Polyp from middle ear emerging Polyp arising from external surface
through an eardrum perforation. of posterior pars tensa.
Granulation polyp (arrow) involving posterior quadrant of pars tensa.
[X - umbo, (+) - lateral process of malleus.
Granulation polyp arising from left pars flaccida (arrow).
Polyp arising from umbo area which resulted in blood-stained discharge and impaired hearing.
Round-shaped granulation polyp (+) with adjacent earwax seen just beyond.
Polyp filling osseous ear canal with blood-stained discharge.
Fleshy polyp passing through a medium-sized perforation
[before & after ear toilet].
An inflamed sessile middle ear polyp (circle) in a patient with chronic suppurative otitis media with underlying chronic mastoiditis. [A - anterior, I - Inferior, S - superior, + malleus remnant, interrupted black line - edges of subtotal perforation]
Images shows a true polyp arising from middle ear mucosa. Probing with blunt ring curette reveals its origin from the malleus handle supriorly (yellow arrow). Polypectomy by snaring or by using sharp instrument is preferred rather than by avulsion technique as to avoid potential ossicular injury.
[green arrow- facial nerve, dotted dark blue circle- round window niche, light blue circle- eustachian tube opening, dotted red- eardrum perforation margin]
Hyperplastic middle ear mucosa with a polyp arising from the promontory.
Snare device suitable to be used for pedunculated granulation/polyp or those
with thin pedicle arising from external ear canal. Temporary brisk bleeding
is to be expected and can be controlled with topical adrenaline pack.
Pre-aural toilet of the the same patient below.
Cavity involving the floor of cartilaginous auditory meatus filled with keratin (rounded rectangle). Bone sequestrum was also removed along with the keratin flakes from this crater earlier. Normal tympanic membrane is seen beyond (TM).
Dullness and opacity involving the pars flaccida
and posterosuperior segment of the pars tensa.
Close-up view of the same patient's eardrum. (X - cholesteotoma materials).
White epithelial pearl arising from attic with an intact tympanic membrane.
Visible whitish hue deep to posterior pars tensa secondary to
congenital cholesteatoma which has finally eroded the attic region.
Serial images displayed to demonstrate its clinical progression over times
before surgical intervention undertaken.
Close-up view of keratin flakes.
A completely obstructed ear canal with a bulging tense membrane.
A close-up view of the above lesion.
Arrow - keratin material filling the ear passage till true ear drum, stars - false tympanic membrane.
Segmental retraction (outlined) which potentially predisposes to deranged epithelial migration and potential formation of secondary-acquired cholesteatoma.
Cleft palate with resultant eustachian tube dysfunction predisposes to severe atelectasis and retraction pocket formation which complicates
into secondary acquired cholesteatoma.
A similar lesion involving the right ear. The patient presented with scanty foul-smell ear discharge, dizziness, reduced hearing and headache. The eardrum appeared severely retracted with granulation seen at the periphery posteriorly and yellow pus in proximity. Fistula test was found positive!
Before ear suctioning After ear suctioning
Attic polyp should raise the possibility of underlying cholesteatoma.
Proper ear toilet should be performed and particular attention paid to attic region. Cholesteatoma flakes can be seen as cheesy white material.
Curvi-linear scar over the incisura area.
Fine healed post-auricular curvilinear surgical scar.
Intact right malleolar-incudal complex in the epitympanum after
healed cholesteatoma surgery. Posteriorly leads to aditus ad-antrum.
View of epithelialized postero-superior cholesteotoma after ear toilet performed.
Healed atticotomy cavity and cholesteatoma-free.
Figure shows epitheliazed post-atticotomy cavity
with some earwax cumulation superiorly.
The epitympanum view after ear toilet showing missing
head of malleus with its adjoining body of incus.
Figure shows the facial nerve (arrow) course in the middle
(horizontal segment) before it turns inferiorly as the
vertical segment a patient who had surgery perfomed for atticoantral disease.
Horizontal segment of facial nerve (arrow)
A clean mastoid cavity.
Figure shows a well-epithealized mastoid cavity after a canal wall down surgery.
Mastoid cavity with epithelial crusts and some earwax.
Figure shows a localized entrapped keratin (arrow)
in a patient who had canal wall down surgery for cholesteatoma.
Early recurrence of cholesteatoma in a mastoid cavity manifested as epithelial pearls (arrows). (TM - tympanic membrane, A - anterior, P -posterior)
Follow-up assessment and inspection serve several objectives:
i. To monitor healing and recovery.
ii.To clean the cavity from epithelial debris or earwax cumulation.
iii.To detect and treat concurrent infection e.g. otomycosis.
iv.To diagnose residual or recurrence disease and plan for further therapeutic intervention.
Another example showing crusts (arrow) in a well-epitheliazed cavity.
Otomycosis occuring after cholesteatoma surgery.
Sequential endoscopic images of right auditory meatus showing post-surgery changes in a 4 year old child who had cholesteatoma operation 2 years earlier. Except for the hearing loss, she is otherwise asymptomatic.
(Epithelial migration figures are courtesy of Dr G Revadi)