An 8-year-old girl is brought to the office due to a small amount of left-sided ear discharge that has persisted for the last 3 weeks. She was seen twice over the last 2 months and completed 2 courses of antibiotics, but the discharge has persisted. She has no pain or fever but has hearing loss on the left side. The patient has had recurrent ear infections and underwent tympanostomy tube placement at age 2. Immunizations are up to date. Vital signs are normal. Otoscopy reveals some scarring on the left tympanic membrane, with peripheral granulation and some skin debris. Which of the following is the most likely diagnosis in this patient?

Question

An 8-year-old girl is brought to the office due to a small amount of left-sided ear discharge that has persisted for the last 3 weeks.  She was seen twice over the last 2 months and completed 2 courses of antibiotics, but the discharge has persisted.  She has no pain or fever but has hearing loss on the left side.  The patient has had recurrent ear infections and underwent tympanostomy tube placement at age 2.  Immunizations are up to date.  Vital signs are normal.  Otoscopy reveals some scarring on the left tympanic membrane, with peripheral granulation and some skin debris.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d657_1185_bc81_07d0785c4df6_MD0003_00 This patient should undergo further evaluation for a possible cholesteatoma, a benign growth of the squamous epithelium with accumulation of keratin debris within the middle ear. In children, cholesteatomas can either be congenital or acquired, with congenital lesions typically found in patients around age 5. Acquired cholesteatomas (which are more common) usually occur due to chronic middle ear disease. The diagnosis should be suspected in any patient with continued ear drainage for several weeks despite appropriate antibiotic therapy. Chronic middle ear disease leads to the formation of a retraction pocket in the tympanic membrane, which can fill with granulation tissue and skin debris, leading to chronic otorrhea. Complications of cholesteatomas include hearing loss (which this patient appears to already have), cranial nerve palsies, vertigo, and potentially life-threatening infections (eg, brain abscesses, meningitis). This patient should be referred to an otolaryngologist for a dedicated otologic examination, possibly accompanied by a CT and/or surgical visualization to confirm the diagnosis. (Choice B) Malignant otitis externa represents osteomyelitis of the external auditory canal and skull base. It typically develops in elderly patients with diabetes mellitus. It can cause discharge and hearing loss but is typically characterized by severe ear pain, prominent discharge, and external auditory canal erythema. (Choice C) Meniere disease is a condition associated with an accumulation of fluid in the inner ear that leads to hearing loss, vertigo, and tinnitus. The presence of ear drainage and the lack of vertigo make Meniere disease unlikely in this case. In addition, most cases of Meniere disease occur in adults. (Choice D) An osteoma is a benign, solitary area of bony overgrowth that can form in the outer ear and lead to hearing loss. Osteomas are more common in adults and typically involve the external ear (rather than the middle ear). The findings on this patient's tympanic membrane are more typical for cholesteatoma. (Choice E) Otosclerosis is a condition in which there is bony overgrowth of the stapes footplate that results in conductive hearing loss. Ear drainage would not be present. Educational objective: Cholesteatomas in children can either be congenital or acquired secondary to chronic middle ear disease. New-onset hearing loss or chronic ear drainage despite antibiotic therapy are typical presenting symptoms of cholesteatomas, and granulation tissue and skin debris may be seen within retraction pockets of the tympanic membrane on otoscopy.

An 8-Year-Old Girl Is Brought to the Office Due to a Small