A 41 year old man presents with longstanding foul smelling brown ear discharge and progressive hearing loss of his right ear. The discharge has persisted despite three courses of antibiotic ear drops. Otoscopy shows perforation of the pars flaccida. A pearly white soft matter is seen at the posterior margin of the perforation. What is the SINGLE most likely diagnosis?
A. Acute Suppurative Otitis Media
B. Chronic Suppurative Otitis Media
C. Acquired cholesteatoma
D. Congenital cholesteatoma
E. Barotrauma
Cholesteatoma The term cholesteatoma is a misnomer as it is actually neither cholesterol nor a tumour. Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. Think of cholesteatoma as an uncommon abnormal collection of skin cells inside your ear that left untreated can continue to grow and damage the bones of the middle ear (ossicles).
Small lesions are associated with a progressive conductive hearing loss but, as the lesion grows and erodes into adjacent structures, there may be additional features such as vertigo, headache and facial nerve palsy
It can be either congenital or acquired.
Acquired cholesteatoma • Occurs following repeated ear infections. Note they are usually poorly responsive to antibiotic treatment • Frequent painless otorrhoea which may be foul-smelling • Progressive, unilateral conductive hearing loss • Tympanic membrane perforation is seen in around 90% of cases or retracted tympanum
Congenital cholesteatomas • Presents in childhood (6 months to 5 years) but may occasionally present much later, in adulthood • Often no history of recurrent suppurative ear disease, previous ear surgery or tympanic membrane perforation • May be an incidental finding on routine otoscopy of an asymptomatic child • Seen as a pearly white mass behind an intact tympanic membrane
Remember: Cholesteatoma is suggested by the following: • Foul discharge • Deafness • Headache • Ear pain • Facial paralysis • Vertigo