it helps.

[Dr. Gopi Shah]
In terms of, you said extensive, sometimes it's hard to tell because the scan's all gray, the mastoid's all gray, the middle ears are all gray. Unless I guess you see bony destruction in the mastoid aerosols, how can you tell what's going to be extensive preoperatively?

[Dr. Gauri Mankekar]
Clinically, if there is destruction of the posterior canal wall, that gives me an indication that that cholesteatoma is going to extend into the mastoid, and so I may have to do a canal wall down, which is probably already partly done by the disease itself, and so in those cases, yes.

(6) Preoperative Patient Discussions

[Dr. Gopi Shah]
Okay. That's very helpful. That makes sense. Then we touched on this before in terms of overall goals, with the family and creating a safe here, that was always the first goal, and cholesteatoma surgery is creating a safe here. How do you explain that to families, and the process, the overall treatment? There could be a second look, there could be maybe not a second look, there's disease surveillance. How do you explain all of this? Because this is really a bomb almost. As a parent, or as a patient, there's a lot that it's called chronic ear for a reason. How do you go into it?

[Dr. Gauri Mankekar]
It's a big discussion preoperatively. I start off by asking the patient, what is their main concern? Is it the drainage or the hearing loss? Most often it is the drainage that they are bothered by, and so rendering it as safe here, removing the disease is always primary. I explained to them that in case we can find a good lean, and ossicles can be either replaced, or we can do something about it, we will address the hearing loss at the same time, and that helps ease the situation and the conversation, but the main aim and the primary goal I emphasize is always getting all the disease out at the first surgery.

[Dr. Gopi Shah]
Are there any questions or themes that patients have that you found it's like, this is the same thing that most patients are concerned about? Anything like that in your practice?

[Dr. Gauri Mankekar]
Well, they want to know whether it's a tumor. For example, they'll always ask me, is it malignant? That's a big discussion too to explain to them that it's just a destructive, benign lesion, but it's because it's destructive, it's likely to cause a lot of complications. That's a big discussion because they are mostly worried about it going into the brain, and, of course, they know that it will occur.

Most of them are very accepting about that fact, so when it comes to discussing how many looks or how much surveillance they will need, most of them accept that they will need surveillance, long-term surveillance, and so that's an easier discussion.

[Dr. Gopi Shah]
In terms of recurrence, how do you tell families? Do you give them a percentage, or high likelihood? How do you explain that part to them?

[Dr. Gauri Mankekar]
I try to keep it open, because with cholesteatoma, it's difficult to predict, and so I try to explain to them that cholesteatomas can recur. It's a little bit of skin in the wrong place that starts to grow, and it can grow even after we've done the surgery. They have to be aware of the fact that we just have to keep looking and hope that it doesn't come back, but in case it does, then we are here to take care of it.

[Dr. Gopi Shah]
No, I hundred percent agree because I think the expectations, especially up front, and knowing the disease process, I think that's important for the overall goals and expectations on both ends to be very clear just because these are very challenging, and sometimes it's like, why did you have the best surgery in the whole world, and yet maybe a year and a half later, here we are?

(7) Expert Advice for Cholesteatoma Surgery

[Dr. Gopi Shah]
Anyways, as we get into surgery, tell me what's your OR setup like, do you go an 80, do you go 90? What's your prep and setup like? Because everybody, it seems like especially neurotologists are very particular about even how the towels are folded.

[Dr. Gauri Mankekar]
Completely.

[Dr. Gopi Shah]
Okay, good.

[Dr. Gauri Mankekar]
Yes, I do most of them under general anesthesia, and so it's, I turn 180, and then reverse Strandberg in most cases. There's always a head ring or a donut and facial, no monitor in all cases, and then we use 1% lidocaine with epinephrine for injection, and as I explain to the residents, I just do the same thing every time, and as you mentioned with the towels, it's the same thing every time. I always inject the postaural even if I don't plan to do a postaural incision, it helps with the ear block, and I think to some extent, it also improves the postoperative pain, and then also in the incisional and the posterior ear canal.

