How should I investigate a suspected cholesteatoma in primary care before referring to ENT?

Investigating suspected cholesteatoma in primary care before ENT referral:

• Perform a thorough otoscopic examination to identify signs such as a retraction pocket, granulation tissue, or aural discharge that may suggest cholesteatoma.
• Exclude other causes of ear symptoms such as impacted earwax or acute infections like otitis externa or otitis media.
• Assess for any red flags that require emergency action, including facial nerve palsy, neurological symptoms, systemic illness, or signs of serious complications (e.g., mastoiditis, intracranial abscess, meningitis). If these are present, arrange emergency hospital admission or urgent ENT advice immediately.
• If no emergency features are present, arrange prompt referral to an ENT specialist for further assessment and confirmation of diagnosis.
• Do not attempt imaging or audiology in primary care; these are part of specialist assessment.
• Provide the patient with information about the referral process and advise on symptom monitoring, especially for worsening or new neurological signs.

In summary, primary care investigation is limited to clinical examination and identification of urgent features; definitive diagnosis and further investigations are performed by ENT specialists.

References: NICE CKS, NICE NG98