Aeration of the middle ear, antrum, and mastoid depends on the free movement of air from the eustachian tube into the mastoid air cells. The narrow pathways for aeration of the mastoid are located between the mucosal folds and ossicles of the middle ear and antrum. These pathways are susceptible to obstruction by edema and inflammation with granulation tissue. The antibiotics should be chosen to eradicate the most common pathogens, P. aeruginosa and S. aureus. Cultures are very useful in guiding antimicrobial therapy, especially in refractory cases when systemic antibiotics are contemplated.
Surgical eradication is necessary in the form of tympanoplasty.
This is performed only in ears that do not have active infection and have been without active infection for some time. These goals are not always achieved in a single stage. If infection persists, intravenous antibiotic therapy directed at specifically identified organisms should be considered. Removal of the tympanostomy tube may be necessary in some refractory cases. Ferlito, A., A review of the definition, terminology and pathology of aural cholesteatoma.