Snapshot A 29-year-old man presents with unresolved left ear pain for the past 5 months. He also states to having a relative hearing loss of the left ear with occasional tinnitus. Medical history is significant for otitis media that was treated with appropriate antibiotics. He reports completing the course of antibiotics. On physical examination, there is an amorphous, white debri in the left middle ear. Preparations are made to undergo a non-contrast computer tomography (CT) scan of the temporal bone. 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 debri accumulate perforation of the tympanic membrane may lead to squamous epithelium migration to the middle ear resulting in squamous debri accumulation Prognosis there may be recurrence of cholesteatoma post-surgery Presentation Symptoms can be asymptomatic hearing loss can occasionally occur with tinnitus dizziness otorrhea cranial nerve palsies 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