High-dose-rate brachytherapy of rhabdomyosarcoma limited to the external auditory canal

PURPOSE

To report on the single-catheter high-dose-rate brachytherapy treatment of a 21-month-old girl child with an embryonal, botryoid-type, rhabdomyosarcoma limited to the external auditory canal (EAC).

METHODS AND MATERIALS

A 2.4-mm diameter catheter was inserted into the right EAC and placed against the tympanic membrane. A computed tomography simulation scan was acquired. A brachytherapy treatment plan, in which 21 Gy in seven fractions was prescribed to a 1-mm depth along the distal 2 cm of the catheter, was generated. Treatments were delivered under anesthesia without complication. A dosimetric comparison between this plan and an intensity-modulated radiation therapy (IMRT) plan was then conducted. A clinical target volume (CTV), which encompassed a 1-mm margin along the distal 2 cm of the catheter, was delineated for both plans. Given positioning uncertainty under image guidance, a planning target volume (PTV = CTV + 3-mm margin) was defined for the IMRT plan. The IMRT plan was optimized for maximal CTV coverage but subsequently normalized to the same CTV volume receiving 100% of the prescription dose (V₁₀₀) of the brachytherapy plan.

RESULTS

The IMRT plan was normalized to the brachytherapy CTV V₁₀₀ of 82.0%. The PTV V₁₀₀ of this plan was 34.1%. The PTV exhibited dosimetric undercoverage within the middle ear and toward the external ear. Mean cochlea doses for the IMRT and brachytherapy plans were 26.7% and 10.5% of prescription, respectively.

CONCLUSIONS

For rhabdomyosarcomas limited to the EAC, a standard brachytherapy catheter can deliver a highly conformal radiation plan that can spare the nearby cochlea from excess radiation.

Nodular Fasciitis of External Auditory Canal

Nodular fasciitis is a pseudosarcomatous reactive process composed of fibroblasts and myofibroblasts, and it is most common in the upper extremities. Nodular fasciitis of the external auditory canal is rare. To the best of our knowledge, less than 20 cases have been reported to date. We present a case of nodular fasciitis arising in the cartilaginous part of the external auditory canal. A 19-year-old man complained of an auricular mass with pruritus. Computed tomography showed a 1.7 cm sized soft tissue mass in the right external auditory canal, and total excision was performed. Histologic examination revealed spindle or stellate cells proliferation in a fascicular and storiform pattern. Lymphoid cells and erythrocytes were intermixed with tumor cells. The stroma was myxoid to hyalinized with a few microcysts. The tumor cells were immunoreactive for smooth muscle actin, but not for desmin, caldesmon, CD34, S-100, anaplastic lymphoma kinase, and cytokeratin. The patient has been doing well during the 1 year follow-up period.

Leiomyoma of External Auditory Canal

This article reports a case of piloleiomyoma of external auditory canal, which is the 7th case of leiomyoma of the external auditory canal being reported and the 2nd case of leiomyoma arising from arrectores pilorum muscles, all the other five cases were angioleiomyomas, arising from blood vessels. A 52 years old male presented with a mass in the right external auditory canal and decreased hearing of 6 months duration. Tumor excision done by end aural approach. Histopathological examination report was leiomyoma. It is extremely rare for leiomyoma to occur in the external auditory canal because of the non-availability of smooth muscles in the external canal. So it should be considered as a very rare differential diagnosis for any tumor or polyp in the ear canal.

Volumetric Changes in the Bony External Auditory Canal in Unilateral Chronic Otitis Media

Background and Objectives

Pneumatization of air cells in the mastoid bone is decreased in chronic otitis media (COM). A decrease in the size of the external auditory canal (EAC) is also found frequently in patients with COM, but this has been little studied. We compared the size of affected bony EACs and the contralateral side in patients with single-side COM using high-resolution computed tomography.

