The hidden enemy of microtia reconstruction: cholesteatoma
Reviewed by Shivanchan Rajmohan

Although ear reconstruction for concha-type microtia is generally successful, its frequent association with congenital aural stenosis introduces a hidden risk of cholesteatoma due to disruption of epithelial migration. This negatively affects hearing and reconstructive outcomes. This single-centre retrospective case series performed in Japan over a four-year period evaluates outcomes of 278 patients (mean age 11.8 years) who underwent auricular reconstruction, among whom 83 patients had concha-type microtia. Sixty ears demonstrated simultaneous congenital aural stenosis defined as an external auditory canal (EAC) diameter of less than 4 mm. Cholesteatoma was identified in five ears representing 6.7% of stenotic ear canals. Timing of detection was variable with one detected preoperatively, two soon after reconstruction and two at later stages during follow-up. All cases were treated with surgical excision and canaloplasty with only one case suffering loss of cartilage graft and, more importantly, no recurrences were observed after two years follow-up. This study highlights the importance of maintaining a high index of suspicion of cholesteatoma during follow-up especially if there is a history of postoperative infection or delayed otologic symptoms. Preoperative screening with thorough otoscopy, high-resolution CT temporal bones, early surgical excision of cholesteatoma when identified, and careful intraoperative handling of EAC to minimise trauma should remain central considerations for the surgeon. Close interdisciplinary collaboration between otolaryngologists and plastic surgery teams is key to optimise outcomes, including preserving graft integrity and preventing long-term morbidity. The development of cholesteatoma after reconstruction despite negative preoperative screening raises the question – how long should patients with microtia be followed up after auricular reconstruction?

Cholesteatoma in Concha-Type Microtia.
Mitsuhashi N, Yotsuyanagi T, Yamashita K, et al.
J PLAST RECONSTR AESTHET SURG
2026 [ePub ahead of print].