Cholesteatoma: The Ear That Keeps Discharging and Will Not Settle

Most causes on this site are things that make a sound. This one is a structural disease of the ear in which tinnitus is a passenger — and it is here because the pattern that should raise it is specific, easy to dismiss, and worth recognising early.

What it is

A cholesteatoma is a growth of skin where skin should not be: in the middle ear, or the mastoid air cells behind it.

Skin is not dangerous. Skin in a sealed cavity that continually sheds and cannot clear itself is, because it accumulates and expands, and as it expands it erodes whatever it presses against. In that few cubic centimetres, what it presses against is the chain of hearing bones, the bony shell of the balance organ, the canal carrying the facial nerve, and eventually the plate separating the ear from the brain.

It is not cancer and not a tumour. The harm is mechanical and it is progressive, which is why the answer is removal rather than management.

The pattern

The 2025 review in Otolaryngologic Clinics of North America puts the clinical suspicion into a single sentence, and it is the most useful thing on this page:

A history of hearing loss with a chronic draining ear, refractory to ototopical medication, raises suspicion for cholesteatoma.

Three elements, and the combination is what matters:

• Hearing loss, typically conductive — the sound is being physically blocked rather than the inner ear failing.
• A chronic draining ear — persistent discharge, often with an odour, that keeps coming back.
• Not responding to ear drops. This is the part that gets missed. An ear infection that clears with drops is an ear infection. An ear that keeps discharging through treatment is a different problem, and the drops failing is information rather than a reason for a second course of them.

The review also says what else to ask about: symptoms of Eustachian tube dysfunction, and prior ear surgery including ear tubes. Both are part of how these develop — Eustachian tube dysfunction creates the persistent negative pressure that can draw part of the eardrum inward into a pocket, and that pocket is where the skin starts to collect.

This is where the tinnitus connection sits. A conductive loss of this kind produces the same reduced input that drives tinnitus elsewhere on this site, and a discharging ear that will not settle is a very different situation from the middle ear infection or perforated eardrum it may have been treated as.

How it is found

By looking at it. The review is explicit that evaluation depends on clinical history and examination with a microscope and/or endoscope — magnified direct inspection of the eardrum and the space behind it. Not a scan first, and not a symptom checklist.

Once it is diagnosed or strongly suspected, audiometry comes before surgery, which is how the extent of the hearing loss and its type are established. How to read that chart covers what the air–bone gap it usually shows actually means.

Imaging supplements that workup rather than replacing it, and the review names when it earns its place — when there are concerning features:

• Vertigo, which suggests the balance organ is involved.
• Third-window symptoms — the pattern also seen in superior canal dehiscence, where a breach in the bony labyrinth makes sound and pressure behave abnormally.
• An asymmetric bone line on the audiogram, meaning the inner ear itself is now affected on that side.
• Facial nerve weakness, because the nerve runs through the same space. Facial weakness with ear symptoms has several causes, and this is one of the ones that must be excluded rather than assumed.

Any of those raises the stakes, and the first two are things a person notices themselves.

Treatment, described honestly

The 2025 management review sets out the goal in five words: a dry, safe, and functional ear. Read that list carefully, because of what is not in it.

Dry — no more discharge. Safe — the disease removed before it erodes anything that matters more. Functional — hearing preserved or restored where possible. Tinnitus is not among the stated aims of the operation, and this page is not going to imply that it is. If the tinnitus is a consequence of a conductive loss, restoring the mechanism may well reduce it; that is a reasonable expectation rather than a promised outcome, and it is worth putting to the surgeon as a question rather than an assumption.

The surgical decision is which operation, not whether:

• Canal wall-up and canal wall-down approaches each have advantages and disadvantages, and the review states plainly that it is not definitive that one approach is clearly more advantageous than the other. If two surgeons propose different operations, that is the literature, not a disagreement about your case.
• Mastoid obliteration techniques show promise in reducing recidivistic disease, but the review says they require further research and standardisation. Promising is not established.
• Endoscopic ear surgery is described as augmenting the ability to see and remove the disease.

The reviews also point to the EAONO/JOS classification and staging system as a framework for recording and comparing outcomes — which tells you something useful in itself. A disease gets a staging system when its results vary enough to need one.

Recurrence is part of this disease. The word the literature uses is recidivism, and its presence in a management review is why follow-up continues long after you feel better. An ear that has had a cholesteatoma is an ear that gets checked.

Tinnitus that arrives or changes after the operation is a separate matter with its own page — tinnitus after ear surgery covers what is known about it.

What to do with this

• If you have an ear that has been discharging for weeks or months and drops have not fixed it, that is the sentence from the review, and it is worth an ENT referral rather than another course of the same treatment.
• If you have hearing loss on one side with a history of ear infections or grommets, mention the history explicitly. The review names prior ear surgery including ear tubes as something to elicit.
• If you also have vertigo or facial weakness, say so first. Those are the features that move imaging up the list.
• If a cholesteatoma has been found, the operation is aimed at a dry, safe, functional ear. Ask directly what is expected to happen to your hearing, and separately what is expected to happen to the tinnitus — they are different questions and only one of them is a stated goal.
• If your tinnitus is not accompanied by discharge or hearing loss, this is almost certainly not your diagnosis. Cholesteatoma announces itself through the ear behaving badly, not through a noise on its own.

Worth reading alongside can tinnitus be cured, which lists the causes that surgery genuinely resolves — and names this one as the counterexample. Ear surgery is not automatically tinnitus surgery, and cholesteatoma is the clearest case on this site where an operation is unarguably necessary for reasons that have nothing to do with the noise.