Subjects and Methods

In total, 99 patients with single-side COM were included. Four indicators related to the size of the bony EAC and IAC were measured using high-resolution computed tomography: the axial and coronal lengths of the tympanic membrane, the length of the isthmus, and the area of the bony ear canal. We also compared both internal auditory canals as negative controls. These assessments were made by radiologists who were blinded to the objective of this study.

Results

In patients with single-side COM, the axial length of the tympanic membrane was significantly shorter than normal, and the volume of the EAC was also significantly smaller. The length of the isthmus of the EAC was shorter on the affected side, but the difference was not significant. The IAC volume showed no difference between the two sides.

Conclusions

COM affects general temporal bony development, including the bony EAC and mastoid bone. Therefore, whether to correct this should be considered when preparing for COM surgery.

Clinical Characteristics of Epidermoid Cysts of the External Auditory Canal

Background and Objectives

The epidermoid cyst is a common benign disease of the skin caused by inflammation of hair cortex follicles and proliferation of epidermal cells within the dermis or superficial subcutaneous tissue. The purpose of this study was to investigate the characteristics of epidermoid cysts of the external auditory canal (EAC) by analyzing the clinical and radiologic features.

Subjects and Methods

The clinical records were retrospectively reviewed for patients diagnosed with epidermoid cyst of the EAC from March 2004 to December 2013. The epidermoid cysts were diagnosed clinically by endoscopy and microscopy examinations and by temporal bone CT images, and were confirmed by histopathologic examination. Characteristics of epidermoid cysts in bony EAC and cartilaginous EAC were compared.

Results

Eight patients had an epidermoid cyst in the bony EAC and nine patients had one in the cartilaginous EAC. Swelling and otalgia were common symptoms, but 47% of cysts were found incidentally. The mean age of patients was 49.6 years (age range, 26-67 years) in the bony EAC cases and 26.1 years (age range, 6-57 years) in the cartilaginous EAC cases. The mean size of the epidermoid cyst was 3.50 mm (size range, 2-7 mm) in the bony EAC cases and 9.55 mm (size range, 2-20 mm) in the cartilaginous EAC cases.

Conclusions

Comparison of epidermoid cysts of the bony EAC and the cartilaginous EAC revealed that epidermoid cysts of the bony EAC is usually found incidentally, arose in older patients and had smaller size.

Anterior tympanic plate fracture following extraction of the lower molar

The present case report describes an external auditory canal injury following extraction of the lower molar. The external auditory canal was torn in the same fashion that occurs in an anterior tympanic plate fracture. This case demonstrates one of the rare complications associated with dental extractions.

Tumor budding and laminin5-γ2 in squamous cell carcinoma of the external auditory canal are associated with shorter survival

Squamous cell carcinoma (SCC) of the external auditory canal (EAC) is rare, usually presents at an advanced stage, and is a more aggressive tumor with poor prognosis. The University of Pittsburgh TNM staging system commonly used in prognostication is not perfect, and more accurate biomarkers predicting prognosis are needed. Tumor budding is an established negative prognostic factor at the invasive front in colorectal cancer. Moreover, immunohistochemical studies showed that laminin 5-γ2 (Ln5-γ2) is expressed at the invasive front in tumor or tumor budding cells. We assessed the prognostic significance of tumor budding and Ln5-γ2 expression by performing Ln5-γ2 immunohistochemistry and evaluated the degree of tumor budding in pre-treatment biopsy specimens, and investigated their correlations to clinicopathological parameters in patients with SCC of the EAC. Patients whose tumors had high budding grade and Ln5-γ2 expression had significantly shorter survival times. Budding grade was significantly correlated with Ln5-γ2 expression. Multivariate analysis revealed that high budding grade predicted poorer prognosis regardless of disease stage. Our results suggested that budding grade and Ln5-γ2 expression can be used as indicators of poor prognosis in patients with SCC of the EAC.

Squamous cell carcinoma of the temporal bone

Temporal bone malignancy presents a significant clinical challenge for the otolaryngologist. This article provides an overview of squamous cell carcinoma of the temporal bone, including clinical presentation, diagnosis, staging, treatment, and prognosis. As demonstrated in this case study, the prognosis for patients with advanced-stage temporal bone malignancy is poor, even with maximal therapy.

