Otology and Neurotology
Core rules
Chronic suppurative otitis media (CSOM) is middle-ear/mastoid inflammation with a perforated tympanic membrane and otorrhea for at least 3 months. Separate mucosal (safe, central perforation) from squamous (unsafe, cholesteatoma) disease. Cholesteatoma is keratinizing squamous epithelium within the middle ear; acquired disease arises from retraction pockets or marginal perforations, while congenital cholesteatoma sits behind an intact drum. Bone erosion is enzyme- and osteoclast-mediated, risking facial palsy, labyrinthine fistula, mastoiditis and intracranial abscess. Sudden sensorineural hearing loss is at least 30 dB across three consecutive frequencies within 72 hours; treat urgently with corticosteroids and MRI. BPPV is diagnosed by Dix-Hallpike for the posterior canal and treated with Epley repositioning. Meniere disease causes episodic vertigo, fluctuating low-frequency sensorineural loss, tinnitus and aural fullness; management includes salt restriction, diuretics and intratympanic steroids. Facial nerve function is graded I–VI by House-Brackmann.
Worked example
A 28-year-old has right foul otorrhea and hearing loss. Otoscopy shows a pars flaccida retraction pocket with keratin debris, and CT shows scutum erosion. There is no facial weakness. This is acquired cholesteatoma, not simple CSOM. Management is tympanomastoidectomy with facial nerve monitoring, not prolonged topical antibiotics alone. Audiometry documents conductive loss; consent covers possible ossiculoplasty and facial nerve risk.
Traps
Do not label every discharging ear as CSOM: malignancy and tuberculosis mimic it. Congenital cholesteatoma occurs behind an intact tympanic membrane. Facial palsy with cholesteatoma is an emergency. BPPV is not treated with betahistine. Avoid aminoglycoside drops when the drum is perforated because of ototoxicity.