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In eustachian-tube dysfunction, the eustachian tube fails to equalize pressure between the middle ear and the atmosphere, resulting in negative middle-ear pressure. This can cause recurrent middle-ear infections requiring myringotomy and tube placement, particularly in children. If the dysfunction persists into adulthood, patients may develop chronic otitis media with tympanic-membrane retraction and cholesteatoma, a collection of keratinized debris that builds up in the retraction pockets.
It is important to recognize cholesteatoma when it develops, because it can become superinfected and/or erode the ossicles. On otoscopy, the tympanic membrane will be retracted and appear concave, with a prominent lateral process of the malleus. In addition, the tympanic membrane may be immobile on pneumatic otoscopy. Patients with cholesteatoma should be referred to an otolaryngologist.
Cerumen impaction may initially be associated with an ear infection, but after the infection and wax are cleared, the ear should look normal.
Acute otitis media does not lead to a buildup of keratinized debris in the ear. The tympanic membrane initially appears bulging and convex; it returns to normal after the infection clears.
Chronic eczematoid otitis externa may be accompanied by white debris in the ear canal, but it clears with treatment, leaving the ear drum normal.
Fungal otitis externa is associated with whitish debris in the ear canal. It will not clear with antibiotics or antibacterial ear drops. The external auditory canal would appear inflamed, and the tympanic membrane would not be retracted.
Citations:
Shaikh N et al. Videos in clinical medicine. Diagnosing otitis media--otoscopy and cerumen removal. N Engl J Med 2010 May 21; 362:e62.
McCoul ED et al. Validating the clinical assessment of eustachian tube dysfunction: The Eustachian Tube Dysfunction Questionnaire (ETDQ-7). Laryngoscope 2012 Mar 1; 122:1137.
Seibert JW and Danner CJ. Eustachian tube function and the middle ear. Otolaryngol Clin North Am 2006 Nov 14; 39:1221.