That is the basic injection, and then the patient is prepped, draped, and as you mentioned with the towels, it's a specific way of draping the towels, of course. Then we start with the look inside the ear, and to clear out the ear. Sometimes we use saline irrigation to clean out the drainage and confirm our findings. That's very important for me to confirm my findings and make sure that there is a cholesteatoma still in existence, and then we inject the ear canal in four quadrants. 12, 3, si6, and 9. Again with epinephrine, 1 in 100,000 with the 1% lidocaine. That's where we start.

[Dr. Gopi Shah]
It's the same 1% lido, 1 in 100 of epi pre-prep, and then after the prep?

[Dr. Gauri Mankekar]
Yes.

[Dr. Gopi Shah]
Do you have a different syringe, or needle, or anything like that for when you're doing your posterior canal injection before, and then when you're under the microscope?

[Dr. Gauri Mankekar]
Yes. For the pre-prep injection, we use a 5 cc syringe, and with a 27 gauge needle. For the post-prep injection, we use a 3 cc syringe with a 27 gauge needle. It's a different syringe and different amount.

[Dr. Gopi Shah]
Then, what do you always want on your back table? What is your techno? "Oh, it's a Dr Mankikar case. I got to have this." What do you like instrument-wise?

[Dr. Gauri Mankekar]
Yes, instrument-wise, I like a Duckbill, a round knife, a Gimmick, a rosen needle, and the suctions, the French gauge three, five, and seven. That's the basics.

[Dr. Gopi Shah]:
Then, in terms of other hemostasis, do you just stick with your local injections, or do you use anything else for hemostasis during the case?

[Dr. Gauri Mankekar]
Yes, I do use gel form soaked in epinephrine, and in endoscopic cases I will use the neuropathy pledgets, again, soaked in epinephrine 1 in 1,000.

[Dr. Gopi Shah]
Okay. Then in terms of raising the tympanomeatal flap, any tips for where your cuts are going to go? Because just raising that flap well, I think it seems like, from what I've seen, and the little bit of chronic ear experience I had earlier on in my career can make or break how that case can go.

[Dr. Gauri Mankekar]
Absolutely right. Because when we make incisions for the tympanomeatal flap, if it's too lateral, the flap is too thick, and it can obstruct view. Then if it's a cholesteatoma case, you want to have a wider exposure of the bone, and so, I will individualize that incision instead of the routine 12, I might make a more anterior incision to expose more of the lateral attic wall. Then also the inferior incision, I would make it maybe at five or six. That will depend upon the location of the perforation and the cholesteatoma.

Let's say, for example, it's a marginal perforation, but it involves from somewhere between 11, and let's say inferiorly about 4 or something like that. Then the incision would have to be more anterior. The inferior incision would have to be anterior.

[Dr. Gopi Shah]
I got you. You have to rotate it depending on exactly where you're going to be working?

[Dr. Gauri Mankekar]
Yes.

[Dr. Gopi Shah]
You're right, if the flap is too long, it can be a problem, but if it's too short, that can be a problem too because it can fall in. I've had experience with that too.

[Dr. Gauri Mankekar]
It contracts. The shorter flap contracts and leaves your bone exposed, and that's a problem too.

[Dr. Gopi Shah]
Yes. In terms of you're starting to raise it, and do you have any tricks or tips or what do you find that helps you, especially when you're with the resident or the fellow in terms of getting into the middle ear?

[Dr. Gauri Mankekar]
I like to raise the flap with a round knife, and while I'm raising it, I will not use the suction on the flap, it has to be on the round knife, and that way it clears my vision, as well as helps me to elevate the flap without ripping into it. It's very important that the suction is used minimally, but it's used on the round knife. I try to train my residents to do that because we have this tendency, "Oh, there is blood here," and we try to suction on the flap, and invariably the flap will tear.

[Dr. Gopi Shah]
In terms of, let's say you have raised your flap, you've entered the middle ear, and you have identified you have a decent plane, right? You got in, but now you're getting to the cholesteatoma. Sometimes there's a nice plane, and the flap comes right off, and it's just like you don't want everybody cheering yet, but it's exciting, right? What do you do though when it starts to get stuck, or it sticks to the flap? You're raising it, but then it's like, "Wait a second." Is that something that you would've prepared for in the beginning at that first look, or how do you continue your plane off of it?

