Dr. Roach: Noncancerous mass in middle ear requires surgery to remove

Keith Roach
To Your Health

Dear Dr. Roach: I have recently been diagnosed with a cholesteatoma in one ear, which has resulted in significant hearing loss. How common is this condition? I have been advised that surgery is my only treatment option. They anticipate the more extensive surgery requiring “drilling a hole in my head” versus going through the ear drum. How successful is this type of surgery? What are the risks, and how frequently do they occur? What percentage of patients regain some of their lost hearing? The surgeon was very doubtful that my hearing would improve. What is the usual follow-up? What percentage of patients require further surgery in the future?

P.S.

Dear P.S.: A cholesteatoma is a noncancerous mass in the middle ear, or the mastoid, one of the skull bones. Loss of hearing typically happens when a cholesteatoma is large or has been there a long time. One major reason for hearing loss in a cholesteatoma is erosion of the three small bones that conduct sound. About one person per 10,000 develops a cholesteatoma each year, making it uncommon but by no means rare.

Surgical treatment for the cholesteatoma depends on the extent of the mass and may require removal of some of the mastoid bone. It sounds as though your cholesteatoma involves the mastoid bone, in which case surgical treatment is imperative. The surgeon may do reconstruction of the sound-conduction bones, often with a graft or prosthesis. Success rates are up to 80% with reconstruction surgery in terms of restoring hearing.

There is a 10% to 25% chance of recurrence of a cholesteatoma, and recurrence has been reported as long as 24 years after treatment, so the need for continued follow-up examination, often with CT scanning, is very important.

Dear Dr. Roach: I am a 71-year-old woman. I have been taking Prolia shots twice a year for five years. When I first started, I was told to be reevaluated at that time. One of my doctors wants to wait and see what the results are, but another said I should absolutely not stop, as that will increase my chances of having a fracture. I am really confused.

M.W.

Dear M.W.: It’s OK to be confused, because it is not 100% clear what to do in this situation.

Your second doctor has a point: Women who stop taking denosumab (Prolia) will have a rapid bone loss and increased fracture risk in as little as seven months after stopping. The risks of fracture increase even further as time goes on. This is in contrast to the bisphosphonate class, where fracture risk does not quickly increase, and one where review of continued need for medication is essential.

On the other hand, no drug is free from the risk of side effects, and for Prolia, these include osteonecrosis of the jaw (exposure of the jawbone) and atypical femur fractures (fracture of the thigh bone). Some experts will stop Prolia after five or 10 years due to these concerns. A long-term trial found that the risk of these adverse events was the same whether the woman stopped the Prolia or continued it. Fracture rates were low in trial participants, but the bone density continued to increase in the group who continued Prolia.

Based on these results, continued treatment for another five years is reasonable. Your doctor might change you to a different osteoporosis medication.

Readers may email questions to ToYourGoodHealth@med.cornell.edu