Cholesteatoma of the External Auditory Canal: Review of Staging and Surgical Strategy

External auditory canal cholesteatoma in children: clinical manifestations

PURPOSE

The purpose of this study was to explore the characteristics of external auditory canal cholesteatoma (EACC) among children and to describe its radiological findings on high-resolution computed tomography (CT) of the temporal bone in order to improve the diagnostic accuracy of primary EACC.

METHODS

The clinical records and CT imaging features of 44 patients who were diagnosed with EACC between January 2017 and May 2022 at Shenzhen Children's Hospital were retrospectively reviewed. Clinical features, including external auditory canal wall findings, hearing damage, symptoms and physical examination findings, were analysed against the level of lesion involvement. The correlation between different types of EACC and the incidence of different clinical symptoms was analysed, and the degree of hearing impairment and the rate of bone wall destruction were examined using CT.

RESULTS

The mean age at EACC onset was 9.02 ± 3.15 years, and the mean age at onset for EACC involving the right ear was older than that of EACC involving the left ear (P < 0.05). There were 44 patients (46 ears), including 10 ears with type I EACC, 23 ears with type II EACC, and 13 ears with type III EACC. Conductive hearing loss was the main type of hearing impairment observed among EACC patients. There were differences in types I, II and III EACC in terms of hearing impairment; specifically, there was a significant difference in moderate hearing impairment between type II and type III EACC patients (P < 0.05). The four most common symptoms were otorrhea, otalgia, itching and bleeding. The incidence of itching symptoms was greater in type I EACC than the incidence of otorrhea, and the incidence of otorrhea symptoms in type II and type III EACC was significantly greater than that in type I EACC(P < 0.05). There were no significant differences in the fracture rates of the anterior, posterior, superior or inferior walls of the external auditory canal within or between type II and type III EACC patients (P > 0.05). The failure rate of scute damage was significantly higher in type III EACC patients than in type II EACC patients (P < 0.05).

CONCLUSION

The presence of otorrhea and hearing loss as well as the identification of granulation tissue during otoscopy suggest the need for a temporal bone CT scan. This imaging modality can aid in the early detection and accurate classification of EACC, thereby guiding the selection of appropriate surgical interventions and greatly assisting in preventing further progression of hearing impairment.

Risk factors for occurrence and progression of external auditory canal cholesteatoma

OBJECTIVE

External auditory canal cholesteatoma (EACC) is characterized by retained squamous debris within the external canal and variable amounts of localized bone destruction. The etiology of primary EACC remains incompletely understood. This study was conducted to analyze the clinical features and backgrounds of patients with primary EACC and to clarify the risk factors for the occurrence and progression of EACC.

METHODS

Sixty-nine ears of 62 patients diagnosed with primary EACC were included in this study (EACC group). Additionally, 74 ears of 60 patients with chronic otitis media (COM) with perforation who underwent tympanoplasty or myringoplasty were included as controls (COM group). We retrospectively investigated the clinical features, life history, and medical history of the patients in both groups. In addition, to investigate the risk factors for progression of EACC, we compared the clinical features and medical history of patients with stage IV (advanced) disease versus stage I + II (mild) disease.

RESULTS

The inferior wall of the bony canal was the main structure affected in patients with primary EACC of all stages. The following factors were significantly more common in the EACC than COM group: older age, female sex, left-sided disease, osteoporosis, renal dysfunction, anemia, and treatment with bisphosphonates. Among these, the most significant factor associated with EACC was renal dysfunction (odds ratio, 11.4; 95 % confidence interval, 2.32-55.9). The significant factors observed in patients with stage IV disease were younger age, male sex, posterior wall involvement, and otorrhea. Surgical treatment was required for more than half of the patients with stage III and IV EACC.

CONCLUSION

Patients with renal dysfunction are at risk of primary EACC. In particular, younger patients and relatively younger elderly patients with posterior wall involvement have a risk of progression to advanced-stage EACC. Canalplasty should be considered in patients with EACC who have these risk factors to prevent progression to advanced-stage disease.

Necrotizing external otitis: diagnostic clues in the emergency department

PURPOSE

The assessment of necrotizing external otitis requires a high index of suspicion by the attending physician. The purpose of the study is to determine the accuracy of parameters available at the Emergency Department for the diagnosis of this pathology.

METHODS

Retrospective diagnostic accuracy study. Patients consulting at the Emergency Department for longstanding ear swelling, severe otalgia, and failure to respond to topical treatment were included. Otoscopy, physical examination, CT appearance, and analytical results were tested for the diagnosis of necrotizing external otitis, using nuclear imaging as gold standard. Sensitivity, specificity, likelihood ratios and ROC curves were calculated.

