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Iatrogenic seeding of cholesteatoma in rare planes

A cholesteatoma is a cystic lesion of keratinizing stratified squamous epithelium commonly found in the middle ear space. Acquired cholesteatomas are often caused by seeding of squamous epithelium into the middle ear space during surgery. We present a 29-year-old male who had a left tympanomastoidectomy and then staged second look with ossicular chain reconstruction for cholesteatoma 6 years prior to presenting with a left pre and post-auricular mass measuring 8.2×2.9×6 cm. He underwent combined surgical excision with facial plastic surgery and neuro-otology. He was found to have cholesteatoma extending from a defect in the mastoid cavity into the pre-auricular and post-auricular soft tissue. This was felt to be recurrent disease seeded from his initial surgery. To our knowledge, we present the largest iatrogenic cholesteatoma reported in the literature. It had explosive growth in a relatively short time period with extension into an unusual location due to presumed iatrogenic causes. Our case highlights the potential to seed cholesteatoma in previously disease-free areas when performing cholesteatoma surgery. It also demonstrates the aggressive nature of pediatric cholesteatomas, and is in line with the literature in that regard. The case enforces the extreme care that needs to be taken when performing cholesteatoma surgery to ensure that disease is not introduced in areas of the head and neck. It also stresses the importance of close, long term follow up for pediatric cholesteatoma given the potential for aggressive reoccurrence and growth.