Orf of the pinna

A case of orf affecting the pinna is discussed. This is an unusual presentation of an infection that is common in farming communities. At the initial presentation the diagnosis was not suspected, the management therefore was inappropriate and probably gave rise to the secondary infection that ensued. The history described is classical. Orf affecting the external auditory canal has been reported once, but orf affecting the pinna has not been described before.

Exostosis of the external auditory canal: an interesting histopathological finding

Perforation of the tympanic membrane is a frequent complication of surgery for exostoses of the external auditory canal. We report an unusual histopathological finding in a temporal bone containing external canal exostoses which suggests that some of these perforations may be unavoidable.

The nature of the epithelium in acquired cholesteatoma. Part 2. Cell culture

The exact nature and role of the epithelial layer in cholesteatoma remains undetermined. The aim of this study was to investigate cholesteatoma epithelium and normal aural epithelia in common cell culture conditions. Samples of cholesteatoma, external meatal epidermis and middle ear mucosa were obtained, successfully grown in cell culture, and subcultured. No significant morphological differences were found between cholesteatoma and aural epidermis. The only differences noted were delayed onset of colony formation, and the need to subculture prior to the cultures becoming confluent in the cholesteatoma cultures. Further research is required to account for these differences in growth patterns.

The surgical treatment of atelectatic ears and retraction pockets in children and adults

Eighty-four ears which underwent tympanoplasty because of an atelectasis of the tympanic membrane were followed up. Thirty-six involved children (4-13 years old). On the average, 50-55 months of postoperative follow-up showed that atelectasis, once operated, shared the same pattern and prognosis in the children as in the adults.

The motility of keratinocytes in cholesteatoma: an ultrastructural approach to epithelial migration

Eight cases of attico-antral cholesteatoma were studied by transmission electron microscopy concentrating on the mechanisms involved in intercellular adhesion. Desmosomes were found in large numbers throughout the epidermis and were arranged in various orientations around the keratinocytes. Those desmosomes found in the stratum corneum were significantly less dense than those in deeper layers and were associated with a large number of intercellular spaces, which would reduce the cohesive strength of this layer. The tortuous basement membrane features numerous hemidesmosomes along its length. The findings of this study were compared with previous ultrastructural observations made on the pars flaccida and pars tensa of the tympanic membrane and external canal skin. This revealed that the morphological characteristics of cholesteatoma resemble pars flaccida and external canal skin rather than pars tensa. The implications of these findings are discussed.

Glomus tympanicum tumors: a clinical perspective

Since Guild first discovered glomus bodies in the middle ear, the diagnostic evaluation and therapy of glomus tympanicum tumors have remained challenging. This study describes 73 cases diagnosed as glomus tympanicum tumors over the past 30 years. During this period, imaging techniques have markedly improved, and surgical approaches have evolved and been refined. These 73 cases were reviewed from a clinical perspective involving presentation, diagnostic evaluation, and therapeutic management. Pulsatile tinnitus was the primary symptom in over half the patients, followed by hearing loss in one third. The physical exam rarely revealed a circumferential view of the lesion, emphasizing the necessity of further diagnostic evaluation. High-resolution computerized tomography (CT) is currently the radiographic study of choice. A transmastoid surgical approach with extended facial recess was most commonly employed. Extension to the jugular bulb or internal carotid was rare, and no intraoperative complications of catecholamine secretion were noted. Postoperative complications were few, and the overall residual/recurrence rate was less than 5%. Additional clinical insights may assist in the management of these rare but fascinating tumors.

First branchial cleft anomalies involving the tympanic membrane and middle ear

First branchial cleft anomalies may involve the tympanic membrane or middle ear. A complete otologic examination must be performed in any patient with a suspected first branchial cleft anomaly. A surgeon treating such a defect must be prepared to perform both the excision of the lesion and reconstructive otologic surgery.

