What is the next best step for a child with chronic otorrhea (discharge from the ear), hearing loss, and a unilateral ear polyp?

Examination Under Anesthesia (EUA) with Biopsy

A child with 4 months of chronic otorrhea and a unilateral ear polyp requires examination under anesthesia (EUA) with biopsy to rule out cholesteatoma and malignancy before proceeding with any other intervention.

Rationale for EUA Biopsy as Next Step

The presence of a unilateral ear polyp in a child with chronic otorrhea (4 months duration) represents a structural abnormality that demands tissue diagnosis. Here's the algorithmic approach:

Why Biopsy Takes Priority

• Cholesteatoma is the most common cause of aural polyps in children with chronic otitis media, occurring in approximately 67.5% of cases with middle ear polyps 1
• Malignancy must be excluded, as failure of diagnosis or prolonged negligence can lead to squamous cell carcinoma, though rare in children 1
• The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that structural abnormalities of the tympanic membrane or middle ear (which includes polyps) require immediate evaluation and are indications for intervention 2

Why EUA Rather Than Clinic Biopsy

• Adequate visualization is essential - a polyp may obscure underlying cholesteatoma or other pathology that requires complete examination under optimal conditions 2
• Children cannot tolerate adequate office-based examination and biopsy of middle ear structures
• Complete assessment of middle ear structures, ossicular chain, and extent of disease is only possible under anesthesia
• Office biopsy risks incomplete sampling and inadequate hemostasis in a pediatric patient

Why Not CT First

• While CT temporal bone imaging is valuable for assessing bony erosion and extent of cholesteatoma, tissue diagnosis must be established first to guide appropriate surgical planning 3, 4, 5
• CT findings will not change the immediate need for tissue diagnosis when a polyp is present
• Ordering CT before biopsy delays definitive diagnosis and appropriate treatment

Why Not Silver Nitrate Cautery

• Cautery without tissue diagnosis is contraindicated - you cannot treat what you haven't diagnosed 1
• If the polyp represents cholesteatoma or malignancy, cautery would be inappropriate and potentially harmful
• Cautery may destroy tissue needed for histopathologic diagnosis

Clinical Decision Algorithm

Step 1: Child presents with chronic otorrhea (>3 months) and unilateral ear polyp

Step 2: Schedule EUA with biopsy to:

• Obtain tissue diagnosis
• Assess full extent of middle ear disease
• Evaluate for cholesteatoma
• Examine ossicular chain integrity
• Assess tympanic membrane for retraction pockets or perforation 2

Step 3: Based on biopsy results:

• If inflammatory polyp: Proceed with appropriate medical/surgical management for chronic otitis media
• If cholesteatoma: Plan definitive surgical excision (tympanomastoidectomy)
• If malignancy: Refer to pediatric oncology for staging and treatment

Step 4: CT temporal bone can be obtained after tissue diagnosis to guide surgical planning if cholesteatoma or other structural pathology is confirmed 4, 5

Critical Pitfalls to Avoid

• Never assume a polyp is benign without histopathologic confirmation - cholesteatoma is present in the majority of cases 1
• Do not delay biopsy for imaging studies when a visible mass is present requiring tissue diagnosis
• Avoid office-based procedures in children when adequate examination and hemostasis cannot be guaranteed
• The 4-month duration of otorrhea indicates this is chronic disease with structural changes requiring definitive evaluation 2