Pediatric Cholesteatoma Can Cause Life-Threatening Intracranial Complications Despite Mild Ear Symptoms: Case Report

These findings of the case report are published in the Indian Journal of Otology by Dr. Aishwarya Jayan and colleagues in Ambala, India.

Clinical Case Overview

A 14-year-old adolescent boy presented to the otolaryngology clinic with a 15-day history of right-sided yellowish, mucopurulent, and intermittently blood-tinged aural discharge. The patient also experienced progressive hearing impairment, intermittent tinnitus, and right aural pruritus. Crucially, classical neurological and systemic red flags—including fever, headache, emesis, vertigo, and altered sensorium—were absent. His medical history was notable for recurrent upper respiratory tract infections accompanied by persistent nasal obstruction and an isolated episode of otorrhea ten years earlier that resolved with conservative therapy, without preceding otologic surgery, systemic disease, or trauma.

Otoscopic evaluation revealed a right tympanic membrane retraction pocket with a pars tensa defect, prompting clinical concern for unsafe chronic otitis media. Because profound unilateral sensorineural hearing loss (>90 dB) with a negative Rinne test appeared disproportionate to the patient’s 15-day history of otorrhea, high-resolution temporal bone CT was performed, identifying middle-ear and mastoid opacification, sigmoid plate erosion, sigmoid sinus thrombosis, and an adjacent cerebellar subdural collection. Due to heightened enzymatic osteolysis and accelerated expansion characteristic of pediatric cholesteatoma, intracranial invasion progressed via direct osseous destruction rather than retrograde thrombophlebitis, remaining entirely asymptomatic without focal neurological signs. The patient was successfully managed with intravenous broad-spectrum antimicrobials and urgent canal wall-down mastoidectomy, achieving complete cholesteatoma clearance and highlighting the critical need to investigate severe auditory deficits even when classic intracranial red flags are absent.

Implications for Clinicians

Clinicians evaluating pediatric otorrhea must maintain a high index of suspicion, particularly when hearing impairment appears disproportionate to symptom duration. A brief history and the total absence of neurological features should never preclude urgent radiological evaluation. Early high-resolution temporal bone imaging paired with prompt broad-spectrum antibiotic administration and definitive surgical extirpation remains essential to prevent life-threatening intracranial morbidity.

Reference

Jayan, A., Gupta, K., Chauhan, B., & Datta, G. (2026). The silent aggressor: Pediatric cholesteatoma with occult intracranial extension. Indian Journal of Otology, 32, 291–293.