Ceruminous adenoma (ceruminoma) arising in a nevus sebaceus of Jadassohn within the external auditory canal of a 3 year-old boy - A case report

Nevus sebaceus of Jadassohn is a congenital yellowish hairless skin lesion, mainly located on the head and neck. A common phenomenon is the coexistence of secondary tumors within the lesion. These are mainly benign tumors, the majority of which are trichoblastoma and syringocystadenoma papilliferum. A ceruminoma is a very rare tumor of the ceruminous glands located in the outer third of the auditory canal. It occurs almost exclusively in adults. We describe the case of a 3-year old boy diagnosed with ceruminous adenoma (ceruminoma) growing within a nevus sebaceus of Jadassohn.

Anthropometry of external auditory canal by non-contactable measurement

Human ear canals cannot be measured directly with existing general measurement tools. Furthermore, general non-contact optical methods can only conduct simple peripheral measurements of the auricle and cannot obtain the internal ear canal shape-related measurement data. Therefore, this study uses the computed tomography (CT) technology to measure the geometric shape of the ear canal and the shape of the ear canal using a non-invasive method, and to complete the anthropometry of external auditory canal. The results of the study show that the average height and width of ear canal openings, and the average depth of the first bend for men are generally longer, wider and deeper than those for women. In addition, the difference between the height and width of the ear canal opening is about 40% (p < 0.05). Hence, the circular cross-section shape of the earplugs should be replaced with an elliptical cross-section shape during manufacturing for better fitting.

[Microtia-atresia: clinical, genetic and genomic aspects]

Mexico has a prevalence of microtia of 7.37/10,000 (newborns), 3 times higher than the prevalence reported in other populations (USA 2-3/10,000). Microtia is defined as a congenital malformation of the external ear characterized by a small auricular lobe with an abnormal shape. It is more often unilateral and on the right side. Males are more frequently affected than females. It can occur as an isolated defect or can be associated with other abnormalities such as stenosis of the external auditory canal. In three of the main pediatric hospitals in Mexico, microtia is among the most important causes of attendance in the Genetics Department. Microtia-atresia must be considered as a major malformation with important repercussions in hearing function requiring multidisciplinary medical care in order to limit the disability associated and to provide genetic counseling. Its etiology is complex. Only in a minor number of cases it has been possible to identify a main genetic component (as in monogenic presentations) or a main environmental cause (as in fetal alcohol syndrome or pregestational diabetes). In most cases this malformation is multifactorial. Due to the relevance that the frequency of microtia atresia has in different health services in Mexico, it is important that all medical professionals are aware of its clinical, molecular and inherited characteristics.

Sentinel lymph node mapping for malignant melanoma of the external auditory canal

We describe a novel technique for sentinel lymph node mapping and biopsy of a primary cutaneous malignant melanoma in the medial portion of the external auditory canal. The approach is illustrated through a case report and technical description of a procedure performed under general anesthesia on a 19-year-old female patient. Due to the hidden and sensitive location of the primary tumor in the medial external auditory canal, the lymphoscintigraphy injection had to be performed by the surgeon immediately prior to the resection of her cT2aN0M0 lesion. Final pathology revealed clear margins at the primary site resection and 2 intraparotid sentinel lymph nodes with microscopic foci of metastatic malignant melanoma, which led to further surgical management. A completion left parotidectomy and neck dissection yielded no additional metastatic disease in the fifty-five nodes that were evaluated. Using this technique, sentinel lymph node mapping and biopsy accurately predicted the highest risk lymph nodes for the primary lesion of the medial portion of the external auditory canal.

