Hearing preservation is, of course, a major concern but should not take precedence over removing the invasive tumor. Most patients who undergo surgery for cholesteatoma are able to maintain or improve their hearing at a subsequent operation for reconstruction of the bones of hearing. However, individuals may not be candidates for further reconstructive surgery if irreversible changes took place in the ear due to the disease. A hearing aid fitting will usually be considered in this situation.
In some instances (less than 1% of operations for cholesteatomas), complete hearing can be lost at the time of surgery or during the healing process. This loss may be due to erosion of the window connecting the middle ear to the inner ear via the invasion of the cholesteatoma, or infection passing through this defect.
The ear drum is generally repaired at the time of surgery by inserting a grafted, new ear drum taken from tissue behind the ear over the skull. In most cases, this new grafted ear drum heals. In less than 10% of cases, it could break down and need to be repaired at the second surgery.
The facial nerve is potentially at risk in all cases of ear surgery, but especially when removing a cholesteatoma. Special care must always be taken to identify the facial nerve. Sometimes, the normal structures may be severely distorted and the nerve very difficult to identify, especially in an infected ear. To counter this difficulty, a facial nerve monitor is often used to identify the facial nerve in cholesteatoma surgery. In cases of advanced cholesteatoma, the bony covering of the facial nerve in the middle ear may be eroded, further exposing the nerve to damage. In this case, the cholesteatoma is carefully removed from the nerve under the operating microscope. A laser may be particularly useful in this situation.
Facial injury leading to paralysis is a rare complication of cholesteatoma surgery, but because of its devastating effect on facial expression it should be discussed before surgery. Facial paralysis as a complication of cholesteatoma surgery occurs in less than 1 of 500 operations. Rehabilitation of the facial movement, even with complete loss of the facial nerve, is also possible.
Surgery for cholesteatoma on an "only hearing ear" places a significant responsibility on the ear surgeon. The ear surgeon must not only remove the cholesteatoma, but preserve as much hearing as possible at all costs. Since it is likely that cholesteatoma left at surgery will regrow, the ear surgeon must call on all of his experience to provide complete removal of tumor and a satisfactory hearing result.