Cholesteatomas usually present with features of audiovestibular nerve dysfunction. The surgical approach is determined by the clinical presentation. If hearing is preserved, a retrosigmoid approach is favored (6/10 in the Cambridge series), whereas a transpetrous approach is used if useful hearing has been lost pre-operatively . Despite this, the chance of preserving hearing is low, with only one of the six patients operated on via the retrosigmoid approach retaining hearing. If the lesion extends far medially, the cochlea may require removal to provide sufficient access. Cholesteatomas usually envelop a multitude of cranial nerves and vascular structures. Whilst the soft contents of the lesion can readily be removed, the capsule, which is usually adherent to vascular and neural structures, needs to be excized to avoid recurrence. Although the mortality from surgery to remove these lesions is low, neurological morbidity in the form of post-operative cranial nerve lesions is frequent. This is most commonly the facial nerve, and is most frequently confined to a House-Brackmann Grade II weakness, but complete lesions can occur. Lower cranial nerve lesions were also present in around 30-40% of cases in the Cambridge series .
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