[Dr. Gauri Mankekar]
Well, it's a little bit, I would compare it to a neck dissection. Let's say a lymph node is stuck, and it's difficult to find a plane in a particular spot, then I will look for a plane a little bit away from it, and get to it. This is especially so in marginal perforations, and then there are granulations, so there is osteitis, and there is often no plane that we can find between the cholesteatoma and the tympanic membrane remnants or edges. We have to go beyond that particular spot, sometimes inferior, sometimes superior to find a plane, and usually we are able to find it. Can't do it at one spot.

[Dr. Gopi Shah]
Create a wider dissection, go further out?

[Dr. Gauri Mankekar]
Correct.
[Dr. Gopi Shah]
Do you find that in that, and does that then eventually help you get that stuck part off, or do you end up having to take some of that drum that is stuck on the cholesteatoma with the cholesteatoma?

[Dr. Gauri Mankekar]
Sometimes the cholesteatoma is part of the eardrum, and those are the times when you have to get it off because it will recur if you leave it behind. It's almost like the squam has inverted and formed part of the tympanic membrane, and in those cases, I will take it off.

[Dr. Gopi Shah]
Do you just get a Rosen needle? What's your technique?

[Dr. Gauri Mankekar]
Yes, I will use Bellucci Scissors, and sharp-cut the edges because sometimes the Rosen may not be able to get off without tearing more than necessary. It's a little difficult to get the right amount off.

[Dr. Gopi Shah]
Then tell me how you handle some of the hard difficult areas before we get into spaces, maybe just around the ossicles? In what situation do you have to raise your flap off of the malleus, or how do you decide when you have to take the head of the malleus, and I realize some of it's just extent of the disease process, but is that something that it's more of decision making as you go along, or are you able to predict sometimes just based on your exam like, "Hey, we're going to be having to go pretty anterior superior, and I'm not going to be able to see everything because of the head of malleus."

[Dr. Gauri Mankekar]
It's both. I would have in a congenital cholesteatoma, for example, I know it's going to be anterior superior, and so there is a likelihood that I might have to take the tympanic membrane off the malleus. In an attic cholesteatoma, the malleus hid me already be destroyed, but in other cases, I will go along, and as I find the disease, I may have to, for example, dislocate the incudostapedial joint, take off the incus if there is cholesteatoma medial to it, or let's say there is cholesteatoma on the tensor tendon, in which case I may have to cut the tensor tendon to get anterior to it. Yes, in those cases I will have to go along as I do the surgery.

[Dr. Gopi Shah]
Then, tell me about some of the other harder-to-reach. Let's say you're not drilling yet, you're not in the master yet, or let's say you're doing endoscopic, any tips or tricks as the cholesteatoma goes posterior or superior anterior?

[Dr. Gauri Mankekar]
I use angled instruments to reach these difficult-to-reach areas. I will, for example, use a RightAngle pick, or a crap free or a gimmick to reach those areas. I also use a lot of irrigation, and sometimes it dislodges the debris and helps me to see better, also clears up blood clots. It's a nice way to get the hydro dissection as I call it, and help clean out these hard-to-reach areas.

[Dr. Gopi Shah]
Is that how you also clear, if you have disease may be in the sinus tympani, are you using angled instruments, angle scopes at that time, or if it's super anterior in the mesotympanum, or if there is more air cells inferiorly in the hypotympanum?

[Dr. Gauri Mankekar]
Yes. I will use a 30-degree. I haven't ever used a 45, but I do use a 30-degree endoscope to look around the corners and the sinus tympani, and especially in the supratubal recess, those are really hard to reach, and so, I will look with an endoscope.

[Dr. Gopi Shah]
Do you have any tricks for taking the matrix off the footplate, or if there's a lot that seems to be around the staple use?

