Assure that your patient who has a presumed perforated otitis media (OM) or otitis externa does not have a cholesteatoma

Assure that your patient who has a presumed perforated otitis media (OM) or otitis externa does not have a cholesteatoma: Excerpt from Avoiding Common Pediatric Errors

Author: Dorothy Chen, MD

What to Do - Interpret the Data

Concern for otitis infections is a common reason for pediatric outpatient visits. Untreated ear infections can have serious consequences. Diagnosing and differentiating between the different types of otitis infections is vital. OM includes suppurative acute OM and nonsuppurative or secretory OM. Perforation, spontaneous rupture of the tympanic membrane, can occur duringacute OM.Otitisexternaincludesbacterialinfection orinflammation of the external ear canal. Similar to OM, there is acute ear pain, decreased hearing acuity, and visible debris and secretions in the ear canal. When either OM with perforation or otitis externa is suspected, a cholesteatoma should be considered.

Cholesteatomas are benign skin tumors, usually located in the middle ear and mastoid spaces. The cysts are lined with keratinized and stratified squamous epithelium with deposits of desquamated epithelium and keratin. Cholesteatomas grow progressively over time.Therearebothcongenital and acquired cholesteatomas.

A congenital cholesteatoma is a cystlike structure of epithelial tissue in the ear, usually medial to an intact tympanic membrane. Children with acquiredcholesteatomasdonottypicallyhaveahistoryofinfectionortympanic perforation. The etiology of the collection of epithelial tissue is unclear. On physical exam, cholesteatomas appear as a small white ball behind the tympanic membrane, next to the eustachian tube. Retraction pockets, chronic drainage, and keratin debris can also be present.

AcquiredcholesteatomasareoftenacomplicationofchronicOM.However, they can also arise from retraction pockets or cell migration. They will appear as white debris or drainage in the ear canal, after having broken through the tympanic membrane. Retraction pockets develop when there is prolonged damage to the eustachian tube. The pars flaccid, the weakest part of the tympanic membrane, will enter the middle ear and become a collection of squamous epithelial tissue. Chronic infection allows metaplasia of the cuboidal mucosa into squamous epithelium. Lastly, epithelial cells can migrate to the middle ear when there is tympanic membrane perforation or insertion of tympanostomy tubes.

The negative impact of cholesteatomas is due to their location and their activity. Because cholesteatomas are found in the middle ear, mastoid spaces, tympanic membrane or the ear canal wall, they grow and can erode bone with easy access to the brain. The lysozymes within the matrix of cells can dissolve both soft tissue and bone. Infection is another common complication, resulting in serious meningitis; thrombi; and epidural, subdural, and brain abscesses. A computed tomography scan of the temporal bone should be performed to evaluate the disease extent. Surgical intervention is usually required to treat cholesteatomas.

Suggested Readings

Haddad J. Congenital malformations. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: Saunders; 2004:2136.
Hughes W, Lee JH. Otitis externa. Pediatr Rev. 2001;22(6):191–197.
Paradise JL. Otitis media. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: Saunders; 2004:2138–2148.
Stone KE. Otitis externa. Pediatr Rev. 2007;28(2):77–78.
Thompson JW. Cholesteatomas. Pediat Rev. 1999;20(4):134–136.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

 » Next page: Do not use aminoglycoside antibiotic eardrops in the presence of a perforation or ventilation tube, because they may be ototoxic if they enter the middle ear (Avoiding Common Pediatric Errors)

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