Clinical Practice Guideline
Developed for the
Aerospace Medical Association
by their constituent organization
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.
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.
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