Suggest you biopsy that ulcerated/granulomatous-looking area. Could it be a cholesteatoma of the canal?

Sir those are the exposed mastoiditis air cells . Picture seems to be that of a automastoidectomy to me. There is no granulomatous tissue which can be biopsied. 

*mastoid air cells....thank you for your opinion. 

this is probably a limited osteomyelitis of the external meatus - it generally epithelialises after some months - keep it under observation

Thank you for your opinion sir . But how would the osteomyelitis subside on its own? Since she has a dry ear now. Also she has no other comorbidities . 

"But how would the osteomyelitis subside on its own?"

A highly relevant question.  An even more pertinent related question, is "Why is the trouble confined to one ear?".  This surely rules out all causes from infectious agents, metabolic, immunological, inflammatory or indeed any systemic factor, so there must have been some local cause, eg trauma. 

I agree with you sir that there should be a local cause . But in the form of some problem in the ventilation pathways of the epitympanum rather than trauma. 

"that there should be a local cause . But in the form of some problem in the ventilation pathways of the epitympanum"

I don't see how you can have a primary unilateral ventilation problem.   A definite problem with one Eustachian tube, for example, is a red flag for a tumor.  And isn't the primary problem more likely in the canal (or nasopharynx), as others have suggested?

Not the eustachian tube per se but in the tensor fold. The patient could have a horizontal complete tensor fold which would hamper the ventilation of the epitympanum. 

This variation can be unilateral I think. Please correct me if I am mistaken. 

Thank you for your opinion.

"The patient could have a horizontal complete tensor fold"

This is really a description rather than an explanation, even if correct.   The problem is unlikely to be solved until we know why any anatomical fault is only unilateral.

The question we need to ask ourselves is does this patient have an issue that needs to be addressed urgently?

She has no hearing loss and no obvious disease process on otoscopy. HRCT also reveals minimal soft tissue in the epitympanum.

Would it not be best to keep her under a regular follow-up?

Academically, to assess the cause for a unilateral negative-pressure related pathology we would have to evaluate the entire ventilation pathway from the nasopharynx to the epitympanum. However, Clinically, how relevant would it be?

Yes sir we have kept her on regular follow up only. But how did the cause subside on its own is the query?

The cause for inadequate ventilation may have been a temporary cause, such as inflammed mucosa, that resolved spontaneously.

Very recently we came across a patient whose entire lateral attic wall was eroded and the head of malleus and body of incus were clearly visible, however there was no active disease process: a classical case of healed chronic otitis media.

Interesting. It is not possible to say if the photograph shows a normal ear. If the ear is normal now, the likely explanation is an anaerobic otitis externa that has got better

I agree with Eishaan sir. But sir so should we do anything specifically to prevent  such inflammatory mucosa to cause more  damage again ? 

should we do anything specifically to prevent such inflammatory mucosa to cause more damage again"

I think inflammatory mucosa is a result of damage or insult, not a cause.

I presume the patient has had no previous ear surgery. If soft tissue swelling is visible, I would take a biopsy. I would consider a revision/obliteration of the cavity (using cartilage) only if there is frequently recurrent discharge, otherwise I would try to manage the problem conservatively.

the lesion is quite far removed from the epitympanum

there is little soft tissue in the epitympanum  so no continuity with the lesion making cholesteatoma less likely

there is exposure of the canal wall bone but no ulcerative lesions suspect for malignacy

i have seen this in 4 patients, mostly elderly but one was in her 30s, once after radiotherapy none were diabetics

it looks like a limited form of invasive otitis externa.

the bone remains exposed for months then gradually epithelialises

take a biopsy of the margins test for diabetes and other immunocompromise

clean the ear regularly

tincture of time

Okay thank you for your opinion sir. Will keep u'll updated regarding her progress.

• Hi Kartik. 

I think you should manage this young 

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she has granulation tissue at the audituve channel...is it so? if yes: I suggest a biopsy

Thank you for your opinion but the patient doesn't have any granulation tissue which can be biopsied. She has a dry ear with those visible mastoid air cells.

Could you give more details about the history of ear discharge?  Was this intermittent and unilateral over a number of years, or an acute bout?  Was it profuse, more than expected if just from the tympanic cavity? Were symptoms reduced when the ear discharged? Did she have any explanation as to what set it off?

Sir the patient had intermittent unilateral discharge over a number of years,it wasn't profuse. She did not have earache or any symptoms which were relieved on discharge. Also she had no idea what could have set it off. 

I think it would be better to do an atticototomy and clear the soft tissue fully. If the lesion is localised we can think of putting a small cartilage strut to cover the defect. And put a fascia graft. 

Thank you for your opinion sir. 

Although you said only a small tissue was seen on HRCT. The otoendoscopy appear to show defect in the attic region.I also believe a small atticotomy with suction clearance of the epitympanic tissue and carlilage reconstruction of the defect will solve this issue

Thank you for your opinion sir. 

Can this automatoidectomy be due to keratosis obturans ? Due to abnormal epithelial migration ? 

I have seen few auto Mastoidectomy cavities. Commonly it's attic lateral wall dehiscence. Sometimes it would be a larger cavity. Not necessarily a case of Keratosis. 

Thank you sir.