[Chronic cholesteatomatous otitis media: the histopathological and clinical aspects]

In recent years the immunologic aspects of the normal and pathological ear have been studied by several authors, with particular attention given to the histopathologic aspects of the epidermis of the tympanic membranes of the outer ear canal and of the middle ear mucosa in normal physiologic as well as in inflammatory conditions. Such studies may help in giving a more precise definition to the pathogenesis and clinical behavior of middle ear cholesteatoma. In this paper we report the results of an immunohistopathologic study carried out using the immunohistochemical technique of monoclonal antibodies on cholesteatoma matrix samples taken during radical mastoidectomy or tympanoplasty. In particular, the presence of T-lymphocytes and Langerhans cells was evaluated using selective monoclonal antibodies and a relationship between the data collected and the clinical expression of the disease in each case was sought. In this study it was not possible to establish a close relationship between clinical behavior and immunohistopathological findings, which appeared rather similar in all the cases. The presence of Langerhans' cells may confirm the hypothesized role they play in phlogistic reactions and bone reabsorption due to the presence of the cholesteatoma in the middle ear. Yet, in order to evaluate their true role correctly, more detailed studies should be carried out on the spatial distribution of T-lymphocytes and Langerhans' cells in the cholesteatoma matrix as well as on their ultrastructural characteristics.

A correlative manometric and endoscopic study of tubal function in dry central perforation of the tympanic membrane

Since good ventilation of the middle ear is a pre-requisite for successful myringoplasty, it was our policy to investigate the tubal function in dry central perforation of the eardrum and to correlate the manometric and endoscopic findings. Nasal endoscopy proved to be indispensable in diagnosing mechanical tubal obstruction and in localizing and even treating 'hidden' lesions in key areas, with probable normalization of the tubal function. The correction of the mechanical tubal obstruction must precede ear surgery. Whenever tubal obstruction is diagnosed as functional or idiopathic, the ventilation of the middle ear should be guaranteed during ear surgery by addition of a tympanostomy tube to the graft or drum remnant, and a guarded prognosis given.

Persistence of the foramen of Huschke in the adult: an osteological study

The foramen of Huschke, which appears during the embryological development of the tympanic bone, usually closes by the age of five years. A review of 377 dried skulls revealed that the foramen of Huschke was present in adult life in 7% of the skulls examined. A patent foramen of Huschke in the adult may, in rare cases, be the cause of temporomandibular joint herniation or fistulization through the anterior wall of the bony external canal.

[DNA cytometric studies of cholesteatoma of the middle ear]

Thirteen smears of middle ear cholesteatomas were investigated by the recently developed interactive DNA cytometry. The demonstration of DNA aneuploidy in 9 of the 13 cholesteatomas possibly indicates that these lesions are neoplasms.

Congenital cholesteatoma of the middle ear in children: a clinical and histopathological report

Forty-one children with congenital cholesteatoma of the middle ear seen from 1978 through 1989 are reviewed. The most common presentation was that of an asymptomatic white mass behind a normal intact tympanic membrane. Computed tomography (CT) scan was useful in documenting extension beyond the mesotympanum. Surgical removal was performed using an extended tympanotomy for lesions in the middle ear and tympanomastoidectomy for those that had extended into attic and mastoid air cells. Observation over an average 3.1-year period indicated that 80% of children were free of disease after initial surgery. Residual disease that required further surgery was present in 20%. The importance of early diagnosis of congenital cholesteatoma is strongly advocated. The prognosis is better when the cholesteatoma is confined to the anterosuperior quadrant of the middle ear. Seventeen patients in this study had such a lesion, and extended tympanotomy allowed removal of an encapsulated closed cholesteatoma with normal postoperative hearing and no residual cholesteatoma. The average age was 2.3 years. Temporal bone histopathological studies of three cases of congenital cholesteatoma demonstrate two distinct pathological types of congenital cholesteatoma. A "closed" keratotic cyst in the anterior mesotympanum, which is easily removed, and an "open" infiltrative type in which there is no containment of the keratotic debris and the cholesteatoma matrix is in direct continuity with middle ear mucosa. Surgical extirpation of the "open" type is difficult and more likely to be associated with residual disease.

Ossicular erosion by cholesteatoma: investigation by scanning electron microscopy utilizing a new preparation technique

A new technique for removing the soft tissues from middle ear ossicles to prepare them for scanning electron microscopy is described. The technique involved use of a solution of hypochlorite. The bony surface of normal ossicles was studied as a control group after preparation by the technique and no morphological distortion was observed. Ossicles eroded by cholesteatoma were then studied, and we propose that the erosion occurs in three stages; pumicing, pitting and cavitating. The mucoperiosteum of normal ossicles and otosclerotic foci were also studied.

