A Case of Chronic Otitis Media with Cholesteatoma

A 25-year-old man presents to the ENT outpatient with complaints of right ear discharge for the past two years. The discharge is small in quantity, white to yellow in colour, purulent, often foul-smelling but not blood stained. It is continuous and not associated with upper respiratory infections.

He also complains of hearing loss in the right ear for about the past one year. He is unable to hear whispers and low tones. He does not complain of ear ache, tinnitus or giddiness. He has no nasal complaints, fever or headache.

Examination

The patient’s right pre-auricular region, post auricular region and pinna are normal. Slight purulent discharge is seen in the ear canal and on the tympanic membrane. This is cleaned away to visualize the tympanic membrane. The pars tensa appears normal but there is a perforation in the attic or pars flaccida. White flaky material can be seen through the perforation.

Tuning fork tests show the following results:

• Rinne negative in the right ear
• Weber’s test is lateralized to the right ear
• Absolute bone conduction is normal on both sides

The left ear, facial nerve, nose, paranasal sinuses, throat and neck are normal.

Questions

Answer the following questions before you go on to read the case discussion below.

• What is your diagnosis?
• How will you manage this case?
• What surgery is required to treat this condition?

Discussion

Ear discharge of two years’ duration associated with hearing loss suggests chronic middle ear infection or otitis media. Scanty, white or yellow, purulent and foul smelling discharge is characteristic of unsafe or squamosal type of chronic otitis media. It may even be blood stained in the presence of granulations.

Unsafe COM is also characterized by perforation in the attic region or a marginal perforation in the posterosuperior quadrant of the pars tensa of the tympanic membrane. The whitish flaky material seen through the attic perforation is cholesteatoma. The tuning fork tests suggest conductive hearing loss in the right ear.

Diagnosis

Right chronic otitis media of the squamosal type with conductive hearing loss

Management

The aim of treatment is to stop the ear discharge and restore hearing.

Investigations

Pure tone audiometry is performed to evaluate the degree of hearing loss. X-rays of the mastoid may be taken to assess the status of pneumatization of the mastoid and look for the presence of cholesteatoma and any variations in the normal structures like the dural and sinus plates. But mastoid x-rays are not very sensitive and many surgeons don’t ask for them. CT scans are not indicated in every case of unsafe COM. The ear may be examined under the microscope for better understanding of the findings.

Treatment

Squamosal COM with cholesteatoma is not amenable to medical management. The treatment of this condition is modified radical mastoidectomy with tympanoplasty. This surgery ensures removal of pathology from the middle ear cavity and the mastoid while at the same time reconstructing the hearing mechanism.

Related posts:

Case of chronic otitis media, safe type

Case of acute otitis media

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