A 32-year-old man presents to the clinic with progressive left-sided hearing loss and chronic foul-smelling ear drainage for the past 6 months. He denies fever or acute pain. He reports a history of recurrent ear infections during childhood. Otoscopic examination reveals a retracted tympanic membrane with a pearly white mass in the upper portion of the middle ear and keratin debris within the external canal. Audiometry demonstrates conductive hearing loss in the left ear.
Which of the following is the most appropriate next step in management?
The correct answer is:
C) Surgical excision of the lesion
This patient’s presentation is consistent with a cholesteatoma, an abnormal collection of keratinizing squamous epithelium within the middle ear that can result from chronic eustachian tube dysfunction and tympanic membrane retraction. Patients typically present with chronic, foul-smelling otorrhea and progressive conductive hearing loss. On otoscopy, a pearly white mass may be seen behind a retracted tympanic membrane. Cholesteatomas are locally destructive and can erode ossicles, mastoid air cells, and adjacent structures, leading to complications such as facial nerve palsy, labyrinthitis, or intracranial infection. Definitive management requires surgical removal.
Answer choice A: High-dose oral amoxicillin therapy, is incorrect. Although secondary infections may occur, antibiotics do not eliminate the keratinizing epithelial mass and are not definitive treatment.
Answer choice B: Intratympanic corticosteroid injection, is incorrect. Steroids are used for conditions such as sudden sensorineural hearing loss, not for cholesteatoma.
Answer choice D: Topical antibiotic ear drops alone, is incorrect. Topical therapy may reduce drainage but does not address the underlying destructive lesion.
Answer choice E: Watchful waiting with serial audiometry, is incorrect. Observation is inappropriate due to the risk of progressive bone destruction and serious complications.
Key Learning Point
Cholesteatoma presents with chronic foul-smelling otorrhea and conductive hearing loss and requires surgical excision due to its locally destructive nature.