[Dr. Gauri Mankekar]
Now, that is very sticky. Sometimes the footplate can be really challenging, because you want to avoid rocking it, and causing any sensorineural hearing loss. If I'm able to find a plane and safely remove it, I will attempt it. There are times when I'm not successful, I will leave it. If I even have a slight suspicion that I may be rocking the foot plate, then I do leave the cholesteatoma behind on the foot plate. In those cases where there is just a posterior crus, so there is a remnant of a posterior crus, and sometimes that little crus has squam on it, and getting that off can be very challenging, so those are the cases where I'll definitely plan for a second look surgery.

[Dr. Gopi Shah]
In your surgery, you're using cold dissection. Do you ever use laser, or is that just going to blow a bunch of cholesteatoma everywhere?

[Dr. Gauri Mankekar]
I haven't used lasers, so I don't have much experience using lasers in cholesteatoma.

[Dr. Gopi Shah]
Because that might just make it spread more?

[Dr. Gauri Mankekar]
Yes, and also I think I don't have the experience, but I think it could cost some charring and make it more difficult to identify debris squam.

[Dr. Gopi Shah]:
In terms of the scutum, how do you know when you need to take some of the scutum down, and how much you need to, what's that decision-making like?

[Dr. Gauri Mankekar]
I start by curating the scutum. I already know from the imaging that it could be small cholesteatoma restricted to the attic, and in those cases just curating the scutum will help me to see beyond that cholesteatoma, and if I can visualize it, then that's all I will need to do. Sometimes I will follow it, and in a technique like inside out, I will follow that cholesteatoma from the attic, and then backwards into the additives. It depends on whether the cholesteatoma is going back into the mastoid.

[Dr. Gopi Shah]
Do you usually like a curette?

[Dr. Gauri Mankekar]
I start with the curette, and if I find that the cholesteatoma is more extensive, then I might use a drill.

[Dr. Gopi Shah]
Any tips or tricks for the matrix that is on the lateral canal, or where it's on the facial nerve, or if the facial nerve is slightly the bone around it's thin, the monitors are going off, how do you handle those?

[Dr. Gauri Mankekar]
I think the imaging would have shown me that there is dehiscence of the facial nerve, and also of the lateral canal fistula, so it's kind of already in my mind that I will be encountering this. If it's easy to find a plane, I will elevate it with blunt dissection, but in case, especially on the facial nerve, if the monitor is really going bizarre, I will avoid.
That's one spot that I may leave the squam on. On the lateral canal though, if there is a fistula, then I will elevate it, and then put a perichondrium or bone dust and close the fistula.

[Dr. Gopi Shah]
In terms of having to convert the canal wall down, you mentioned a lot of times the posterior canal is already being eaten away with the cholesteatoma. If you have to leave some on the lateral canal or the facial nerve, do you convert them at that time? Are there other reasons, or when do you have to switch the canal wall down?

[Dr. Gauri Mankekar]
If I see any tegmen dehiscence or sigmoid sinus dehiscence, those are the other indications where I would consider canal wall down. Or if it's a very deep mastoid dip, and very cellular mastoid with cholesteatoma in each and every one of those air cells, so I would consider a canal wall down.

[Dr. Gopi Shah]
Then let's say you started endoscopic, what are reasons where you are like, "You know what, we need to just convert to microscopic?" For some of us we'll just keep pushing, and just keep, I'm going to say, and here we are two hours later, and not much has been accomplished. What are your thresholds to make you just go ahead and switch?

[Dr. Gauri Mankekar]
If I were to see that the cholesteatoma is extending into the aditus, I'm following the cholesteatoma. I have already tried to clear it in from the lateral attic and epitympanum, but now I find that it's going beyond that, then I will just convert to a microscope. A limited cholesteatoma endoscopic is easier, but if it's a little bit more extensive, at least right now I'm not comfortable doing it endoscopically.

[Dr. Gopi Shah]
Then in terms of the OR, how do you decide, let's say the cholesteatoma is out, it looks good. Who are the patients you're going to go ahead and do your OCR, and say, "Okay, we're just going to do it as a single stage." Who are the patients that you're going to stage in? Is this a decision that's pretty much made preoperatively for you, or are there findings in the OR that make you change that from a single to a double stage?

