A Look at Risk Factors for Cholesteatoma in Children Factors Associated With Developing Cholesteatoma: A Study of 45,980 Children With Middle Ear Disease

Background: We are taught that cholesteatoma occurs due to tympanic membrane retraction that is usually secondary to eustachian tube dysfunction. Many children with poor eustachian tube dysfunction get tubes, which has been described as an independent cause of cholesteatoma. Objective: To describe the risk factors for cholesteatoma in children with tympanostomy types. Design: Retrospective review. Participants: 45,980 children <15 years of age in Western Australia treated with tympanostomy tubes after 1980. Methods: State records were reviewed to identify all cases of children who had undergone tympanostomy tube placement between January 1, 1980, and December 31, 2004 in Western Australia. Other data collected included age at tube placement, metropolitan or rural location, presence of cleft palate, and race. Interventions: Tympanostomy tube placement. Results: Of the 45,980 children who had at least 1 tympanostomy tube placement during the study period, 460 (approximately 1%) were given a diagnosis of cholesteatoma. The mean age at first tympanostomy tube placement was 3 years, and the mean age at admission to the hospital with cholesteatoma was 8 years. The risk of cholesteatoma development increased with each additional tympanostomy tube placement. For example, children who had ≥4 tubes had a cholesteatoma risk of 5.2%. Children who had multiple tubes placed in quick succession had a lower risk than those whose tubes had a longer temporal separation. Risk factors for cholesteatoma included number of tubes placed, a history of adenoidectomy, cleft palate, and rural residential location. Although those with adenoidectomy had a high risk of cholesteatoma, the risk dropped slightly after the adenoidectomy was performed indicating that adenoidectomy had a protective effect. Several factors were not associated with cholesteatoma risk, including calendar year of first tube placement, race, gender, and type of hospital. Conclusions: Poor eustachian tube function and negative middle ear pressure are major contributing factors to cholesteatoma development. Reviewer's Comments: I had hoped this study would tell us something about the risk of cholesteatoma being caused by tympanostomy tube placement itself. As it turns out, the study largely just supports the popular theory of cholesteatoma development. This study had several limitations. First, only patients admitted to the hospital were counted, so some cholesteatomas may have been missed. Also, the dataset used did not include in which ear the tube was placed and which side developed a cholesteatoma or the type of tympanostomy tube placed. We also do not know that all of these cholesteatomas were acquired or the incidence of cholesteatoma in children who did not get tympanostomy tubes. Finally, the study does not tell us anything about other known risk factors such as exposure to tobacco smoke. (Reviewer-Benjamin T. Crane, MD).