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H71 – Cholesteatoma of the Middle Ear | ICD-10

H71 is the ICD-10 code for cholesteatoma of the middle ear – a benign but destructively growing tissue mass in the middle ear that can cause serious complications if left untreated.

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Things worth knowing about "H71"

H71 is the ICD-10 code for cholesteatoma of the middle ear – a benign but destructively growing tissue mass in the middle ear that can cause serious complications if left untreated.

What is H71 (Cholesteatoma of the Middle Ear)?

The ICD-10 code H71 refers to cholesteatoma of the middle ear – a non-cancerous but aggressively growing accumulation of keratinized squamous epithelium (skin cells) that forms in the middle ear or mastoid region. Despite its name, a cholesteatoma is not a true tumor. Instead, it is a cyst-like collection of skin cells that builds up in layers and gradually erodes surrounding bone structures, leading to potentially serious complications.

Causes

There are two main types of cholesteatoma:

Congenital cholesteatoma: Present from birth due to embryological development errors. Skin tissue becomes trapped behind an intact eardrum without any prior infection or injury.
Acquired cholesteatoma: The more common form, typically resulting from chronic middle ear infections (chronic otitis media) or prolonged dysfunction of the Eustachian tube. Persistent negative pressure in the middle ear can cause the eardrum to retract and form a pocket where shed skin cells accumulate.

Symptoms

Cholesteatoma symptoms often develop gradually. Common signs include:

One-sided hearing loss that progressively worsens
Persistent, often foul-smelling ear discharge (otorrhea)
Pressure or pain in the ear
Tinnitus (ringing in the ear)
In advanced cases: dizziness, facial nerve palsy, or meningitis if the infection spreads to adjacent structures

Diagnosis

Diagnosis of cholesteatoma is made by an ear, nose, and throat (ENT) specialist and typically involves:

Otomicroscopy: Direct microscopic examination of the ear canal and eardrum – the primary diagnostic tool.
Audiometry (hearing test): To assess the degree of hearing loss.
CT scan of the temporal bone: Imaging to evaluate the extent of the cholesteatoma and associated bone erosion.
MRI (Magnetic Resonance Imaging): Used as a complementary tool, especially for detecting recurrence.

Treatment

Cholesteatoma requires surgical treatment in most cases, as it does not resolve on its own and can lead to life-threatening complications if left untreated.

Surgical Procedures

Tympanoplasty: Reconstruction of the eardrum and ossicles (small ear bones) after removal of the cholesteatoma.
Mastoidectomy: Surgical opening and cleaning of the mastoid bone to ensure complete removal of the cholesteatoma.

Regular follow-up examinations after surgery are essential, as cholesteatomas have a high tendency to recur. Early diagnosis and prompt treatment are critical to prevent permanent damage.

Complications

Without treatment, cholesteatoma can lead to serious complications, including:

Destruction of the ossicles resulting in permanent hearing loss
Formation of a labyrinthine fistula (abnormal opening into the inner ear)
Facial nerve palsy due to involvement of the facial nerve canal
Meningitis or brain abscess if infection spreads intracranially

References

World Health Organization (WHO): International Classification of Diseases, 10th Revision (ICD-10), Chapter VIII – Diseases of the Ear and Mastoid Process, H71. Geneva, 2019.
Jackler R.K., Cho M.: Atlas of Skull Base Surgery and Neurotology. Thieme Medical Publishers, New York, 2009.
Tos M.: Surgical Management of Cholesteatoma. Annals of Otology, Rhinology & Laryngology, 1988.

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