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Case 162


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A 23-year-old male patient comes to UFMG’s Otolaryngology service complaining of chronic, purulent, intermittent ear discharge in both ears, currently on the right, associated with bilateral hearing impairment, more pronounced at the right side, which began at age of two. On physical exam, the Weber test was lateralized to right, the Rinnie test was negative in both ears and vocal emission was of low intensity. Brought an audiometry and a CT of mastoid (done 4 and 2 years ago, respectively). The otoscopy was documented on the following images.

Analyzing the images and the clinical presentation, which is the most likely diagnosis in both Right (RE) and Left (LE) ears, respectively?

a) RE malignant/necrotizing external otitis; LE otitis media with effusion


b) RE and LE chronic otitis media with congenital cholesteatoma


c) RE suppurative chronic otitis media ; LE chronic otitis media


d) RE chronic otitis media with acquired cholesteatoma; LE chronic otitis media


Image Analysis

Image 1: Otoscopy of the Left ear- chronic otitis media. It is noted anterior perforation (red arrows), indicating a chronic inflammatory process. Observe the malleus, the ostium of the Eustachian tube and cells of the hypotympanum.


Video 1: Otoscopy of the Right ear – purulent, suppurative chronic otitis media. Observe the extensive central tympanic membrane perforation and purulent secretion, making it difficult to visualize the structures of the inner ear. The Scheibe signal, characterized by beats of the inner ear synchronous with the heartbeat may also be observed.


Image 2: Audiometry performed four years before shows gap between bone and air conduction (arrows), revealing conductive hearing loss in both ears, being more intense in the left ear (at this time, the patient presented with otorrhea only in the Left ear).


Image 3: Axial view of CT without contrast of the mastoid, showing opacification of the mastoid cells (arrows), with preservation of the bone structure, without coalescence. Note also eburnean mastoid and absence of signs of cholesteatoma.


Image 4: Coronal CT without contrast of the mastoid, showing a thickening of the tympanic membrane of the left ear (red arrow), Chaussé’s spur preserved, veiling of the epitympanum (green arrow) and preservation of the ossicles, which indicates lack cholesteatoma.


- A chronic otitis media is characterized by dry central tympanic perforation with intermittent periods of otorrhea and mucoid hyaline or yellowish ear discharge, rarely purulent.

- There is a mild to moderate conductive hearing loss. Audiometry reveals normal bone transmission and an air-bone gap of about 30dB.

- Temporal bone CT scan can show reversible changes in the middle ear and mastoid bone. CT is important for the differential diagnosis with cholesteatoma and for surgical planning.

- The treatment is surgical, aiming to eliminate disease as well as to reconstruct the tympanic membrane and the ossicular chain.

- Preoperative preparation includes cleaning the ear canal, antibiotics (ciprofloxacin and polymyxin B), with or without the association of corticosteroids.

- The following precautions must be passed on to the patient and his or her family: Avoid baths, treat respiratory infections and keep the vaccination card updated.


- Costa, S. S.; Cruz, O. L. M.; Oliveira, J. A. A. e cols. Otorrinolaringologia:   princípios e prática. 2ª Edição. Porto Alegre:   Artmed; 2006.

- Lee, K. J. Princípios de otorrinolaringologia - Cirurgia de Cabeça e Pescoço. 9ª Edição. São Paulo: Artmed; 2010.

- Lieberthal, A. al. The Diagnosis and Management of Acute Otitis Media. The American Academy Of Pediatrics. 2013, Feb 25. (131) e964-e999.


Ana Júlia Furbino Dias Bicalho, fifth year medical student at the UFMG School of Medicine. Email: anajuliabicalho[at]


Paulo Crosara, professor and head of the Otorhinolaryngology Department at the UFMG School of Medicine. Email: pcrosara[at]


Luanna Monteiro, Hércules Riani, Júlio Domingues, Viviane Parisotto.


Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG School of Medicine. Email: barbara.bragaglia[at]


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