A 28-year-old man presents with chronic foul-smelling right ear discharge for 18 months and progressive hearing loss. Otoscopy reveals an attic retraction pocket with white keratin debris. Tuning fork tests show Rinne negative on the right (bone air) and Weber lateralizing to the right. Pure-tone audiometry shows the pattern marked **C** in the diagram — a 50 dB conductive hearing loss with normal bone conduction and a wide air-bone gap. A flat tympanogram is noted. What is the most likely diagnosis?

Question

A 28-year-old man presents with chronic foul-smelling right ear discharge for 18 months and progressive hearing loss. Otoscopy reveals an attic retraction pocket with white keratin debris. Tuning fork tests show Rinne negative on the right (bone > air) and Weber lateralizing to the right. Pure-tone audiometry shows the pattern marked **C** in the diagram — a 50 dB conductive hearing loss with normal bone conduction and a wide air-bone gap. A flat tympanogram is noted. What is the most likely diagnosis?

Accepted Answer

C. Acquired cholesteatoma with ossicular erosion. ## Why "Acquired cholesteatoma with ossicular erosion" is right

The audiometric pattern marked **C** — significant conductive hearing loss with intact bone conduction and a wide air-bone gap — combined with the clinical triad of chronic foul-smelling otorrhea, attic retraction pocket with keratin debris, and negative Rinne test (bone > air) is pathognomonic for acquired cholesteatoma. The foul smell results from anaerobic bacterial overgrowth (Pseudomonas, Proteus) within keratin debris. The flat tympanogram confirms middle ear pathology. HRCT shows erosion of the scutum and ossicular chain. This is a destructive keratinizing lesion requiring surgical management (canal wall down or canal wall up mastoidectomy with tympanoplasty) for cure (Scott-Brown ENT 8e).

## Why each distractor is wrong

- **Acute suppurative otitis media with effusion**: Presents with acute symptoms, conductive loss, and effusion on tympanometry. Does NOT produce chronic foul-smelling discharge, keratin debris, attic retraction pockets, or ossicular erosion. Tympanogram would show Type B (flat) or Type C (negative pressure), but the clinical picture is acute, not chronic over 18 months.
- **Otosclerosis with stapes fixation**: Produces conductive or mixed hearing loss, but presents with progressive hearing loss WITHOUT discharge, retraction pockets, or keratin debris. Tympanogram is normal (Type A). Rinne would show bone > air, but Weber would NOT lateralize to the affected ear in pure conductive loss. Otosclerosis does not cause foul-smelling otorrhea.
- **Congenital stapes fixation**: Similar to otosclerosis — causes conductive loss without discharge, retraction, or keratin debris. Presents in childhood with congenital hearing loss, not acquired progressive loss with chronic infection. No foul smell or tympanic membrane pathology.

**High-Yield:** Cholesteatoma = chronic foul-smelling otorrhea + conductive loss + attic retraction pocket + keratin debris → surgical cure required; medical therapy alone is palliative.

[cite: Scott-Brown ENT 8e — Cholesteatoma]

Answer

A. Congenital stapes fixation

Answer

B. Otosclerosis with stapes fixation

Answer

D. Acute suppurative otitis media with effusion

Explanation

Why "Acquired cholesteatoma with ossicular erosion" is right

Why each distractor is wrong

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