[Dr. Gauri Mankekar]
I have already counseled the patients and family that they may need a second stage, but intraoperatively, if I find that there is no cholesteatoma covering the ossicles, or there's no cholesteatoma medial to the ossicles, then I will consider doing OCR at the same time. If I find that there is cholesteatoma somewhere around medial to the malleus hid, or let's say the incus is completely covered, or the stapes is covered, then I would like to wait. Especially in cases where there is cholesteatoma on the foot plate, those are the cases where I will not put in a tarp to reconstruct at the same stage.

[Dr. Gopi Shah]
Does age in a child or does pediatric versus adult ever matter, or is it really how extensive is the cholesteatoma?

[Dr. Gauri Mankekar]
For me it's more the extent of the cholesteatoma, and how severe it is.

[Dr. Gopi Shah]
Then in terms of rebuilding the drum or the scutum, how do you usually like to rebuild those areas? What do you like to use?

[Dr. Gauri Mankekar]
I will use either temporalis fascia, or cartilage, or perichondrium, or composite cartilage perichondrium. It'll depend on the case. If I have to reconstruct the scutum, it'll be with the cartilage either tragal or conchal, and if there is retracted eardrum preoperatively, then I will use cartilage to reconstruct the eardrum. If there is good middle ear space then I will use temporalis fascia. I kind of individualize depending on the findings.

(8) Cholesteatoma Surgery Complications

[Dr. Gopi Shah]
Then in terms of potential complications, what are things that you counsel their families on, and things that you do in the OR to prevent them?

[Dr. Gauri Mankekar]
I think the most important complication that I counsel families about is facial nerve injury and the chorda tympani nerve injury. Taste, sensation, and then injury to the tegmen, meningitis, dizziness, of course, hearing loss, and wound infections postoperatively. These are the main things that we discuss preoperatively, and the way we prevent it, of course, is perioperative antibiotics for the wound infection, facial nerve monitoring intraoperatively, very fine dissection around the chorda tympani nerve avoiding stretching the nerve.
Sometimes if there's cholesteatoma completely covering the nerve, it's difficult to keep the nerve, or the chorda tympani. That's a challenge, and then avoiding hearing loss. As far as possible, very gentle dissection around the ossicles, avoiding drilling with the incus in place, and then not rocking the foot plate. Every step is important, and I think as one of my residents said, caressing the ossicles.

[Dr. Gopi Shah]
That's good. Haven't heard that one yet.

[Dr. Gauri Mankekar]:
Yes.

(9) Post-operative Cholesteatoma Care

[Dr. Gopi Shah]
Post-op. Do you have them on drops? Do you have them weighed? What's your dryer precautions? Do you do orals, and how long do you have dryer precautions or straining precautions and things like that?

[Dr. Gauri Mankekar]
Straining precautions for about two weeks, and weight precautions also for about two weeks. Then water precautions for three months, especially in summer because everybody wants to swim, and so we want to avoid any kind of infections. I see them at two weeks post-op, and then again three months post-op, and then follow every six months. If it's a canal wall down cavity, I might see them every four months, and then at approximately the one year post-op, I will get a DWIMRI to confirm if there is any recurrence.

Then antibiotic ear drops, I will have them used for about a month post-operatively, mainly to have the packing or gel foam in the ear dissolved. I don't like to remove the gel foam because I might accidentally suction the graph, so I continue the ear drops for about a month.

[Dr. Gopi Shah]
When do you get an audio? Do you get an audio in three months or?

[Dr. Gauri Mankekar]
At the three-month point yes, I do get an audio at the three-month point.

[Dr. Gopi Shah]
If you have to do a second stage, when are you planning for that?

[Dr. Gauri Mankekar]
Somewhere after the MRI. Let's say we did a one year MRI, I would consider doing it sooner if the child started especially, and this is so more in children, if they started to have foul smelling drainage earlier, then I would try to go in earlier. Maybe around the eight months to one year.

[Dr. Gopi Shah]
Then let's say it looks good, do you get longer term surveillance? Do you get MRIs again at like year, three year, five? How far out, and how frequent do you have to keep getting imaging for cholesteatoma in your experience? Or what do you do in your practice? I don't know if there's guidelines for this or not yet.

