A 35-year-old man from Delhi presents with a 3-year history of right ear discharge and hearing loss. On examination, otoscopy reveals a foul-smelling discharge obscuring the tympanic membrane. After aural toileting, a marginal perforation is seen with a polyp at the margins. High-resolution CT temporal bone shows erosion of the scutum and lateral semicircular canal. Audiometry reveals mixed hearing loss. What is the most appropriate next step in management?

Explanation

## Diagnosis: Chronic Suppurative Otitis Media — Atticoantral (Unsafe) Type with Cholesteatoma **Key Point:** Marginal perforation with scutum erosion and lateral semicircular canal involvement on CT indicates atticoantral CSOM with cholesteatoma — a surgical emergency requiring definitive mastoidectomy. ### Distinguishing Features: Tubotympanic vs. Atticoantral CSOM | Feature | Tubotympanic (Safe) | Atticoantral (Unsafe) | |---------|---------------------|----------------------| | **Perforation site** | Central | Marginal/attic | | **Cholesteatoma risk** | Rare (<5%) | Common (>80%) | | **Bone erosion** | Ossicles only | Scutum, SCC, facial canal | | **Otorrhea character** | Purulent, foul | Scanty, foul, blood-stained | | **Polyp/granulation** | Granulation tissue | Polyp (cholesteatoma) | | **Management** | Medical + ossiculoplasty | Surgical mastoidectomy | **High-Yield:** Scutum erosion + lateral semicircular canal erosion = cholesteatoma with bone-eroding potential. This mandates surgical intervention. ### Surgical Decision Tree ```mermaid flowchart TD A[Atticoantral CSOM + Cholesteatoma]:::outcome --> B{Intact Canal Wall Feasible?}:::decision B -->|Yes - Young patient, limited disease| C[Intact Canal Wall Mastoidectomy]:::action B -->|No - Extensive disease, recurrent| D[Cortical/Canal Wall Down Mastoidectomy]:::action C --> E[Lower recurrence, better hearing]:::outcome D --> F[Higher recurrence risk, CHL residual]:::outcome A --> G{Intracranial Signs?}:::decision G -->|Yes - Facial palsy, meningitis| H[Urgent imaging + surgical decompression]:::urgent G -->|No| I[Proceed to elective mastoidectomy]:::action ``` **Clinical Pearl:** Scutum erosion is a red flag for bone-eroding cholesteatoma. Lateral semicircular canal erosion increases risk of vertigo and labyrinthitis. Surgical intervention cannot be delayed. **Mnemonic — Atticoantral Red Flags (SCUBA):** - **S**cutum erosion - **C**holesteatoma (polyp) - **U**nsafe perforation (marginal) - **B**one erosion (SCC, facial canal) - **A**ttic involvement **Warning:** Mixed hearing loss (conductive + sensorineural) suggests labyrinthine involvement — ossiculoplasty alone is insufficient; mastoidectomy must address the cholesteatoma first.