Differentials
Chronic suppurative otitis media
SIGNS / SYMPTOMS
On otoscopy there is perforation of the pars tensa but no evidence of cholesteatoma.
INVESTIGATIONS
Diagnosis is clinical.
Otitis externa
SIGNS / SYMPTOMS
On otoscopy there is swelling of the external canal and a scant discharge. The tympanic membrane is not visible or, if visible, appears inflamed, but no evidence of cholesteatoma.
INVESTIGATIONS
Diagnosis is clinical.
Benign necrotising otitis externa
SIGNS / SYMPTOMS
The patient reports severe otalgia; a history of diabetes or other immunosuppression.
On otoscopy there are granulations in the ear canal but no evidence of cholesteatoma.
INVESTIGATIONS
CT scan demonstrates soft tissue swelling of the ear canal with or without erosion of the petrous temporal bone.
Myringitis
SIGNS / SYMPTOMS
On otoscopy there is inflammation of the tympanic membrane with or without granulations, but no evidence of cholesteatoma.
INVESTIGATIONS
Diagnosis is clinical.
Otitis media with effusion
SIGNS / SYMPTOMS
Patients typically present with aural fullness or pressure, and a feeling of ear blockage.[34] Discharge is not typically present. On otoscopy, the tympanic membrane may appear dark, with an amber, grey, or blue hue. There may be bubbles or an air-fluid level.[35] In chronic disease (i.e., ≥3 months’ duration) the tympanic membrane may be retracted, in which case normal landmarks such as the short process of the malleus will appear more prominent.[36]
INVESTIGATIONS
Diagnosis is usually clinical.
Pure tone audiogram demonstrates a conductive hearing loss.
CT may be required if there is diagnostic uncertainty. CT of the petrous temporal bone would demonstrate opacification of the middle ear but no bone erosion.
Nasopharyngeal cancer
SIGNS / SYMPTOMS
May present with unilateral otitis media with effusion on otoscopy. Epistaxis and unilateral nasal obstruction may be reported.
INVESTIGATIONS
Lesion observed on nasopharyngoscopy (most lesions arise from the lateral pharyngeal recess). MRI or CT of nasopharynx, skull base, and neck identifies suspicious lesions and metastatic disease. Tumour cells identified on biopsy of lesion.
Granulomatosis with polyangiitis
SIGNS / SYMPTOMS
Can present with otorrhoea, hearing loss, and tympanic perforation. This is a multisystem inflammatory disease so other symptoms will usually be present. Other upper respiratory symptoms include: sinus pain; nasal discharge and crusting; epistaxis; hoarseness; stridor; oral and nasal ulcers; mucosal bleeding and inflammation; nasal septal perforation; saddle nose deformity; and sinus tenderness. Patients may also present with lower respiratory tract symptoms (e.g., cough, haemoptysis, chest pain, and dyspnoea), constitutional symptoms (e.g., fever, malaise, and anorexia), as well as ocular, neurological, musculoskeletal, and cutaneous manifestations.[37]
INVESTIGATIONS
Urinalysis typically shows haematuria, proteinuria, dysmorphic red blood cells, and red blood cell casts. ANCA is typically positive.
Ramsay-Hunt syndrome
SIGNS / SYMPTOMS
Typically presents with sudden-onset (<72 hours) unilateral peripheral facial palsy, severe ear/facial pain, and a vesicular ear rash.[38] Aural discharge is not present.
INVESTIGATIONS
Diagnosis is clinical. If there is uncertainty regarding diagnosis, vesicular lesions, if present, can be swabbed directly for confirmation of varicella zoster virus by polymerase chain reaction.
Tympanosclerosis
SIGNS / SYMPTOMS
On otoscopy there are hard white plaques with an irregularly sharp edge, as opposed to the smooth, curved edge of cholesteatoma.[4]
INVESTIGATIONS
Diagnosis is clinical.
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