Case contribution: Dr Radhiana Hassan


  • A 23 years old lady
  • No known medical illness
  • Presented with tingling and pulling sensation of the left side of the face for the last few months
  • Associated with reduce hearing left side and tinnitus.
  • Clinical examination shows left facial nerve palsy, House Brackmann Grade III.
  • Audiometry: conductive hearing loss of left ear.
  • Otoscopy left ear: Dull TM, distorted malleolus.
HRCT temporal bone in coronal plane
HRCT temporal bone in axial plane

CT scan findings:

  • Left external ear canal and tympanic membrane is intact.
  • There is soft tissue density (mean HU 32) within the left middle ear cavity (white arrows), involving the mesotympanum, epitympanum and Prusak space.
  • Hypotympanum is clear.
  • Associated erosion to the tegmen tympani with blunted of scutum are noted (yellow arrow).
  • The normal appearance of incudo-malleolar joint is not seen, suggestive of disruption (red arrows).
  • Suspicious involvement of the tympanic segment of facial nerve is seen.
  • The inner ear structures are normal in appearance and intact. No evidence of semicircular canal or facial nerve dehiscence.
  • There is fluid density within the left mastoid air cells which associated with bone remodelling. The aditus ad antrum is otherwise clear.

Diagnosis: Cholesteatoma (HPE proven)


  • Cholesteatoma is a well-demarcated non-neoplastic lesion in the temporal bone.
  • The annual incidence of cholesteatoma is reported as 3-9 cases per 100 000 population.
  • It is classified based on either the pathogenesis or the location in the middle ear cavity in relation to the tympanic membrane.
  • HRCT is the imaging of choice due to its high sensitiviy. Typical findings include a sharply marginated expansile soft tissue lesion, retraction of the tympanic membrane, blunting of scutum and erosion of the tympanic tegmen and ossicles.

Progress of patient:

  • Operation done in another hospital
  • EUM with combined approach tympanoplasty and tympanoplasty type Vb
  • Confirmed cholesteatoma
  • Uneventful recovery
  • Follow up assessment 2 months after surgery shows minimal left facial asymmetry, able to close eyes but not fully, minimal drooling of saliva when drinking.



Author: radhianahassan