PANCE Blueprint EENT (7%)


Patient will present as→ a 43-year-old male with a “lifelong” history of chronic ear infections and episodic purulent drainage from his right ear canal. The patient currently is without symptoms. Examination of the ear shows a clear external canal, but the tympanic membrane is retracted and there is a pocket of white material and an opacity of the pars flaccida. The Weber test lateralizes to the right and Rinne shows air conduction > bone conduction on the left and bone conduction > air conduction on the right. Preparations are made to undergo a non-contrast computed tomography (CT) scan of the temporal bone.

What two things (if given in the patient history) should make you think cholesteatoma?
Painless otorrhea + strong odor

Cholesteatoma is an abnormal growth of skin in the middle ear behind the eardrum.

  • Commonly occurs as a complication of recurring ear infections and by chronic eustachian tube dysfunction which results in chronic negative pressure which inverts part of the TM causing granulation tissue that over time, erodes the ossicles and leads to conductive hearing loss. 
  • Pt will present with painless otorrhea (brown/yellow discharge with strong odor) it may not be bothersome to the patient.
  • May also present with hearing loss, tinnitus, dizziness, otorrhea, and cranial nerve palsies.

Diagnosis can be made with otoscopic visualization of granulation tissue

  • Confirm with CT scan and audiogram to evaluate hearing loss

Management of cholesteatoma includes surgical excision of the debris/cholesteatoma and reconstruction of the ossicles

Question 1
The most appropriate treatment for cholesteatoma is
Oral antibiotics
Antibiotic otic drops
Oral steroids
Tympanostomy tube placement
Surgical removal
Question 1 Explanation: 
Cholesteatoma refers to a keratinized, desquamated epithelial collection in the middle ear or mastoid. A cholesteatoma results from a chronic otitis media and perforation of the tympanic membrane or as a primary lesion. Prolonged dysfunction of the eustachian tube with the development of chronic negative pressure results in the formation of a squamous epithelial lined sac, which remains chronically infected. Cholesteatomas may be recognized during otoscopic examination by the white debris in the middle ear and the destruction of the ear canal bone adjacent to the perforation. Bone destruction due to an otherwise unsuspected cholesteatoma may be demonstrated on a CT scan. Aural polyps are usually associated with cholesteatomas. A cholesteatoma, particularly with an attic perforation, greatly increases the probability of a serious complication (e.g., purulent labyrinthitis, facial paralysis, intracranial suppuration). A cholesteatoma typically erodes the temporal bone and may destroy the small ossicle bones. With time, they can erode into the facial nerve or into the brain. Treatment involves surgical removal.
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References: UpToDate

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