PANCE Blueprint EENT (7%)

Cholesteatoma

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
A 35-year-old man is diagnosed with cholesteatoma. He has no signs of complications, such as facial nerve paralysis or intracranial extension. What is the most appropriate management for this patient?
A
Conservative management with regular follow-up
Hint:
Not appropriate for cholesteatoma as it can lead to complications.
B
Systemic antibiotics
Hint:
May be used for secondary infections but do not treat the underlying cholesteatoma.
C
Topical antibiotic drops
Hint:
Useful for controlling discharge but do not address the cholesteatoma itself.
D
Surgical removal of the cholesteatoma
E
Hearing aid fitting
Hint:
May be needed for associated hearing loss but does not treat the cholesteatoma.
Question 1 Explanation: 
Surgical removal is the most appropriate management for cholesteatoma, especially to prevent potential complications. Cholesteatomas do not resolve with medical treatment and can lead to significant morbidity if not removed.
Question 2
A 50-year-old female with a history of chronic ear infections presents with hearing loss and a foul-smelling discharge from her right ear. Examination reveals a mass behind the tympanic membrane. What is the most appropriate imaging study to evaluate the extent of her condition?
A
CT scan of the temporal bone
B
MRI of the brain
Hint:
Useful for intracranial pathology but less so for cholesteatoma.
C
Audiometry
Hint:
Important for assessing hearing loss but does not visualize the cholesteatoma.
D
Tympanometry
Hint:
Assesses middle ear function but does not provide imaging of cholesteatoma.
E
Ultrasound of the neck
Hint:
Not relevant for middle ear pathology.
Question 2 Explanation: 
A CT scan of the temporal bone is the most appropriate imaging study to evaluate the extent of a suspected cholesteatoma. It provides detailed information about the bony structures of the middle ear and mastoid, and can help assess the extent of disease and any complications.
Question 3
In evaluating a patient with ear-related complaints, which two historical findings are most suggestive of a cholesteatoma?
A
History of frequent swimming and ear pain
Hint:
These symptoms are more indicative of external otitis (swimmer's ear) rather than cholesteatoma.
B
Persistent foul smelling otorrhea and hearing loss
C
Sudden onset of vertigo and tinnitus
Hint:
While these symptoms can occur in various ear disorders, they are not specifically indicative of cholesteatoma.
D
Intermittent ear fullness and allergic rhinitis
Hint:
These symptoms are more commonly associated with Eustachian tube dysfunction or allergic conditions, not cholesteatoma.
E
History of head trauma and unilateral tinnitus
Hint:
While these can be seen in various ear conditions, they do not specifically point towards cholesteatoma.
Question 3 Explanation: 
Persistent otorrhea (chronic ear discharge), especially with a foul smell, and hearing loss are classic historical findings suggestive of a cholesteatoma. Cholesteatomas are abnormal skin growths in the middle ear behind the eardrum that can lead to chronic infections and conductive hearing loss. They often develop as a result of chronic middle ear infections.
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References: UpToDate

Middle ear (PEARLS) (Prev Lesson)
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