## Medical Management of Cholesteatoma **Key Point:** Cholesteatoma is primarily a surgical disease, but pre-operative medical management aims to control active infection and reduce drainage. ### Role of Topical Fluoroquinolones Ciprofloxacin otic drops are the first-line medical agent for cholesteatoma because they: - Penetrate biofilm-forming bacteria (especially *Pseudomonas aeruginosa*) commonly found in chronic suppurative ear disease - Achieve high local concentrations in the middle ear and mastoid - Are safe for use with a perforated tympanic membrane (unlike aminoglycosides) - Help reduce drainage and control infection pre-operatively **High-Yield:** Fluoroquinolone otic drops (ciprofloxacin, ofloxacin) are preferred over aminoglycosides in cholesteatoma because aminoglycosides are ototoxic and contraindicated when tympanic membrane integrity is compromised. ### Definitive Treatment **Clinical Pearl:** Medical management is adjunctive only. Definitive treatment of cholesteatoma is **surgical** — either canal wall-up (intact canal wall, ICW) or canal wall-down (CWD) mastoidectomy, depending on disease extent and patient factors. ### Timeline of Intervention | Stage | Intervention | |-------|-------------| | Active infection | Topical fluoroquinolone drops (ciprofloxacin) | | Infection controlled | Surgical consultation | | Definitive | Mastoidectomy ± ossicular reconstruction | **Warning:** Systemic antibiotics (oral amoxicillin-clavulanate) are less effective than topical agents because they do not achieve adequate concentrations in the biofilm-laden middle ear space.
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