Clinical Practice Guideline
for
CHOLESTEATOMA
Developed for the
Aerospace Medical Association
by their constituent
organization
American Society of Aerospace Medicine Specialists
Overview: A
cholesteatoma is a collection of viable and desquamated squamous epithelium in
the middle ear or mastoid air spaces, which are normally lined only by mucous
membrane. It often develops into an
expansile mass filled with desquamative skin debris. As the desquamation occurs the cholesteatoma
slowly grows. The lining of the
cholesteatoma has the capacity to dissolve bone, resulting in destruction of
the ossicles, mastoid air cells, semicircular canals, cochlea, and even
extension into the middle and posterior cranial fossa. Patients usually present with foul smelling
otorrhea (75%), otalgia (<50%), and vertigo (<50%). Less common symptoms are unilateral hearing
loss, and neurological deficits such as facial paralysis. Diagnosis depends on a careful otoscopic
examination. Of the two types of
cholesteatoma, congenital and acquired, the vast majority is acquired. Acquired cholesteatomas have been found to be
associated with previous ear operations, and or a history of chronic ear
infections.
Recurrence
rates for cholesteatomas depends
on staging and the amount residual cholesteatoma left in the ear canal after
surgery. Although closed
tympanomastoidectomy have resulted in fewer long-term complications, residual
hearing loss (>20 dB) occurs in as much as 40% of individuals receiving this
procedure.
Aeromedical
Concerns: The aeromedical concerns include: 1) hearing loss 2)
dysequilibrium and 3) development of more extensive disease such as facial
paralysis and intracranial suppurations.
Surgical repair with the closed tympanomastoidectomy technique as
compared to open tympanomastoidectomy has resulted in fewer of these
complications.
Medical
Work-up:
Aeromedical
Disposition (military): Full evaluations including prognosis by an audiologist and
an otolaryngologist are required. If
surgery has been performed, a copy of the surgical report plus the
aforementioned consults should be forwarded to the military waiver authority or
to the FAA’s aeromedical certification division.
Aeromedical
Disposition (civilian): As long as there are no side effects adverse
to flying such as vertigo or hearing loss significant enough to fail the
civilian standards, one can gain medical certification in the civil sector. An airman can loose significant hearing in a
single ear and pass the testing required to demonstrate that they are safe to
pilot an aircraft. The case of
cholesteatoma should be deferred to the Aeromedical Certification
Division. The airman needs to secure the
results of any audiometric testing and proof that there is no vertigo. If the airman has had a tympanomastoidectomy,
they need to provide the operative report.
Waiver
Experience (military): As of November 1997, one military service has granted
waivers to 100% of the individuals with cholesteatoma who have applied to their
aeromedical consult service.
Waiver Experience (civilian): As of this writing the FAA does not have a specific
pathology code for cholesteatoma.
References:
Mckeenan K.X,
Cholesteatoma: Recognition and Management.
American Family Practice, 1990; 43(6): 2091-2096.
Schuring A.G., et al. Staging for
cholesteatoma in the child, adolescent, and adult. Ann Otol Rhinol Laryngol, 1990; 99(4
Pt 1): 256.
Tarabichi M. Endoscopic management of
acquired cholesteatoma. American Journal of Otolaryngology,
1997; 18:544-549.
November 19, 2002