70-year-old Woman with Decreased Hearing

A 70-year-old woman presents to primary care with concern for decreased hearing in her right ear. She has a history of a right ear cholesteatoma that was removed when she was a child. She denies any pain or drainage from the right ear. The following image of her right ear was obtained with the WiscMed Wispr digital otoscope.

What is the next step in management?

A. The tympanic membrane (TM) shows changes consistent with her reported historical surgery; no further action is necessary.
B. The TM is concerning for the recurrence of a cholesteatoma; otolaryngology (ENT) should be consulted.
C. The TM is normal.
D. The TM is concerning for an infection; antibiotics should be started.

The patient’s TM is clearly not normal. There is evidence of scarring in the pars flaccida region, likely from her childhood surgery to remove the historical cholesteatoma. In addition, there is a pearly nodule that potentially represents the recurrence of the cholesteatoma. Cholesteatomas are benign cysts behind the ear drum made up of skin cells. Although they are benign, they can do real damage to the ossicles in the middle ear. The ossicles translate TM vibration to the inner ear and are critical for hearing. Cholesteatomas can lead to hearing loss and need to be evaluated by an ENT. There is no evidence of an infection, such as acute otitis media (AOM) and therefore no indication for antibiotics.

The patient was sent for a CT scan by the ENT. The CT report read “6 mm recurrent pars flaccida cholesteatoma with erosion of the incus and stapes and suspected erosion of the facial nerve canal.”

At the time of this case, the patient was waiting for a surgical appointment.

Right Ear Cholesteatoma

Normal Left Ear

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