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Ep 231 - Cholesteatoma:"I Have a Client Who . . ."Pathology Conversations with Ruth Werner

A woman with sinus pressure holds her hand to her nose and temple.

In a follow up from an early episode, we revisit what we thought was a stubborn sinus infection but turns out to be something entirely different. This client’s sensation of stuffiness and muffled hearing persisted and got worse, long after her sinus infection cleared up. Further investigation revealed cysts growing in her middle ear—what in the world is going on?

Listen in for more information on cholesteatomas.

Author Images
Ruth Werner, author of A Massage Therapist's Guide to Pathology.
Ruth Werner's logo, blue R and W interlinked.
Author Bio

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP’s partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at And more information about her is available at   


Pocket Pathology:

Cholesteatoma - an overview | ScienceDirect Topics (no date). Available at: (Accessed: 5 May 2022).

Cholesteatoma Diagnosis & Treatment NYC | Mount Sinai - New York (no date) Mount Sinai Health System. Available at: (Accessed: 3 May 2022).

Cholesteatoma: Practice Essentials, Background, Etiology and Pathophysiology (no date). Available at: (Accessed: 4 May 2022).

Cholesteatoma: Symptoms & Treatment (no date) Cleveland Clinic. Available at: (Accessed: 3 May 2022).


Books of


About Anatomy Trains:

Anatomy Trains is a global leader in online anatomy educationand alsoprovides in-classroom certification programs forstructuralintegration in the US, Canada, Australia,Europe, Japan, and China, as well as fresh-tissue cadaverdissectionlabs and weekend courses. The work of Anatomy Trains originated with founder Tom Myers, who mapped the human body into 13 myofascial meridians in his original book, currently in itsfourthedition and translated into 12 languages. The principles of Anatomy Trains are used by osteopaths, physical therapists, bodyworkers, massage therapists, personal trainers, yoga, Pilates,Gyrotonics, and other body-minded manual therapists and movement professionals. Anatomy Trains inspires these practitioners to work with holisticanatomy in treating system-wide patterns to provide improved client outcomes in terms of structure and function.



Full Transcript

0:00:08.0 Ruth Werner: Hi, and welcome to "I have a client who... " pathology conversations with Ruth Werner, the podcast where I will discuss your real-life stories about clients with conditions that are perplexing or confusing. On Ruth Werner, author of a massage therapist Guide to pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes as we have all learned, that is harder than it looks.

0:00:54.7 RW: Today, we are going to follow up on one of our earlier episodes, number 65, which came out in August 2020. And in that episode, we discussed a client who had a sinus infection and lingering ear stuffiness after their antibiotic treatment, their massage seemed to help a lot, and the massage therapist was curious to know how this could even be possible. It is possible, if our work can indirectly stretch or manipulate the eustachian tube promote drainage from the middle ear, this helps to equalize pressure, which lets the tympanic membrane vibrate more precisely as it receives vibrations from the outside world, and of course, these vibrations are then transferred to our middle ear bones, do you remember the malleus or hammer, the incus or anvil, and the stapes or stirrup, and these bones pass all this information on to the cochlear nerve in the inner ear, and that is how we perceive sound, and it improved after this person's fairly conservative massage of the face and neck of the affected side, the client was wearing a mask, so really specific work in this neighborhood wasn't possible at the time, all of this was in the context of a diagnosed and treated sinus infection, and the client had some relief and it all seemed fairly straightforward, but it wasn't, and their symptoms were not over yet.

0:02:19.2 RW: There is your first clue. I have recently put out a call to my networks that includes you, by the way, dear listener, for some more, "I have a client who... " stories, because my stash of anecdotes is getting a little low, and the massage therapist who first sent me this story had some follow-up information that ended up being a bit surprising. So this is what I got from our original contributor just this week, after getting better and better, then worse then better then much worse, she finally got into a specialist and has cholesteatoma. Thankfully, it never got bad enough to cause permanent damage and she had a successful surgery to remove the cysts and she's healing well. But I had never heard of this before, I'm guessing the massage helped drain the fluid of it to ease the blocked feeling, and then it all just kept filling up again. Anyhoo, weird. Weird indeed. Cholesteatoma, what in the world is that? Let's find out. You may already know that the suffix oma means growth or maybe tumor. Cholest that has something to do with cholesterol, and steato means fat, so fatty tumors in the ear?

0:03:33.5 RW: Well, not quite, they may have been called that because when they occur in children, which is who usually gets them, these growths, which are not cancerous tumors by the way, they look shiny and white, like little fat deposits sort of like sebaceous cysts, but inside the ear, hold that thought. I have a handful of reputable websites where I usually go for more information on topics that are new to me, and the description of this situation is pretty much the same at all of them. A cholesteatoma is in the words of the Cleveland Clinic, an abnormal, non-cancerous growth that forms behind the eardrum. Cholesteatomas can become a large enough to affect hearing and increase your risk of other serious conditions. Early treatment can help you get symptom relief and avoid complications. Okay, thanks Cleveland Clinic. So it's an abnormal but not cancerous growth in the middle ear, that's the area between the eardrum and the inner ear, and this lesion is defined as a collection of trapped keratinized squamous epithelium and tissue studies of these growths show that they look a lot like sebaceous cysts. That's important. Because sometimes, in fact, often sebaceous cysts harbor bacteria.

