Cholesteatoma with an intact tympanic membrane.

The accompanying otoscopic view of a left ear shows a completely normal tympanic membrane (figure). The malleus is vertical, and the short process is seen at its upper edge as a cream-colored protrusion. The pars tensa is intact, and there is a good light reflex at the center of the photograph. The promontory is barely visible through the center of the pars tensa. The incus appears at the upper-right edge of the tympanic membrane, and the prominent feature is a spherical, cream-colored mass seen through the translucent pars tensa anterior to the malleus. This represents a cholesteatoma in the middle ear.

Once these lesions were thought to be congenital rests of epithelium, but it has now been shown that cholesteatomas are acquired. A healed, grossly invisible fistula accounts for the entrance of squamous epithelium into the tympanum. The true congenital cholesteatoma normally involves the

cerebellopontine angle or temporal bone, and clearly extends from the temporal bone into the middle ear. The cholesteatoma is treated by complete surgical excision. If attachment to the pars tensa is identified, the fistulous tract must be excised and the area grafted.

From the Pulec Ear Clinic, Los Angeles (Dr. Pulec), and from private practice (retired) Gap, France (Dr. Deguine).