Capillary Haemangioma: A Rare Vascular Tumour of the External Auditory Canal

Haemangiomas are relatively common in the head and neck region, but cases in the temporal bone are rare. Hemangioma of the external auditory canal (EAC) is a rare otologic entity. Up till now (till 2013), only 18 cases of hemangioma EAC have been reported in the English literature. It is commonly classified as capillary or cavernous hemangioma. According to the literature, this case represents the fourth patient with capillary hemangioma of the EAC. A 22-year-old male presented to our department with a 3 years history of right-sided aural fullness, mild pain and decreased hearing. There was no history of ear discharge, pulsatile tinnitus, vertigo and local trauma. Oto-microscopic and otoendoscopic examination revealed a smooth surface, reddish pulsatile mass arising from the right postero-superior portion of bony canal wall, which measured about 1 cm in diameter, obstructing 2/3rd of the EAC. The tympanic membrane was not seen. No facial nerve dysfunction was observed. Patient had moderate conductive hearing loss in right ear on audiology. HRCT temporal bone showed soft tissue mass involving the right EAC and middle ear. The lesion was excised via a postaural approach under general anesthesia. The tumor was a reddish, soft mass and measured 1.6 × 1.7 × 2.8 cm. The histopathologic assessment indicated a capillary hemangioma.

"Bat Wing Surgical Approach for the Temporomandibular Joint"

INTRODUCTION

The temporomandibular joint (TMJ) is anatomically complex; with its close proximity to neurovascular structures, including the facial nerve that gives a high degree of difficulty during surgical exposure. When the first description on TMJ surgery by Orlow in 1913 was published it gave an account describing the basic retroauricular, preauricular, endoaural and submandibular approaches, on treatment of articular pathologies as used today. The proposed study of the 'Bat Wing' approach, first described in 1993 by Garcia y Sanchez J.M. as a surgical alternative, offers great advantages is that it avoids the section of the ear canal and provides a wide surgical field. The management of the proposed technique has wide application with multiple joints addressed, achieving major objectives such as avoiding facial nerve damage, as well as avoiding the section of the external auditory canal with an optimum visibility of the operative field.

MATERIAL AND METHODS

The Department of Maxillofacial Surgery National Medical Center XXI Century records over a period of approximately 18 months have completed twenty TMJ surgeries using the 'Bat Wing', approach.

CONCLUSIONS

The bat wing approach is a surgical alternative that offers broad exposure of the surgical field in TMJ, it is effective and meets the goal of exposing the area to intervene safely, good visibility and access to the site to intervene. It perfectly fulfills the above described.

Malignant melanoma of the external auditory canal

Primary malignant melanoma of the external auditory canal is rarely reported. Malignant melanoma of the ear is estimated to occur in 1-4% of all skin melanomas and about 7-20% of melanomas of the head and neck region. The pathophysiology of these tumours is different from other skin lesions because of their anatomical and functional characteristics. The case presented is of a 11 year old female child with malignant melanoma of the external auditory canal confined to the right side, who initially presented with right ear pain, bleeding, post auricular swelling and also a mass in the external auditory canal which was thought to be an aural polyp in the right ear. Excision of the tumour was accomplished by a radical mastoidectomy. It was confirmed to be malignant melanoma after histopathological examination and Immunohistochemistry. Despite all efforts, the patient succumbed to the disease after receiving three cycles of chemotherapy. Even though this malignancy is rarely found in the external auditory canal, it should be expanded into the differential diagnosis of an aural polyp and a post aural abscess. The incidence, symptoms, investigations, treatment and prognosis of malignant melanoma of the external auditory canal is discussed in this article.

A case of a cholesterol granuloma occluding the external auditory canal in a 12-year-old girl

Cholesterol granulomas are benign granulomatous lesions caused by tissue reaction to a foreign body such as cholesterol crystals. These crystals have been are associated with pathological conditions of pneumatized spaces, including those causing inadequate aeration, obstruction of drainage, and hemorrhage in pneumatized spaces, and where materials trapping materials, such as hemosiderin or cholesterol become trapped, and then forming a cholesterol granuloma. Cholesterol granulomas are frequently found in the temporal bones, with the middle ear, mastoid caverna, and petrous apex being the most commonly affected sites. As there have been few reported cases of cholesterol granulomas presenting as a mass in the external acoustic canal (EAC), a cholesterol granuloma occluding the entire EAC in a pediatric patient is considered quite rare. We encountered a large cholesterol granuloma occupying the entire EAC, resulting in total EAC occlusion in a 12-year-old girl. The granuloma was diagnosed via medical imaging and surgically excised.

