How can I differentiate between a cholesteatoma and other middle ear pathologies during a clinical examination?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 16 August 2025Updated: 16 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

To differentiate a cholesteatoma from other middle ear pathologies during clinical examination, focus on the following key features:

  • Appearance of the ear canal and tympanic membrane: Cholesteatoma often presents with a retraction pocket or a pearly white mass behind the tympanic membrane, sometimes with associated granulation tissue or chronic ear discharge that does not resolve with standard treatment. This contrasts with acute otitis media, which typically shows a bulging, erythematous tympanic membrane without a mass, and otitis externa, which primarily affects the external ear canal rather than the middle ear ,,.
  • Presence of persistent or recurrent ear discharge: Unlike uncomplicated otitis media or otitis externa, cholesteatoma is associated with persistent or recurrent foul-smelling otorrhoea due to keratin debris accumulation .
  • Hearing loss characteristics: Conductive hearing loss is common in cholesteatoma due to ossicular erosion, whereas other middle ear infections may cause temporary conductive loss without bony destruction ,.
  • Complications and signs: Look for signs of complications such as facial nerve palsy, neurological symptoms, or systemic illness, which suggest advanced cholesteatoma and require urgent referral .
  • Examination limitations: If the tympanic membrane cannot be fully visualized due to canal debris or swelling, microsuction or aural toilet may be needed to assess for cholesteatoma or other pathologies .

Summary: Cholesteatoma is suspected when there is a retraction pocket or white mass behind the tympanic membrane, persistent foul-smelling discharge, conductive hearing loss, and possible complications like facial nerve palsy. These features help distinguish it from acute otitis media, otitis externa, and otitis media with effusion during clinical examination. Prompt ENT referral is essential for confirmation and management ,,,.

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