[Experimental middle ear cholesteatoma originated from free skin graft of the external ear]

The pathogenesis of middle ear cholesteatoma has been thought to be invasion of squamous epithelium originated from the external ear skin including the tympanic membrane. There is no evidence, however, that the external ear skin has more potential to form cholesteatoma than that of other sites. In this report experimental middle ear cholesteatoma of guinea pigs originated from the external ear skin was histologically compared with that originated from the auricular skin. Cholesteatoma as dermal cyst was seen in the middle ear of almost all animals (25/28 = 89.3%), using a free skin graft (3 x 3 mm), regardless of the skin taken from superior (group A) or inferior (group B) part of the external ear, or the auricle (group C) eight weeks after skin implantation. The activity of epithelium such as keratinization was evident in group C. There is, however, no obvious difference in surrounding granulation tissues among group A, B, and C. In a half of this series, cyst wall was broken and its contents (debris) mainly consisted of keratin were put on surrounding granulation tissues three weeks after skin implantation. Striking keratinized epithelium and subepithelial inflammations in relation to the amount of debris were observed at the eighth week. These findings suggest that the external ear skin does not have specific potential to form cholesteatoma and keratin plays some roles in growth of cholesteatoma.

Effect of 5-fluorouracil in cholesteatoma development in an animal model

This investigation was designed to evaluate the effects of the antimetabolite 5-fluorouracil (5-FU) on cholesteatoma formation in a chinchilla model. The animals received middle ear applications of propylene glycol according to a procedure previously shown to produce cholesteatomas in 60% to 70% of animals. A 5% solution of 5-FU was then applied to the lateral surface of the tympanic membrane (TM) and, after 1 month, temporal bones were taken for histologic study. No macroscopically visible cholesteatomas were present in any of the 16 temporal bones included in the study. However, microscopic invasion of epidermis to the medial side of the TM was observed in four specimens; perforations were present in three of these. Although there was considerable variability in the response to 5-FU application, the majority of specimens showed little or no proliferation of connective tissue in the lamina propria of the TM. In the four specimens in which epidermis reached the medial side of the TM, it did so either by migration through microscopic breaks in the fibrous layer or via TM perforations. Thus, 5-FU did not completely inhibit migration of epidermis into the middle ear. However, the results of this study indicate that it does tend to reduce the proliferation of TM epidermis and connective tissue, thereby reducing the likelihood of cholesteatoma formation in the experimental model.

Inflammatory middle ear disease of the dog: the clinical and pathological features of cholesteatoma, a complication of otitis media

During a study of inflammatory middle ear disease in the dog cholesteatoma was found to accompany otitis media in seven of the 62 ears examined (11 per cent). The clinical, radiological and pathological findings in these animals imply that cholesteatoma in the dog is an aggressive lesion which must be differentiated from uncomplicated otitis media.

The nature of the epithelium in acquired cholesteatoma

Monoclonal antibodies with defined specifications for individual cytokeratins were used to stain the epithelia of the external auditory meatus, the middle ear and cholesteatoma. The observed staining indicated that the epithelium of the external auditory meatus has a pattern of keratin expression typical of epidermis in general and the epithelium of the middle ear resembles simple columnar epithelia. The pattern of staining of cholesteatoma closely resembled that of the skin of the external auditory meatus.

Lymphadenosis benigna cutis resulting from Borrelia infection (Borrelia lymphocytoma)

Swelling and erythema of the right pinna developed in a 7-year-old girl. Six months later a biopsy specimen showed a dense, diffuse lymphoplasmacytic infiltrate involving most of the dermis except for a thin Grenz zone. The appearance was consistent with lymphocytoma cutis. She had been bitten by a tick on the right ear in Switzerland 6 weeks before the onset of the lesion. Serologic tests by enzyme-linked immunosorbent assay for Borrelia burgdorferi, done 6 and 11 months after the bite, yielded optical density readings of 1.04 and 0.65, respectively; indirect immunofluorescence yielded titers of 1:256 and 1:128. A Borrelia-like organism was identified by a modified Steiner stain; immunohistochemistry was noncontributory. The spirochetal origin of lymphadenosis benigna cutis is briefly reviewed.

