12-year-old girl with complaints of foul smelling discharge,

A 12-year-old girl is brought to the office by her mother with complaints of foul smelling discharge, and hearing loss in left ear for the past few days. The girl has no past medical history. She underwent an uneventful appendectomy at the age of 9, after which she was discharged from the hospital within 3 days. On examination, the girl is afebrile with normal vital signs. Head and neck examination did not reveal any abnormalities. Examination of the left ear shows purulent discharge in the external auditory canal. After clearing the external auditory canals, otoscopic examination shows a perforation in the pars flaccida. Apart from the perforation, small bits of amorphous white debris are also found in the left ear. Examination of the right ear is normal. Appropriate management of this patient's condition is


A. antibiotic eardrops, decongestants, and follow-up in 4 weeks
B. mastoidectomy
C. oral antibiotics and follow-up in 2 weeks
D. reassurance and follow-up in 3 weeks
E. tympanoplasty

The answer is B. The condition described in this girl is a cholesteatoma. A cholesteatoma occurs when the middle ear is lined with stratified squamous epithelium. The squamous epithelium desquamates in a closed space, which cannot be cleared and hence accumulates serving as a culture medium for the organisms. Cholesteatomas have the ability to destroy bone, including ossicles. Those arising in association with a perforation in the pars flaccida are called primary acquired cholesteatoma, while those arising in association with marginal perforations are called secondary acquired cholesteatoma. The presence of cholesteatoma greatly increases the probability of the development of serious complications, such as purulent labyrinthitis, facial paralysis, or intracranial suppurations like meningitis, brain abscess, subdural empyema, or epidural abscess. They are usually recognized by the small bits of amorphous white debris in the middle ear, and by the destruction of the bone of the external auditory canal superior to the perforation. A CT scan of the temporal bone is helpful in determining destruction of the bone. Cholesteatoma requires surgical treatment. The primary goal of the operation is to make the ear safe and the secondary goal is to maintain, or improve the hearing. The objective of the therapy is to remove the cholesteatoma or exteriorize it. A mastoidectomy, sparing the tympanic membrane, is the appropriate form of therapy for a cholesteatoma. In a radical mastoidectomy, the middle ear including the attic, the antrum, and the mastoid antrum are converted into one cavity that is in communication to the exterior, through the ear canal. The modified radical mastoidectomy spares the tympanic membrane remnants and ossicles to preserve the hearing.

Antibiotic eardrops and decongestants are not sufficient forms of therapy in treating a cholesteatoma (choice A). Delay in the treatment without a mastoidectomy, usually results in the progression of the disease.

Oral antibiotics (choice C) are not a sufficient form of therapy in treating a cholesteatoma. Although after a mastoidectomy, this condition can be treated with antibiotics, initially surgical treatment is the option.

Reassurance and follow-up in 3 weeks to see if the perforation closes spontaneously (choice D) is not optimal treatment. Cholesteatoma usually progresses, with the destruction of the bone and becomes a culture medium for the bacteria, unless a surgical debridement is carried out.

Tympanoplasty (choice E) is not a safe option, as this will not treat the primary pathology in a cholesteatoma.