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Clinical Images

An Ear in Deep Waters

Tulasi Kota Karanth, MBBS, Bryan K Ward, MD and Dennis Poe, MD, PhD

May 10, 2018

A 5 year-old boy with seasonal allergies, adenoid hypertrophy and bilateral recurrent otitis media with effusion, despite multiple sets of tympanostomy tubes and adenoidectomy, presented to clinic with mild left ear pain without otorrhea. On examination, an extruding tube was seen on the right. On the left, the tympanic membrane was atelectatic with an attic retraction pocket, which was collecting debris, suggesting cholesteatoma. Pure tone audiometry showed a low frequency mild conductive hearing loss for the left ear.

Surgical removal of the suspected cholesteatoma was planned. Aside from nasal congestion, no additional symptoms were reported by the patient’s parents. After general anesthesia was induced, the left ear was examined with binocular microscopy (See Image 1). The procedure was abandoned due to acute inflammation, and purulent fluid was collected for culture and sensitivity. Ultimately, culture results were non-diagnostic. The patient recovered after an intraoperative dose of cefazolin and a course of topical drops and successfully underwent the planned procedure on a later date.


MCQ 1: How did the cholesteatoma form in this child?

  1. By metaplasia due to chronic inflammation
  2. By immigration from the margin of tympanostomy site
  3. By transformation of normal epithelium into fetal type
  4. Epidermal hyperplasia forming invasive cones in the retraction pocket


MCQ 2: What is the intraoperative diagnosis?

  1. Bullous Myringitis
  2. Acute Suppurative Otitis Media
  3. Acute Mastoiditis
  4. Otitis Externa


MCQ 3: What is the next best step in management?

  1. Administer a brief course of antibiotic ear drops, and proceed with surgery in one week, once the ear discharge ceases
  2. Continue surgery, and provide intravenous antibiotics to cover the infection
  3. Administer antibiotic ear drops for the infection and consider surgery in 6 weeks, after confirming that the ear is dry
  4. Administer antibiotic ear drops for the infection and defer surgery as cholesteatoma is no longer visible

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  1. Persaud R, Hajioff D, Trinidade A, Khemani S, Bhattacharyya MN, Papadimitriou N, Kalan A, Bhattacharyya AK. Evidence-based review of aetiopathogenic theories of congenital and acquired cholesteatoma. J Laryngol Otol. 2007 Nov;121(11):1013-9.
  2. Chin-Lung Kuo, An-Suey Shiao, Matthew Yung, et al. Updates and Knowledge Gaps in Cholesteatoma Research. BioMed Research International 2015; 2015:854024.


Author Information:

Tulasi Kota Karanth, MBBS is a resident in Department of ENT-HNS, Kasturba Medical College and Hospital, Manipal.' She has 3 publications and has been awarded a short-term studentship from the Indian council of medical research and also has a patent published to her credit.

 Bryan K Ward, MD is a clinical fellow in neurotology at Johns Hopkins Hospital.

Dennis Poe, MD, PhD is a professor of Otolaryngology at Harvard Medical School and a full-time faculty member at Boston Children’s Hospital.