Unilateral foul otorrhea with facial weakness: cholesteatoma or Bell palsy?
A 46-year-old man presents with a 5-year history of intermittent right-sided ear discharge that has become continuously foul-smelling over the past 6 weeks. He has noticed progressive right hearing loss and 10 days of right facial weakness, House-Brackmann grade IV, involving both forehead and lower face. There is no vesicular rash, tick exposure, or bilateral weakness. Otoscopy shows an attic retraction pocket filled with keratin debris and granulation tissue; the tympanic membrane is intact inferiorly. Pure-tone audiometry shows a right mixed hearing loss with air-bone gap 30 dB and bone-conduction threshold 45 dB; left ear is normal. CT temporal bone shows soft tissue in the epitympanum, scutum erosion, and erosion of the long process of the incus; there is no mastoid abscess or sigmoid sinus thrombosis. He is otherwise healthy and afebrile. He works as a commercial driver and asks whether he can be treated as an outpatient.
1. What is the most likely diagnosis, and how should the facial palsy change your immediate management compared with idiopathic Bell palsy?
Read the worked answer
The combination of chronic foul otorrhea, attic keratin debris, scutum erosion, and incus erosion makes an acquired cholesteatoma the leading diagnosis. Facial palsy in this setting is a complication of infection and pressure on the facial nerve, not idiopathic Bell palsy. Red flags against Bell palsy include unilateral ear disease, progressive weakness, and a visible cholesteatoma; atypical features would also include vesicles suggesting Ramsay Hunt, bilateral palsy, or a normal ear examination. He should not be treated as an outpatient. Admit for IV antibiotics covering Pseudomonas and anaerobes, urgent contrast MRI if there is concern about abscess or nerve enhancement, and prompt tympanomastoidectomy. Steroids alone are inappropriate because they do not address the infected keratin and bony erosion. The driving issue and the facial weakness both require urgent specialist care.
2. At surgery, how would you plan the approach and what steps protect the facial nerve and hearing?
Read the worked answer
I would plan a canal wall up mastoidectomy with atticotomy through a postauricular approach because the disease appears limited to the epitympanum and ossicles on CT. Use facial nerve monitoring from the outset. Identify the facial nerve at the second genu after skeletonizing the lateral semicircular canal, and keep dissection away from a possibly dehiscent fallopian canal. Remove cholesteatoma from the attic, scutum, and around the eroded incus. If the stapes suprastructure is intact and the ossicular chain can be reconstructed, consider a staged ossiculoplasty because the ear is infected; do not place a prosthesis into active infection. Preserve the posterior canal wall if disease can be completely removed, and convert to canal wall down if there is extensive tegmen or sinus involvement. Send tissue for culture and pathology. The hearing goal is a stable, dry ear first, then reconstruction.
3. What postoperative follow-up and counseling would you give regarding facial recovery and recidivism?
Read the worked answer
Facial recovery depends on the duration and degree of nerve compression, not just surgery. Document House-Brackmann grade, protect the eye with lubricants and taping or a temporary tarsorrhaphy, and start facial physiotherapy. Most infectious palsies improve over weeks to months, but grade IV at presentation carries a guarded prognosis. Counsel that surgery addresses the infection but does not guarantee facial recovery. For recidivism, arrange clinical follow-up every 3-6 months, annual audiometry, and non-EPI diffusion-weighted MRI at 12 months if a canal wall up procedure was performed; second-look surgery is considered if MRI is equivocal or if the ossicular chain was reconstructed in a staged manner. He should not drive commercially until facial function and vestibular symptoms are stable and local regulations allow.