What are the key clinical features that suggest a diagnosis of cholesteatoma in a patient presenting with ear symptoms?

When a patient presents with ear symptoms, several key clinical features may suggest a diagnosis of cholesteatoma, necessitating prompt specialist assessment ¹,²,³.

• Persistent Ear Discharge: A history of ear discharge (other than wax) that has not resolved, has not responded to prescribed treatment, or recurs is a significant indicator ³. This type of discharge is also a feature of chronic suppurative otitis media (CSOM), which requires specialist referral to rule out underlying conditions like cholesteatoma ².
• Hearing Loss: Unilateral or asymmetric hearing loss, or hearing loss that fluctuates and is not associated with an upper respiratory tract infection, should prompt further investigation ³. Audiology assessment is a component of the specialist evaluation for suspected cholesteatoma to determine the type and degree of hearing loss ¹.
• Abnormal Ear Appearance: Concerning signs include an abnormal appearance of the outer ear or eardrum, such as inflammation, polyp formation, a perforated eardrum, abnormal bony or skin growths, swelling of the outer ear, or blood in the ear canal ³. Specifically, a perforation in the upper part of the eardrum is more likely to lead to mastoiditis, which may require surgery ². Specialist assessment may involve microsuctioning or debridement to clearly view the tympanic membrane perforation and detect polyps or cholesteatoma ².
• Ear Pain: Pain affecting either ear that has persisted for one week or more and has not responded to first-line treatment warrants further investigation ³.
• Associated Complications or Severe Symptoms: Certain features indicate more extensive or advanced disease and require urgent attention ¹. These include:
  • Facial Nerve Palsy: The presence of an associated facial nerve palsy is a critical sign, as delayed treatment is linked to a poor prognosis ¹.
  • Neurological Symptoms or Signs: These may indicate potentially life-threatening intracranial complications ¹.
  • Systemic Illness: If the patient is systemically unwell, this may suggest a more advanced stage of the disease ¹.
  • Signs of Serious Complications: Clinical features suggesting a serious or life-threatening complication, such as acute mastoiditis, intracranial abscess, or meningitis, necessitate emergency hospital admission or urgent ear, nose, and throat (ENT) specialist advice ¹.
• Tinnitus: Persistent tinnitus that is unilateral, pulsatile, has significantly changed in nature, or is causing distress should also prompt referral ³.

For an Admin in General Practice, it is important to recognise these features as they indicate the need for prompt referral to an ENT specialist for further assessment, confirmation of the diagnosis, and potential surgical intervention ¹,². Diagnostic imaging, such as CT or MRI of the temporal bone, may be used to identify soft tissue masses and bony erosion in the middle ear and mastoid ¹,² ((Maxwell and Hoff, 2025)).