Membranous band between the tympanic membrane and the external auditory canal

Two cases of a membranous band between the tympanic membrane and the external auditory canal are presented. These characteristic structures are rare, but observed in several first branchial cleft anomalies. Neither patient presented with an infection. In Case 1, an eleven-year-old girl has this structure in her right ear. In Case 2, a thirteen-year-old boy has this structure in his left ear. Both patients demonstrated slight air-bone gaps in the affected ear with a pure-tone audiometric test, due to limited vibrations of the tympanic membrane.

Cancer of the external auditory canal

INTRODUCTION

Cancer of the external auditory canal is a rare tumour with an annual incidence of one per one million inhabitants. The objective of this study was to evaluate the 5-year overall survival and disease-free survival rates in a series of patients with carcinoma of the external auditory canal and to compare our results concerning the clinical presentation, management and survival with those of the literature.

PATIENTS AND METHOD

Ten patients were included in this retrospective, single-centre study over a 20-year period. Data concerning age, symptoms, imaging, TNM stage according to the Pittsburgh classification, histology, management, sequelae, recurrences and survival were recorded.

RESULTS

The mean age of the patients of this series was 60.7 years. Seven patients had a squamous cell carcinoma. The other histological types were undifferentiated carcinoma, adenoid cystic carcinoma and neuroendocrine carcinoma. Staging was based on the Pittsburgh classification with one stage I, one stage III and eight stage IV tumours. Five-year overall survival rates were 100%, 50% and 0%, respectively. The mean 5-year overall survival rate was 35% and the mean 5-year disease-free survival rate was 24%.

CONCLUSION

Carcinoma of the external auditory canal is a difficult diagnosis when the tumour does not present as a fungating mass protruding from the external auditory canal. The Pittsburgh classification was used for TNM staging of these tumours, allowing comparison of our results with those of the literature. The clinical findings and survival rates observed in this study are comparable to those reported in the literature. These tumours are associated with a poor prognosis on the basis of our results and published data.

Keratinic amyloidosis of the external auditory canal

OBJECTIVE

We present a rare case of keratinic amyloidosis of the external auditory canal. This is only the seventh case reported of localized cutaneous amyloidosis of the external auditory canal with no systemic symptoms.

PATIENT

A 62-year-old man, who had complained of an itchy external auditory canal and left-side hearing loss, was referred to our hospital because of a bilateral external auditory canal mass.

INTERVENTION

Biopsy of the external auditory canal mass suggested a diagnosis of amyloidosis. However, total systemic examination failed to identify any disease due to systemic amyloidosis. This led us to diagnose him with localized cutaneous amyloidosis of the external auditory canal.

MAIN OUTCOME MEASURE

We follow up periodically with systemic examination and local observation.

RESULTS

Thirty months after the initial diagnosis, he remains in follow-up and has not shown any significant aggravation of the disease.

CONCLUSION

In previous cases, the chief complaints were itching sensations and pain in the external auditory canal as well as a sense of discomfort when wearing a hearing aid. This suggests that chronic stimulation and inflammation of the skin lining the external auditory canal induced amyloidosis.

Squamous papilloma in the external auditory canal: A common lesion in an uncommon site

Squamous papillomas (SPs) are common benign neoplastic lesions, usually affecting the skin, oral mucosa, upper aerodigestive tract and genital organs. However, SPs of the external auditory canal (EAC) are rarely reported in the English literature. In this report, we present a 19-year-old female with left EAC SP. The etiology, natural course, diagnosis and management of this disease are discussed, with a brief review of the literature.

HRCT evaluation of microtia: A retrospective study

Purpose:

To determine external, middle, and inner ear abnormalities on high-resolution computed tomography (HRCT) of temporal bone in patients with microtia and to predict anatomic external and middle ear anomalies as well as the degree of functional hearing impairment based on clinical grades of microtia.

