There is clear erosion of the superior aspect of the ear canal into the attic of the middle ear with what appears to be moist keratin. The head of the malleus appears to be eroded. The pars tensa of the tympanic membrane appears intact and the chorda tympani appears unaffected. It is difficult to establish where the pars flaccida currently is positioned.
Such appearance of otoscopy is pathognomonic for cholesteatoma (classically epitympanic) with concurrent otitis media(likely chronic supporative otitis media).
Further management involves first treating the localised infection with topical anitbiotics. Second an audiogram should be performed to establish the degree of hearing loss associated. Finally a CT PTB is arranged to establish extent of disease and for surgical planning rather than diagnosis.