(10) Managing Cholesteatoma Recurrence

[Dr. Gauri Mankekar]
Yes, so, I do the MRI for the first one year, and then clinically follow them, and if I suspect there's drainage, if there is any suspicion, then I would repeat the MRI. Otherwise, I try to get it at the three-year point, and then if it's still clear, then just follow them clinically.

[Dr. Gopi Shah]
These are going to be lifetime patients that come at least once a year type of thing?

[Dr. Gauri Mankekar]
Yes.

[Dr. Gopi Shah]
Audio ear check?

[Dr. Gauri Mankekar]
Yes.

[Dr. Gopi Shah]
Your long-term surveillance?

[Dr. Gauri Mankekar]
Yes. Audio as well as clinical.

[Dr. Gopi Shah]
As we start to round this out, Gauri, thank you so much. Any other final pearls or tricks, whether it's diagnosis or surgical management of cholesteatoma?

[Dr. Gauri Mankekar]
I think we have to individualize the surgical approach based on our clinical findings and imaging studies. The scope is here to stay, so it's really a very useful tool. The instruments are improving, so we can use them around the corners. I think it's there for the long term. Then, in cholesteatoma, long-term surveillance is absolutely essential. Sometimes, we can see a recurrence as late as five to even eight years down the line, even longer, and so, we do need to see these patients in the long term.

[Dr. Gopi Shah]
Actually, that's one last question I was going to ask you. In terms of red flags on your surveillance, what are things that are going to tip you off that it's back?

[Dr. Gauri Mankekar]
Foul smelling drainage, granulation tissue, any squamous debris, especially in the mastoid tip or hard-to-see areas clinically.

[Dr. Gopi Shah]
Does the audio ever tip you off? Are there ever changes on the audiogram that might tip you off, or is that not as common, it's mostly your exam?

[Dr. Gauri Mankekar]
The audiogram doesn't tip me off to the cholesteatoma. The audiogram tips me off more towards worsening hearing loss, so it's more related to the ossicles or to the inner-ear issues, but let's say it's a canal wall up. Then, I would think the audiogram would tell me that there's some destruction or fluid. Sometimes there's just middle-ear effusion in these cases, so, yes.

[Dr. Gopi Shah]
Because sometimes even with cartilage, it's hard to examine if the audiogram is rebuilt with cartilage.

[Dr. Gauri Mankekar]
Yes, it's difficult to see.

[Dr. Gopi Shah]
Yes, it can be hard to tell. Then, in terms of hearing aids, just for unilateral cholesteatoma, when do you consider-- I know, insurance in the states, it's going to be different, especially for unilateral, they can be very difficult depending on the resources. Let's say, you are able to get a hearing aid, or the family is interested, when do you consider the amplification?

[Dr. Gauri Mankekar]
If we are waiting for a second stage surgery for ossicular reconstruction, then I would typically get it done after the three-month audiogram, so especially in children, I would refer them for amplification. In adults, it is a little bit difficult because as you mentioned, the insurance may not cover it, and they may not be able to afford it. In those cases, I may have to wait a little longer to do the ossicular reconstruction, or even to offer them, say , a bone-anchored hearing aid.

[Dr. Gopi Shah]
Well, thank you so much, Gauri. I learned so much. l appreciate all your time. If our listeners have any more questions for you, or want to reach out to you, are you on any social media, or is there a way that they can connect with you?

[Dr. Gauri Mankekar]
Yes, Gopi. Thank you for having me on this podcast. I enjoyed it. They can contact me on Instagram, I'm on Instagram.

[Dr. Gopi Shah]
Awesome, we'll make sure we put it on when we release this episode as well. For all our listeners, thank you for stopping by. For our new listeners, thank you for checking us out. Older listeners, thanks for continuing to listen. Give any suggestions, comments. Everyone who wants to come on the show or has another speaker in mind, please reach out. I think it's a wrap. Thank you.

Podcast Contributors

Dr. Gauri Mankekar

Dr. Gauri Mankekar is an otolaryngolgist and head and neck surgeon with Ochsner LSU Health in Shreveport, Louisiana.

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, July 18). Ep. 120 – Evaluation and Management of Cholesteatoma [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.