0:04:53.9 RW: And guess what? So do cholesteatomas. Cholesteatomas May start small, but they grow. They can completely fill the middle ear, and if these growth harbor bacteria, they essentially function as low-grade long-term abscesses. They can corrode into healthy tissues. They can wreck the tiny ear bones that help us translate vibrations in the air, into sensation and sound. In extreme cases, they can expand into the hollow areas of the mastoid process, causing Mastoiditis, which can be very serious. Inflammatory material clogs up and shuts down the eustachian tubes, and the results can include dizziness, vertigo, potentially permanent hearing loss and the chance of damage to some cranial nerves and a low but not zero risk of infections or blood clots within the brain. And they don't go away on their own. The signs and symptoms in most cases begin with, in the words of e-medicine, painless otorrhea technically, that means runny ear or constant drainage from the ear. This is accompanied by hearing loss. The e-medicine writer here waxed a bit poetic.

0:06:07.9 RW: Waxed poetic about ears. I crack myself up, but here's what they said, large cholesteatomas interfere with sound transmission by filling the middle ear space with desquamated epithelium with or without associated mucopurulent discharge. Mucopurulent discharge if or more likely, when bacteria colonize this area, they are hard to eradicate because nothing here has a dedicated blood supply, topical antibiotics and ear drops can help at the edges of the growth, but they don't penetrate large ones.

0:06:46.3 RW: For this reason, most doctors recommend excision of cholesteatomas, and there are a couple of different approaches to this procedure depending on the needs of the patient. A lot of times these growth recur even after surgery and may have to be treated again. I read about some of the variables that go into this decision, and may I just say, how glad I am not to be an Otolaryngologist. So to return to our client, here's how our contributor described them in that first story. They said, "I have a client who... " just came in for her first appointments since February of last year. She told me she'd had a bad sinus infection in July that cleared with one round of antibiotics. She's in her early 40s and said this was the first sinus infection she's ever. Everything has returned to normal except for her right ear, which still feels blocked. She doesn't notice hearing loss except for at night when her good ear is pressed against the pillow, and then she notices she can't hear as much through that right ear. She noted that when she went to Vermont a few weeks ago, driving up and down the mountains caused her left ear to pop, but her right ear remained unchanged. So I did the massage and I did some extra work to her right neck and the underside of her jaw and the skull, all around her right ear, the occipital area, the forehead and temples. In non-pandemic times, I would have worked with her cheeks and full jaw, but this time, I didn't because she was masked.

0:08:11.1 RW: After the massage, she said she could feel movement in her right ear and also felt it pop. There was no pain or anything intense enough to cause pressure. So my question is this, Can massage really make fluid or anything move in the inner ear? My gut says yes, because she felt something change, but I truly have no idea what could be happening via message or how, and I'd love to know more. So if she returns, I can take a more skilled approach if this issue is persistent. And then just this week we heard this. "So after getting better and better then worse then better then much worse." She finally got into a specialist and has cholesteatoma. Thankfully, it never got bad enough to cause permanent damage, and she had successful surgery to remove the cysts and she's healing well.

0:08:57.4 RW: But I had never heard of this before. I'm guessing the massage helped drain the fluid a bit to use the blocked feeling, and then it all just kept filling up again. It sounds to me ah sounds to me, I can't stop. It sounds to me like this massage therapist is spot on. Their work helped to manipulate the tissues to open up the eustachian tubes so material could drain a bit from the middle ear, by the way, not the inner ear, and this improved the client sensation of stuffiness and muffled hearing. But we cannot claim that our work could have any impact on what is essentially a large and getting a larger sebaceous cyst that is developing in the middle ear. Cholesteatomas are not the kind of thing we hear about every day.

0:09:44.1 RW: But if you have a client with ongoing symptoms of stuffiness and loss of hearing, and if treatment for allergies or sinus infection just isn't making a dent, maybe in addition to skilled facial massage, which will make it worse, but is not gonna clear this up. We could recommend that this person consult their doctor for a closer look. We definitely don't want, for the temporary relief, our work can offer to be a reason someone doesn't pursue the situation with their primary care providers because the situation gets worse and worse and could lead to some serious long-term repercussions that can be avoided with early attention. I wanna thank our contributor who started us off with a great story about a sinus infection, and now has added to that by expanding our vocabulary about ear issues with cholesteatomas, and I wanna be sure to invite you to send me your, "I have a client who... " stories.

0:10:39.8 RW: Hey everybody, thanks for listening to, "I have a client who... " pathology conversations with Ruth Werner. Remember, you can send me your, "I have a client who... " stories to, That's ihaveaclientwho all one word, all lowercase I can't wait to see what you send me and I'll see you next time.