Radiology quiz case 3. Congenital cholesteatoma of the middle ear with secondary bleeding.

A 17-YEAR-OLD BOY HAD BEEN TREATED FOR acute otitis media of the left ear for 3 months before he was referred to our department. He stated that during those 3 months he had experienced severe pain in his left ear. He had been hearing impaired since childhood but had no history of pulsatile tinnitus, otorrhea, ear infection, or ear surgery. On physical examination, he was afebrile but appeared to be very ill. Otoscopy revealed bulging and redness of his left eardrum. His right ear was normal in appearance. Audiometry showed a conductive hearing loss of 42 dB in his left ear, and the tympanogram was B type. High-resolution computed tomography of the temporal bone (Figure 1) and magnetic resonance imaging of the head revealed a mass in the left ear. A T1-weighted image with gadolinium (Figure2) showed no enhancement within the mass. After myringotomy was performed to relieve the patient’s severe otalgia before surgery, hemorrhaging of the puncture site occurred but was stopped without much difficulty. Otoscopy was performed 10 days after myringotomy (Figure 3). What is your diagnosis?