Understanding cholesteatoma and the symptoms you should recognise

If the ear keeps getting infected, discharging, especially after treatment for an “ear infection”, it deserves a closer look. One possible cause is a cholesteatoma, an abnormal collection of skin cells that can grow behind the eardrum and gradually damage nearby structures.

Cholesteatoma is not cancer, but it is not a condition to leave unchecked. The NHS notes that it can affect hearing, balance and, in advanced cases, the facial nerve or the bone surrounding the ear. If left untreated, a cholesteatoma acts like a slow-growing skin cyst inside the ear that gradually expands and wears away the surrounding bone. Starting behind the eardrum, it can spread locally to destroy the delicate bones of hearing, move deeper to damage the inner ear (causing severe dizziness or permanent deafness) or the nerve that controls facial movement, and break outward to create painful infections and lumps in the neck or behind the ear. In severe cases, it can even erode upward through the thin bone separating the ear from the brain, leading to dangerous complications inside the head like brain abscesses or meningitis. The earlier it is identified, the more options there are to protect hearing and prevent complications.

Recurring discharge is one of the cholesteatoma symptoms that matters most

Many people expect a serious ear condition to cause severe pain. Cholesteatoma often behaves differently. The first warning can be a persistent, unpleasant-smelling fluid leaking from one ear. These ear discharge symptoms may be watery, yellowish or crusted around the ear canal, and they can return after antibiotic ear drops appear to help.

That pattern is important. A simple outer-ear infection commonly settles within days or weeks with appropriate treatment. Discharge that repeatedly comes back over several months, particularly with a strong odour, needs an ear examination. We have seen patients put this down to “wax” or a recurring infection for far too long because the discharge was not particularly painful.

Ear pain can occur when infection or inflammation develops around the cholesteatoma, but pain alone does not confirm the condition. If your main concern is discomfort rather than discharge, an assessment for persistent ear pain and its possible causes can help establish what is happening.

Hearing loss may be gradual enough to miss

A cholesteatoma can erode the three small hearing bones in the middle ear, known as the ossicles. This usually produces conductive hearing loss, where sound is blocked from travelling efficiently to the inner ear. You may notice that voices sound muffled on one side, television volume needs to increase, or phone calls are clearer in one ear than the other.

Yet the less obvious change is often what brings people to clinic: difficulty following conversation in a busy restaurant, for example, rather than a sudden loss of hearing. Has one ear been doing more work than the other for months? That is worth mentioning during an ENT appointment.

Dizziness and facial weakness need prompt attention

Most cholesteatomas remain confined to the middle ear at first. However, growth can extend into the mastoid bone behind the ear or affect structures responsible for balance. Vertigo, unsteadiness, nausea or a spinning sensation are not the most common early signs, but they should never be ignored when they occur alongside discharge or worsening hearing.

A new weakness on one side of the face is rarer and more urgent. This may show as difficulty closing an eyelid, an uneven smile or drooping at the corner of the mouth. The facial nerve runs through the temporal bone close to the middle ear, and involvement requires same-day medical advice. Balance symptoms also have many other causes, so a dedicated assessment of dizziness, vertigo and imbalance can distinguish an ear-related issue from other conditions.

How serious is cholesteatoma when symptoms are mild

The answer is straightforward: the seriousness depends on its size, location and rate of progression, not on how dramatic the symptoms feel. A small cholesteatoma can cause little more than intermittent discharge while still slowly damaging the ossicles. Left untreated, it may lead to permanent hearing loss, mastoid infection, balance problems or, very rarely, meningitis or a brain abscess.

These severe complications are uncommon, but they explain why ENT specialists treat suspected cholesteatoma carefully. Surgery is usually needed to remove it, although the exact operation depends on the area involved and the condition of the hearing bones. When caught early, the condition can often be treated using a minimally invasive endoscopic approach performed directly through the ear canal, leaving no visible external scars. Otherwise, a small incision behind the ear may be necessary, which leaves a discreet mark hidden out of direct view. We take a firm view on this point: repeated drops / oral antibiotics without establishing why one ear keeps discharging is not a long-term plan.

Cholesteatoma diagnosis combines examination and imaging

A cholesteatoma diagnosis begins with a detailed look at the ear canal and eardrum, often using an operating microscope or an endoscope. An ENT specialist looks for a retraction pocket, trapped skin debris, a polyp, inflammation, perforation or changes to the normal shape of the eardrum.

Hearing tests provide a baseline and show whether the middle ear is affecting sound transmission. A CT scan of the temporal bones can map bone erosion and mastoid involvement, while MRI may be used when there is concern about residual or recurrent disease after surgery. These tests answer different questions, which is why one scan does not automatically replace the other.

If you have ongoing discharge, one-sided hearing change or repeated infections, arrange an ENT consultation in Cambridge rather than waiting for symptoms to become more disruptive. Bring details of previous ear drops, operations and any hearing test results, as these can make the first assessment more precise.

Questions people ask about cholesteatoma symptoms

Can cholesteatoma cause tinnitus

Yes. Tinnitus, such as ringing, buzzing or humming in one ear, can occur when hearing is affected. It is not specific to cholesteatoma, but tinnitus with discharge or one-sided hearing loss should be assessed.

Does cholesteatoma always cause a bad smell

No. A foul-smelling discharge is a recognised sign, but some cholesteatomas remain dry, particularly in earlier stages. Hearing loss, fullness, recurrent infections or an abnormal eardrum can still raise suspicion.

Can ear drops cure cholesteatoma

Ear drops can control infection and reduce discharge, but they do not remove the trapped skin cells. When cholesteatoma is confirmed, surgery is commonly required to clear the disease and reduce the risk of further damage.

The practical message is simple: note whether symptoms affect one ear, how long they have lasted and whether discharge returns after treatment. Those three details can help an ENT specialist identify the next sensible step.