Complete removal of cholesteatoma is critical but challenging when the matrix adheres to or destroys surrounding vital structures, such as the facial nerve, inner ear, internal carotid artery, dura mater, jugular bulb, sigmoid sinus, cavernous sinus, etc. Damage to these structures can lead to severe complications such as cerebrospinal fluid leakage, life-threatening hemorrhage, and nerve deficits.

We reviewed 9 cases of extensive cholesteatoma extending beyond the temporal bone that were treated in our department between 2010 and 2022, focusing on surgical approaches and the role of endoscopic assistance.

We used various strategies to manage cholesteatoma matrices adhering to critical structures, including blunt or sharp dissection, combined dural resection with reconstruction, and targeted tumor content removal while leaving the matrix intact. Endoscopic assistance enabled us to identify and remove residual matrix remnants that were difficult to visualize with microscopy alone. Incomplete removal and gross residual lesions were associated with high recurrence rates within one year, highlighting the necessity of maximal matrix removal. Where feasible, gross total removal is preferred to minimize recurrence risk.

Effective management of extensive cholesteatoma requires careful balancing of complete matrix removal with protection of critical structures. Endoscopic assistance offers enhanced visualization, improving surgical outcomes by reducing residual matrix and lowering the risk of early recurrence.

Cholesteatoma

Combined approach

Endoscope

Magnetic resonance imaging

© 2025 The Author(s). Published by Elsevier Inc.