Materials and Methods:

It was a retrospective study conducted on Indian population. Fifty-two patients with microtia were evaluated for external, middle, and inner ear anomalies on HRCT of temporal bone. Clinical grading of microtia was done based on criteria proposed by Weerda et al. in 37 patients and degree of hearing loss was assessed using pure tone audiometry or brainstem-evoked response in 32 patients. Independent statistical correlations of clinical grades of micotia with both external and middle ear anomalies detected on HRCT and the degree of hearing loss were finally obtained.

Results:

The external, middle, and inner ear anomalies were present in 93.1%, 74.5%, and 2.7% patients, respectively. Combined cartilaginous and bony external auditory canal atresia (EAC) was the most common anatomic abnormality in our group of microtia patients. Hypoplastic mesotympanum represented the commonest middle ear anomaly. The incidence of combined ossicular dysplasia and facial canal anomalies was lower as compared to other population groups; however, we recorded a greater incidence of cholesteatoma. Both these factors can have a substantial impact on outcome of patients planned for surgery. We found no significant association between grades of microtia and external or middle ear anomalies. Similarly, no significant association was found between lower grades of microtia (grade I and II) and degree of hearing loss. However, association between grade III microtia and degree of hearing loss was significant. A significant association between congenital cholesteatoma and degree of pneumatization of atretic plate and mastoid process not previously studied was also recorded in our study.

Compound Nevus Occurring Near External Auditory Canal: Successful Treatment by CO2 Laser Abrasion

Melanocytic nevus is common pigmented skin tumor, but it has rare occurrence near the external auditory canal. A skin graft is required if a wide surgical excision is performed for the nevi occurring near the external auditory canal. A CO2 laser was considered to be a good alternative for the removal of melanocytic nevus in this area. We herein report a case of compound nevus occurring near the external auditory canal that was successfully treated by CO2 laser abrasion.

A case of Basal cell carcinoma of external auditory canal

Malignant tumor originated from external auditory canal (EAC) is very rare with an annual incidence of around 1 per million. Pathologically, squamous cell carcinoma is incidentally most common, and adenoid cystic carcinoma, basal cell carcinoma, and melanoma follow in decreasing order. Due to the rarity of malignant tumor of EAC, there is no widely accepted treatment modality yet. But basal cell carcinoma, known to be less aggressive tumor, can be removed with a minimal safety margin and have better treatment results. Recently we experienced a case of basal cell carcinoma in the EAC, confined in the cartilaginous portion of EAC, presenting with intermittent otorrhea for several years. The patient was treated with a sleeve resection of the EAC with a safety margin reconstructed with a split-thickness skin graft. No tumor recurrence or complication was noted in the first postoperative year.

Cavernous haemangioma of the external auditory canal: clinical case and review of the literature

Although benign vascular lesions are frequent in the head and the neck region, clinical evidence of cavernous haemangioma of the external auditory canal is extremely rare; when present, the lesion invades the middle ear space. Herein, a rare case of a soft mass filling the external auditory canal, not involving the tympanic membrane, in a symptomatic 59-year-old male is described. Clinical and audiological characteristics, imaging studies and surgical treatment with histological evaluation are reported, which led to a diagnosis of a cavernous haemangioma. This is only the seventh case described in the literature, to date, not involving the tympanic membrane and the middle ear space. In addition, a review has been made of the relevant literature with respect to epidemiology, presentation, evaluation, pathology, and management options for haemangiomas arising in the external auditory canal.

Prosthodontic rehabilitation of a patient with bilateral auricular deformity

Maxillofacial prosthodontics is an art and science which provides life like appearance to the person with facial deformity. Maxillofacial prosthetic rehabilitation for acquired defects has become more complex and sophisticated with advancement in techniques and materials. This case report describes the clinical and laboratory procedure for fabricating an auricular prosthesis for a patient with trauma related bilateral auricular deformity. Ear prosthesis was fabricated in two parts taking retention from external auditory canal.