A 30-year-old patient with longstanding CSOM (attico-antral type) develops sudden onset facial nerve palsy, vertigo, and purulent otorrhoea. CT temporal bone shows erosion of the lateral semicircular canal and tegmen tympani. Which complication of cholesteatoma is most likely, and what is the urgent surgical priority?

• A Subdural abscess — immediate neurosurgical drainage before ENT surgery
• B Gradenigo's syndrome — treat with IV antibiotics alone
• C Labyrinthine fistula with meningeal involvement — urgent mastoidectomy with fistula management ✓
• D Petrous apicitis — drainage of petrous apex only

Explanation

Labyrinthine fistula (most commonly involving the lateral semicircular canal dome) is a recognised intratemporal complication of cholesteatoma causing vertigo and progressive SNHL. Concurrent facial nerve palsy implies involvement of the fallopian canal. Tegmen erosion raises concern for intracranial extension. Urgent surgical management involves canal-wall-down mastoidectomy (radical/modified radical) to completely remove cholesteatoma; the fistula is typically managed by leaving a thin matrix over the fistula opening (if no meningeal involvement) or removing matrix and sealing with fascia, balancing the risk of further hearing loss against recurrent/persistent cholesteatoma.

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.