A 5 year old girl had earache and some yellowish foul smelling discharge, perforation at the attic and conductive hearing loss. She has no past history of any ear infections. What is the most appropriate diagnosis?

The key is c. Acquired cholesteatoma. [Acquired cholesteatomas develop as a result of chronic middle ear infection and are usually associated with perforation of the tympanic membrane at the attic

(mass is seen in attick with perforation at pars flaccida- in contrast to medial to tympanic membrane which is in congenital). Clinical presentation usually consists of conductive hearing loss, often with purulent discharge from the ear].

In congenital:

• mass medial to the tympanic membrane

• normal tympanic membrane

• no previous history of ear discharge, perforation or ear surgery.

[discrepancy like no previous infection is the only point in favour of congenital here and may be due to a bad recall!!!]