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JAMA Otolaryngol Head Neck Surg. 2017 Aug 1;143(8):757-763. doi: 10.1001/jamaoto.2017.0130.

Association Between Middle Ear Cholesteatoma and Chronic Rhinosinusitis.

Kuo CL1,2,3,4,5, Yen YC6, Chang WP7, Shiao AS1,2,3,4.

Author information

Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan, Republic of China.
Department of Otolaryngology, National Yang-Ming University School of Medicine, Taipei, Taiwan, Republic of China.
Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China.
Department of Otolaryngology-Head and Neck Surgery, National Defense Medical Center, Taipei, Taiwan, Republic of China.
Department of Otolaryngology, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan, Republic of China.
Center of Biostatistics, College of Management, Taipei Medical University, Taiwan, Republic of China.
School of Health Care Administration, College of Management, Taipei Medical University, Taiwan, Republic of China.



Chronic rhinosinusitis (CRS) can cause an obstruction of the tubal orifice and thereby compromise ventilation of the middle ear. The resulting negative pressure in the middle ear may, in turn, lead to the formation of an eardrum retraction pocket and subsequent acquired cholesteatoma. This study hypothesizes that CRS may increase the risk of cholesteatoma.


To evaluate the risk of cholesteatoma in patients with CRS.

Design, Setting, and Participants:

This study used a nationwide, population-based claims database to test the hypothesis that CRS may increase the risk of cholesteatoma. The Longitudinal Health Insurance Database of Taiwan was used to compile data from (1) 12 670 patients with newly diagnosed CRS between January 1, 1997, and December 31, 2002, and (2) a comparison cohort of 63 350 matched individuals without CRS, resulting in a CRS vs control ratio of 1:5. Data analysis was performed from June 1 to October 27, 2015. Each patient was followed up for 8 years to identify those in whom cholesteatoma subsequently developed. The Kaplan-Meier method was used to determine the cholesteatoma-free survival rate, and the log-rank test was used to compare survival curves. Cox proportional hazards regression models were used to compute the 8-year hazard ratios (HRs).

Main Outcomes and Measures:

Diagnosis of cholesteatoma.


Among the 76 020 patients enrolled in this study, 35 220 (46.3%) were female; mean (SD) age was 27.57 (22.03) years. A total of 209 patients developed cholesteatoma, 66 (101 084 person-years) individuals from the CRS cohort and 143 (506 540 person-years) from the comparison cohort were diagnosed with cholesteatoma during the 8-year follow-up period. The incidence of cholesteatoma per 1000 person-years was more than twice as high among patients with CRS (0.65; 95% CI, 0.50-0.81 person-years) than among those without CRS (0.28; 95% CI, 0.24-0.33). The absolute difference in the incidence density between CRS and non-CRS group was 0.37 (95% CI, 0.21-0.53) per 1000 patient-years. After adjusting for potential confounders, patients with CRS had a 69% increased risk of cholesteatoma within 8 years, compared with those without CRS (HR, 1.69; 95% CI, 1.23-2.32). Patients with CRS presented a significantly lower 8-year cholesteatoma-free survival rate than did those in the comparison group. The absolute difference in the 8-year cholesteatoma-free survival rate between the CRS and non-CRS groups was 0.0029 (95% CI, 0.0016-0.0043).

Conclusions and Relevance:

This is the first large-scale study, to date, to demonstrate a prospective link between CRS and the subsequent development of cholesteatoma within a follow-up period of 8 years. The purpose of the study was to draw attention to the possibility of development of cholesteatoma among patients with CRS. Because that possibility exists, clinicians should keep this association in mind as well as the importance of a thorough head and neck examination.

[Indexed for MEDLINE]
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