RESULTS

24 patients were included; 13 cases were necrotizing external otitis, and 11 cases were other external ear pathologies. Erythrocyte sedimentation rate and C-reactive protein levels were significantly associated with necrotizing external otitis (AUC 0.92 p < 0.001, and 0.8 p < 0.001). Positive likelihood ratios were 10.15 for values of erythrocyte sedimentation rate over 26 mm/h, and 8.25 for C-reactive protein levels over 10 mg/L. Negative likelihood ratios were 0.08 and 0.28, respectively. These results were significant. The rest of clinical and radiological parameters were less accurate.

CONCLUSIONS

Erythrocyte sedimentation rate and C-reactive protein are useful parameters in the evaluation of a case of longstanding otitis with clinical suspicion of necrotizing external otitis. If any of them is elevated, the probability of suffering this condition is significantly increased. If they are within normal ranges, an alternative diagnosis should be sought.

External Auditory Canal Cholesteatoma after Radiation Therapy for Nasopharyngeal Cancer: Case Series and Systematic Review

The authors performed a systematic review, in accordance with the PRISMA guidelines, across multiple databases, including all original studies published until November 2022, focusing on External auditory canal cholesteatoma (EACC) after radiation therapy (RT) for nasopharyngeal cancer (NC). Inclusion criteria were original articles reporting on secondary EACC after RT for NC. Articles were critically appraised to assess level of evidence using the Oxford Center for Evidence-Based Medicine criteria. Overall, 138 papers were identified and after duplicate removal (34 papers) and excluding papers not in English, 93 papers were assessed for eligibility; finally, only five papers were included and summarized with the three cases coming from our institution. These mainly involved the anterior and the inferior part of the EAC. The mean time of diagnosis after RT was the largest series of 6.5 years (with a range from 0.5 to 15.4 years). Patients undergoing RT for NC have 18 times a higher risk of developing EACC compared to the normal population. EACC is probably one of the most underreported side effects, because patients may present variable clinical findings, which could lead to misdiagnosis. Early diagnosis of RT related EACC is advised to enable conservative treatment.

Clinical Analysis of 85 Cases of External Auditory Canal Cholesteatoma Surgery under Specialized Endoscopy

Objective

To investigate the clinical characteristics, surgical experience, and surgical outcomes of external auditory canal cholesteatoma (EACC) surgery under endoscopic otolaryngoscopy.

Methods

A retrospective analysis of 85 EACC cases admitted to the Department of Otolaryngology, Renji Hospital, Shanghai Jiaotong University School of Medicine, from January 2016 to February 2021 was performed, followed by retrospective analysis of clinical data to explore the feasibility and clinical characteristics of all-oral endoscopic EACC surgery. A total of 85 EACC patients (90 ears) with a mean age of 49.93 ± 14.87 years were included in the study. According to Udayabhanu staging, 43 ears (47.78%) were stage I, 40 ears (44.44%) were stage II, and 7 ears (7.78%) were stage III. All patients underwent transendoscopic surgery.

Results

79 ears (87.78%) underwent endoscopic EACC resection alone (+external auditory canal tumor resection/tympanostomy tube insertion), 9 ears (10%) underwent endoscopic EACC resection+tympanostomy+tympanoplasty, 1 ear (1.11%) underwent endoscopic EACC resection+tympanoplasty, and 2 ears (2.22%) underwent EACC resection+otolaryngotomy+tympanoplasty+auditory chain reconstruction endoscopically. Of these, 7 ears (7.78%) underwent auricular cartilage-chondroplasty and 2 ears (2.22%) underwent auricular cartilage membrane repair. All patients were reviewed at 1 week, 2 weeks, 1 month, 3 months, 6 months, and 1 year postoperatively. One patient with stage II external auditory atresia had a recurrence after 6 months and underwent endoscopic ear surgery (ESS) again. One patient with stage 2 atresia recurred after 1 year and again underwent endoscopic ear surgery. The rest of the patients recovered well after the surgery, and the grafts healed well.

Conclusion

EACC surgery through the external ear canal under a dedicated endoscope is a safe, reliable, and effective method. Patients with stage I and II external auditory canal cholesteatoma surgery under endoscopy have a rapid postoperative recovery with significant hearing improvement, and stage IIIA patients can also achieve good results under strict evaluation of indications.

Cholesteatoma Classification: Review of Literature and Proposed Indian Classification System—TAMPFIC

Classification systems provides a tool for segregating cases based on their similarities. It can be used by healthcare professionals for representation, comparison, communication, discussion and for standardizing treatment protocols across the geographical boundaries. Cholesteatoma is prevalent in developed as well as developing nations posing a great burden on economic and health sector. Even though systems for classification of cholesteatoma are already being used in some places, however none of them is yet universally accepted due to their complex nature. After a thorough review of the most popular systems, we attempt to propose an Indian classification system for cholesteatoma "TAMPFIC". The system is based on clinical representations and will allow us to standardize the reporting of the disease and its extension along with all possible complications in a simple and unique way and will also help in reporting surgical outcomes for the same. Reporting of surgical outcomes will not only help in comparison but will also help in standardizing treatment protocols for similar kind of cases in future. It will require multi centric approach for validating our system to reach a common consensus for defining treatment protocols. We hope this system acquires universal acceptance and presents itself as a single new tool for classification of cholesteatoma with international consensus in near future.