Facial nerve and medially invasive petrous bone cholesteatomas

Eight patients with extensive petrous bone cholesteatomas that invaded the labyrinth and fallopian canal are presented. The eight cases are added to a tabulation of prior literature reports to elucidate concepts of routes of extension of medially invasive temporal bone cholesteatoma. Medially invasive petrous bone cholesteatoma develops insidiously, often without symptoms other than facial palsy and/or unilateral deafness. Typically, a history of chronic ear disease can be obtained. While hearing is unlikely to be preserved in this group of patients, facial nerve function can usually be preserved, and a facial nerve graft was not necessary in our series. Acute facial nerve palsy or facial nerve paresis progressing to palsy in patients with a history of chronic ear disease should be studied radiographically for petrous bone cholesteatoma, even if there is no physical evidence of cholesteatoma.

Lymphotoxin in human middle ear cholesteatoma

The progressive growth of epidermis appears to be a crucial factor in the pathogenesis of cholesteatoma. How this growth is encouraged is still not well understood. In the present study, lymphotoxin was found in human middle ear cholesteatoma tissues by the immunoperoxidase method using rabbit anti-human lymphotoxin immunoglobulin G (IgG). Lymphotoxin was localized in the epithelium and connective tissues of the cholesteatomas studied. The epithelium of normal external ear canal skin was lightly stained, but the stain was much weaker than that of the cholesteatomas. In vitro, recombinant human lymphotoxin stimulated proliferation, protein synthesis, and terminal differentiation of basal keratinocytes. These findings suggest that lymphotoxin may be one of the mediators involved in the development of cholesteatoma.

Juvenile spring eruption of the ears: a probable variant of polymorphic light eruption

We report 18 cases in which a pruritic, erythematous, papular and vesicular eruption developed on the ears following sun exposure. Four of these patients had, on other occasions, suffered from typical polymorphic light eruption. The clinical features, histological changes, and results of phototesting suggest that juvenile spring eruption of the ears is a localized form of polymorphic light eruption.

Inflammatory middle ear disease of the dog: the pathology of otitis media

Inflammation within the middle ear cavity was recognised in 62 of the ears of 42 dogs with chronic otitis externa and otitis media, after biopsy or necropsy of the middle ear. The pathological changes in the middle ear resembled those reported in other species or after the experimental induction of otitis media in dogs. Perforations in the tympanic membrane were rarely found; on the contrary, the membrane was often thickened. However, the question of whether a perforation in the tympanic membrane must occur before otitis externa can extend to otitis media was not resolved.

The role of tumor necrosis factor-alpha in bone resorption of cholesteatoma

Recent investigations have indicated that cytokines such as tumor necrosis factor-alpha (TNF-alpha) play a potential role in the bone resorption associated with inflammatory diseases. In this immunoperoxidase study, TNF-alpha was localized in mononuclear cells, macrophages, fibroblasts, osteoblasts, and osteoclasts adjacent to bone resorption areas in both human and experimental middle ear cholesteatomas. In vitro, TNF-alpha stimulated monocytes to form multinucleated cells that demonstrate tartrate-resistant acid phosphatase activity, a marker enzyme for osteoclasts. These multinucleated osteoclast-like cells induce resorption of devitalized bone. The extent of bone resorption was increased by the co-cultures of osteoblasts and osteoclasts in the presence of TNF-alpha, suggesting that cell to cell interaction plays a significant role in bone resorption. Moreover, TNF-alpha was capable of stimulating macrophages to produce acid phosphatase and collagenase, and osteoblasts to produce prostaglandin E2 and collagenase. These chemical mediators have been known to lead to bone resorption. Our findings suggest that TNF-alpha may play an important clinical role in the destructive process of cholesteatoma.

[Histological and ultrastructural aspects of oto-mastoid cholesteatoma in children]

Cholesteatomas were intraoperatively removed from subjects under 14 years of age presenting widespread cholesteatoma with bone erosion. The samples were studied under light and transmission electron microscopy in order to consider the features of inflammation and bone erosion. The results showed that the perimatrix of cholesteatoma in children is rich in mononuclear inflammatory elements and generally presents the features of chronic, as well as acute, inflammation. The perimatrix infiltrates and erodes the surrounding bone. Next to the resorption areas many areas were observed having new bone the surface of which is lined with osteoblasts. The new bone formation activity is marked in these cases of childhood cholesteatoma and appears to be an attempt at spontaneous repair which is thwarted by the persistence of inflammation.