Abstract
Cholesteatoma is a progressive, destructive lesion of the temporal bone arising from keratinising squamous epithelium within the middle ear or mastoid. It frequently presents with chronic ear discharge and a conductive hearing loss[Learning Box 1] and can lead to serious complications if unrecognised or untreated. This article discusses an anonymised case of a patient presenting with persistent otorrhoea and hearing loss, whose otoscopic examination and CT temporal bone imaging confirmed an acquired attic cholesteatoma. The case highlights key diagnostic features, the limitations of conservative measures, and the central role of surgery in its definitive management.
Introduction
Cholesteatoma is an important cause of chronic otitis media and hearing loss. Although relatively uncommon, its locally destructive nature, ability to erode ossicles and bone, and potential to cause intracranial complications make early recognition essential. Patients often present with persistent, foul-smelling otorrhoea that persists despite repeated courses of topical or systemic antibiotics. Progressive conductive hearing loss is common, less commonly patients develop dizziness, facial nerve symptoms, or headaches with disease progression and complications.
Diagnosis is primarily clinical, supported by otoscopic examination and imaging—particularly high-resolution CT of the temporal bones. Management is almost always surgical, with the aim of fully removing the disease and preventing complications, while preserving or reconstructing hearing where possible.
Case Presentation
Clinical History
A patient presented with several months of chronic right-sided ear discharge, which had not responded to multiple courses of topical antibiotics. The discharge was described as persistent
and malodorous. Alongside this, the patient reported gradually worsening hearing on the affected side. There was no history of acute otitis media, but the patient noted intermittent ear fullness and progressive hearing loss. The chronicity of symptoms and lack of improvement with standard medical therapy raised suspicion for an underlying structural cause rather than a simple infective process.
Otoscopy
Microscopic examination of the ear canal revealed debris and keratin within the attic region, accompanied by retraction of the pars flaccida. The presence of a retraction pocket with keratin accumulation is highly suggestive of acquired cholesteatoma. The tympanic membrane appeared opaque and retracted superiorly, and granulation tissue was noted in the attic area. (Figure 1) Attempts at cleaning revealed deeper keratinous material consistent with squamous debris. These findings pointed strongly toward a diagnosis of attic cholesteatoma
Figure 1
CT Temporal Bone Imaging
High-resolution CT of the temporal bone was subsequently obtained for surgical planning. (Figure 2) Imaging demonstrated soft tissue density centred in the epitympanum with extension into the mastoid antrum. There was erosion of the scutum and early erosion of the head of the malleus and incus. The lateral semicircular canal, tegmen tympani, and facial nerve canal appeared intact.
The imaging confirmed the extent of disease and the presence of bony erosion—hallmarks of cholesteatoma that distinguish it from simple chronic otitis media.
Figure 2
Discussion
Cholesteatoma is characterised by keratinising squamous epithelium within the middle ear, which produces keratin debris and enzymes that erode bone. (Figure 3) If untreated, it can damage ossicles, invade the mastoid, or cause more serious complications such as labyrinthine fistula, facial nerve palsy, meningitis, or intracranial abscess.
In this case, the combination of clinical history, coupled with microscopic examination and CT-confirmed the diagnosis. While topical treatment may temporarily reduce discharge by controlling secondary infection, it does not alter the underlying pathology. Cholesteatoma does not resolve spontaneously, and delaying intervention risks further complications. GP management should focus on recognising when discharge is disproportionate, persistent, or resistant to standard therapy, and making timely referral to ENT.
Figure 3
Surgical Management
Surgery is the definitive treatment. The primary aim is complete removal of the cholesteatoma to create a safe, dry ear.
Secondary goals include restoration or improvement of hearing where feasible. Surgical approaches include:
- Canal wall up mastoidectomy, which preserves the posterior canal wall and may allow a more natural postoperative ear, but carries a higher risk of recurrence.
- Canal wall down mastoidectomy, which creates an open cavity and allows excellent exposure for disease clearance, but requires ongoing care and may alter hearing and swimming tolerance.
The choice depends on disease extent, patient anatomy, hearing status, and risk of recurrence. In this case, given the attic origin, scutum erosion, and mastoid involvement, either approach may be appropriate depending on intraoperative findings. Ossicular chain reconstruction may be performed at the same sitting or as a staged procedure.
Postoperative surveillance is essential, particularly for canal wall up procedures, as cholesteatoma can recur or persist.
Conclusion
This case demonstrates the importance of recognising the hallmark signs of cholesteatoma—persistent, foul-smelling otorrhoea and progressive conductive hearing loss, particularly
when accompanied by attic retraction and keratin debris. CT imaging is valuable for assessing the extent of disease and adjacent structures but must be interpreted alongside otoscopic findings.
For GPs, persistent discharge unresponsive to medical therapy should prompt referral to ENT. Early diagnosis and timely surgical management are key to preventing complications and optimising hearing outcomes. Cholesteatoma remains a surgically treatable condition, and with appropriate intervention, long-term control and good functional results can be achieved.
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