Concern for otitis infections is a common reason for pediatric outpatient visits. Untreated ear infections can have serious consequences. Diagnosing and differentiating between the different types of otitis infections is vital. OM includes suppurative acute OM and nonsuppurative or secretory OM. Perforation, spontaneous rupture of the tympanic membrane, can occur during acute OM. Otitis externa includes bacterial infection or inflammation of the external ear canal. Similar to OM, there is acute ear pain, decreased hearing acuity, and visible debris and secretions in the ear canal. When either OM with perforation or otitis externa is suspected, a cholesteatoma should be considered.

Cholesteatomas are benign skin tumors, usually located in the middle ear and mastoid spaces. The cysts are lined with keratinized and stratified squamous epithelium with deposits of desquamated epithelium and keratin. Cholesteatomas grow progressively over time. There are both congenital and acquired cholesteatomas.

A congenital cholesteatoma is a cystlike structure of epithelial tissue in the ear, usually medial to an intact tympanic membrane. Children with acquired cholesteatomas do not typically have a history of infection or tympanic perforation. The etiology of the collection of epithelial tissue is unclear. On physical exam, cholesteatomas appear as a small white ball behind the tympanic membrane, next to the eustachian tube. Retraction pockets, chronic drainage, and keratin debris can also be present.