A patient with active COM with cholesteatoma develops acute onset vertigo, nausea, and a positive fistula test. CT shows dehiscence of the lateral semicircular canal. The MOST appropriate immediate management is:

• A Systemic corticosteroids and vestibular suppressants only, defer surgery
• B Urgent surgical exploration with removal of cholesteatoma and grafting of fistula ✓
• C Intratympanic gentamicin ablation of the affected labyrinth
• D High-dose IV antibiotics for 6 weeks then elective surgery

Explanation

A labyrinthine fistula (most commonly involving the lateral semicircular canal) from cholesteatoma is a surgical emergency because it carries risk of labyrinthitis, permanent sensorineural hearing loss, and meningitis. The treatment is urgent surgical exploration, complete removal of the cholesteatoma matrix from the fistula site, and grafting (e.g., fat, periosteum or fascia). Attempting to leave the matrix over the fistula to protect residual hearing is controversial; most surgeons remove it. Steroids alone or delaying surgery risks progression to labyrinthitis and permanent inner ear damage.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.