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Bilateral External Auditory Canal Cholesteatomas

A 67-year-old man was referred for evaluation of bilateral external auditory canal cholesteatomas. Five months earlier, he had developed right-sided otorrhea and severe otalgia requiring a visit to the emergency department. In the months that followed, he had experienced four or five similar episodes, including one with frankly bloody otorrhea. He complained of bilateral hearing loss, slightly worse on the left side. He reported occasional disequilibrium and sometimes vertigo with certain motions, such as rising from a chair or rolling over in bed. He reported a distant history of foreign body (cotton) impaction in the left ear, without trauma to the tympanic membrane. His otologic history was otherwise unremarkable. His medical history was significant for chronic kidney disease dependent on hemodialysis. Otoscopic examination of the right ear revealed a cholesteatoma with significant erosion of the canal floor and some degree of bone exposure. The tympanic membrane was intact and showed pulsatile movement, and there appeared to be fluid within the middle ear space. Examination of the left ear revealed a canal cholesteatoma extending through a well-circumscribed defect of the posterior bony canal wall just lateral to the tympanic membrane. Purulent fluid and squamous debris were noted within the mastoid through the mouth of the cholesteatoma (figure 1). A Weber test lateralized to the right, and a Rinne test was negative bilaterally. The remainder of the patient's head and neck and cranial nerve examination was within normal limits. Audiometric testing on the right side demonstrated a mild, then sharply downsloping to profound, highfrequency sensorineural hearing loss (SNHL) with 80% discrimination. On the left, there was a profound, flat SNHL with no measurable discrimination. Figure1. Otoscopic imageoftheleftearshowsacanalcholesteatoma causing destruction of the posteriorbony canal wall but sparing the tympanic membrane.