Dry central perforation with tympanosclerosis and cholesteatoma. (Otoscopic Clinic).

This otoscopic view of a left ear shows a dry 85% perforation of the pars tensa, tympanoscierosis in the anterior tympanic membrane remnant, and a solitary accumulation of cholesteatoma attached, and most likely confined, to the umbo and the inferior half of the long process of the malleus. There is no evidence of fluid or pus. The malleus appears to be intact and very likely is mobile. Only the fibrous annulus remains from 4 o'clock counterclockwise to 1 o'clock. In the posterosuperior part of the view through the perforation, the incus with its lenticular process is seen and appears to be attached normally to a normal stapes. The stapedius tendon is intact, inferior to the stapes are the round window niche and round window membrane. The mucous membrane on the medial surface of the tympanum appears to be completely normal and free of cholesteatoma or scar.

Effective treatment is outpatient surgery performed through a speculum through the external auditory canal, using a local anesthetic in the adult. A No. 1 knife and a sharp right-angle hook are used to carefully and completely excise the cholesteatoma attached to the malleus. The squamous epithelium on the tympanic membrane remnant, along with the anterior canal wall skin and periosteum, are removed and trimmed; these are used either alone or with a perichondrial or fascial graft, to reconstruct the tympanic membrane. No mastoidectomy is needed, and no film is used in the middle ear because the mucous membrane is excellent.