Cholesteatoma of the Temporal Bone

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Abstract
Cholesteatoma presents a variable clinical picture with freedom from symptoms for periods of different duration. The roentgen diagnosis is based upon destruction of bone by the tumor (4). Cholesteatoma develops in a setting of chronic middle-ear infection and a poorly pneumatized mastoid. Perforation of the membrana flaccida or of the posterior margin of the pars tensa should arouse suspicion of this lesion. In response to infection the stratified squamous epithelium from the external auditory canal extends through the perforation. The mucosa is gradually destroyed and replaced by epidermal cells as a result of extension of epidermis from the external auditory canal through the ruptured drum, or by cellular metaplasia of the cuboidal-cell lining within the middle ear. The desquamated débris gradually collects and forms a constantly enlarging mass, which erodes the adjacent bone. Antibiotics have no effect on the growth of a cholesteatoma. The tegmen tympani may be destroyed, allowing the cholesteatoma to enter the middle fossa. The posterior wall of the external canal may show erosion. The mastoid antrum may be grossly enlarged. Roentgen examination may detect a cause of cholesteatoma that has not manifested itself clinically or may confirm the clinical diagnosis and outline the extent and anatomy of the lesion. It is the purpose of this paper to summarize the criteria used in the roentgen diagnosis of cholesteatoma and to point out the usefulness of tomography in this disease. In a ten-year period between 1947 and 1957 there were performed in the Section of Otolaryngology of the Department of Surgery of The New York Hospital 40 endaural radical mastoidectomies and 34 endaural modified mastoidectomies. Of the 74 cases, 2 were diagnosed postoperatively as carcinoma and 72 as chronic suppurative otitis media with perforation. At operation 28 cholesteatomas were found. Of these 28 cases, 3 had inadequate film coverage. Routine roentgenograms of the remaining 25 patients were available for study. It was possible to make a preoperative roentgen diagnosis of cholesteatoma in 13 instances. This result is in accord with other reports, showing a preoperative roentgen diagnosis in 45 to 68 per cent of the cases proved by operation (1, 2, 5). Routine examination of the mastoids in the Law's, Mayer's, and fronto-occipital positions has consistently shown that a cholesteatoma, if demonstrable radiologically, will most often be clearly defined on the fronto-occipital view. The most important diagnostic feature is an enlargement of the mastoid antrum. Law's view will not demonstrate the antrum because of the superimposition of the dense labyrinthine mass. Mayer's view can demonstrate the antrum, but minimal abnormalities may be difficult to see. The fronto-occipital view projects both mastoid antra clear of other shadows and affords good definition of these structures (1, 2, 5).

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