Snapshot A 27-year-old man presents to his primary care physician for the evaluation of ear discharge of the right ear. He also reports mild hearing loss on the affected ear with occasional episodes of tinnitus. Medical history is significant for 3 episodes of otitis media treated with antibiotics. On physical exam, there is amorphous, white debris in the right middle ear. Introduction Clinical definition a collection of keratinized squamous epithelium in the middle ear or mastoid Epidemiology incidence unknown demographics acquired cases occur in children and adults congenital cases begin in childhood location soft tissue and bony structures of the temporal bone risk factors family history long-standing Eustachian tube dysfunction cleft palate and other craniofacial anomalies Pathophysiology pathoanatomy prolonged middle ear negative pressure may retract the tympanic membrane which can create a pocket where keritinized squamous debris accumulate perforation of the tympanic membrane may lead to squamous epithelium migration to the middle ear resulting in squamous debris accumulation Prognosis there may be recurrence of cholesteatoma post-surgery Presentation Symptoms can be asymptomatic hearing loss can occasionally occur with tinnitus dizziness otorrhea Physical exam may have tympanic perforation except in congenital cases mucopus and granulation tissue on otoscopic examination Imaging Computed tomography (CT) scan indications if there is suspicion for extracranial complications and to make preparations for surgical removal Studies Clinical diagnosis Differential Bulging acute otitis media Otitis externa Tympanosclerosis Treatment Operative mastoidectomy indication treatment of choice in most patients with cholesteatoma Complications Hearing loss Acute mastoiditis Brain abscess Subperiosteal abscess