External Auditory Canal Cholesteatoma: Clinical and Radiological Features

Introduction  External auditory canal cholesteatoma (EACC) is often misdiagnosed.

Objectives  To outline the clinical presentation of EACC, and to describe its radiological findings on high-resolution computed tomography (HRCT) of the temporal bone.

Methods  The clinical records of all patients diagnosed with EACC from April 2017 to March 2020 in a tertiary care center were retrospectively reviewed. The clinical presentation, the findings on the HRCT of the temporal bone, and the treatment provided were analyzed.

Results  A total of 9 patients, 7 males and 2 females, with a mean age of 30 years, were diagnosed with primary EACC. Six patients presented with otorrhoea, three, with otalgia, three. with hearing loss, and one with facial palsy. Some patients had multiple symptoms. The most common findings on otomicroscopy were destruction of the posterior and inferior canal walls, with cholesteatoma and intact tympanic membrane (six patients). Two patients had aural polyp, and one had a narrow ear canal due to sagging of the posterior canal wall. On HRCT, all nine patients showed soft-tissue density in the external auditory canal with erosion of the canal wall. The disease extended to the mastoid in eight cases, and to the cavity of the middle ear in one. There were three cases of dehiscence of the facial canal. Dehiscence of the dural and sinus plates was observed in two cases each. Eight patients underwent mastoidectomy, and one underwent debridement with canalplasty.

Conclusion  Review of the clinical and radiological findings is essential to reduce the rate of misdiagnosis.

Rare case of ballooning herniation of the tympanic membrane

Herniation of the tympanic membrane is a rare benign malformation of the tympanic membrane into the external auditory canal. It may be asymptomatic or associated with symptoms such as aural fullness, tinnitus, otalgia or hearing loss. We present a case of a symptomatic herniation of the tympanic membrane and its surgical therapy with hernia excision and tympanoplasty. An internal review board exemption was obtained.

Primary external auditory canal cholesteatoma of 301 ears: a single-center study

PURPOSE

Limited literature exists on primary external auditory canal (EAC) cholesteatoma (EACC). Here, we focus on the clinical features of this rare disease, especially the invasive patterns of lesion progression, through a large population study and present simple and practical staging.

METHODS

In all, 276 patients (male 99; female 177; mean age 41.3 ± 21 years; ears 301) with primary EACC were retrospectively analyzed. Stage I indicated EACC without bony lesions, stage II indicated invasion confined within EAC, stage III indicated invasion beyond the EAC involving mastoid air cells or tympanic cavity, but within the temporal bone, and stage IV indicated invasion beyond the temporal bone.

RESULTS

In all, 41, 219, 40, and 1 ear with Stage I, II, III, and IV lesions were found, respectively. Common clinical symptoms were hearing loss (237 ears, 78.7%), otalgia (221 ears, 73.4%), and otorrhea (85 ears, 28.2%). The mean air conduction and air-bone gaps were 45.4 ± 17.9 dB HL and 24.6 ± 15 dB HL, respectively. EACCs were found to invade in all directions of the EAC, with the inferior wall (224 ears, 74.4%) > posterior wall (207 ears, 68.8%) > anterior wall (186 ears, 61.8%) > superior wall (86 ears, 28.6%) invasion; multiwall invasions (207 ears) were common; however, inward invasions into the tympanic cavity were rare.

CONCLUSION

Primary EACCs occurred mostly in women and often unilaterally invaded multiple bony walls in the lower half of the EAC. The present staging reflects the patterns and severity of lesion progression and may be beneficial in treatment planning.

Cholesteatoma debridement for primary external auditory canal cholesteatoma with non-extensive bone erosion

Background: External auditory canal (EAC) cholesteatoma (EACC) is rare and its treatment for different lesions has not yet been standardized.Objective: This study aimed to explore the clinical features of EACC with bone erosion, and to assess the curative effect of initial complete cholesteatoma debridement (ICCD).Material and methods: Clinical characteristics and prognosis of 41 ears were analyzed retrospectively.Results: The bone erosion of the EAC was most commonly affected on the posterior wall (37 ears), next by the inferior wall (34 ears), the anterior wall (30 ears) and the superior wall (23 ears). Hearing loss (36 ears) was the most common symptom, followed by otalgia (33 ears), otorrhea (18 ears), tinnitus (11 ears) and pruritus (3 ears). The hearing impairment of mean air conduction and air-bone gaps were improved from 39.2 dB to 22.7 dB, and 23.5 dB to 7.1 dB after the ICCD procedure, respectively. Four ears presented recurrence during the follow-up time and accepted a revision-debridement.Conclusion and significance: The ICCD might be applicable in the treatment of patients in the early stages and with non-extensive bone defect; however, close and long-term surveillance is essential and serial debridement is probable.