External auditory canal cholesteatoma: reassessment of and amendments to its categorization, pathogenesis, and treatment in 34 patients

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.

A Case of Primary EAC Cholesteatoma Extending into Antrum with Normal Middle Ear

Introduction A cholesteatoma is a three-dimensional sac lined by keratinized squamous epithelium containing desquamated keratinized epithelial cell which secretes enzymes that have the tendency to expand and erode the bony structure underlying it and cause intracranial and extracranial complications. This cystic mass is in an abnormal location such as the middle ear, the petrous apex, or the external auditory canal (EAC). It is mostly found in the middle ear and rarely in the EAC. Here we have reported a rare case of unilateral primary EAC cholesteatoma with mild hearing loss in a middle-aged male.

Case Report We have reported a case of a 34-year-old male with complaints of right-sided ear discharge and right-sided decreased hearing for the last 5 to 6 years. On examination, right ear EAC was found to be dry, and a sac was observed in posterior wall extending to mastoid present with clear attic, and intact retracted tympanic membrane that was then followed by radiological evaluation to establish the diagnosis of EAC cholesteatoma. This was surgically treated and ear was cleared of all disease. Patient's symptoms improved postoperatively.

Conclusion Primary EAC cholesteatoma with disease-free middle ear is a rare finding and there is very less definitive literature available on the pathogenesis of the same.

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.

Taste Alteration in External Auditory Canal Cholesteatoma: Indicator of Impending N VII Affection

INTRODUCTION

External auditory canal cholesteatoma (EACC) is a rare disease, with an estimated incidence of approximately 1:1,000 adult and 1.6:1,000 pediatric otologic patients. Systematic studies of chronic ear disease and taste alteration prior to surgery are rare; in fact, there are no such studies for EACCs. Therefore, we describe chorda tympani nerve (CTN) dysfunction and the related clinical consequences in EACC patients.

METHODS/STUDY DESIGN

Between 1992 and 2021, we retrospectively analyzed the symptoms, signs, and radiological and intraoperative descriptions of CTN involvement in 73 patients. Liquid taste tests and, since 2009, Taste StripsTM as well as an olfactory screening test (Smell DiskettesTM) have been performed for all symptomatic patients and, when feasible, all other EACC patients.

LEVEL OF EVIDENCE: 4

RESULTS

Ten of 73 patients complained subjectively of dysfunction, and 8 showed abnormal taste test results. Four patients complained of olfactory dysfunction (3 cases with pathological taste tests). Gustatory dysfunction was most frequent in radiogenic EACC cases (n = 4), followed by postoperative EACC (n = 3). Two postoperative patients were asymptomatic despite abnormal test results. Rarely, patients with idiopathic (n = 2) and posttraumatic (n = 1) EACC showed acute taste dysfunction that was confirmed in each with abnormal test results.

DISCUSSION/CONCLUSION

CTN dysfunction often developed asymptomatically in chronic ears, except for idiopathic and posttraumatic EACCs under previous healthy middle ear conditions. Taste disturbance is not a cardinal symptom of EACC, but objective testing suggests that up to one out of 10 EACC patients with advanced disease may experience regional gustatory dysfunction prior to surgery. Especially in context of a new and acute presentation, regional taste dysfunction may alert the clinician of potential progressive EACC invasion and danger to the facial nerve.

Transcanal Endoscopic Ear Surgery for Advanced External Auditory Canal Cholesteatoma in Naim Stage III and IV

OBJECTIVE

To report the clinical characteristics and treatment outcomes, as well as endoscopic-assisted ear surgery techniques used in patients with advanced external auditory canal cholesteatoma (EACC).

STUDY DESIGN

Retrospective case series.

SETTING

University hospital.

METHODS

From October 2014 to September 2017, adult patients (age > 18) with advanced EACC (Naim's classification: stage III or IV) who underwent transcanal endoscopic ear surgery (TEES) were enrolled. The presenting features, extent of the lesion, and reconstruction techniques used were assessed. The healing time which was defined as the time required to develop a dry, re-epithelialized, and self-cleaning external auditory canal, was compared between stage III and IV.

RESULTS

Twenty-three patients were included. EACC was categorized as stage III in 11 ears and stage IV in 12 ears. Cholesteatoma involved the mastoid (30%), middle ear (26%), chorda tympani (22%), temporomandibular joint, antrum, and facial nerve (17% for each). In 96% of patients, a dry and self-cleaning external auditory canal (EAC) was maintained after a mean follow-up of 15 months. The median healing time was 8 weeks in stage III, which was significantly shorter than the 12 weeks required for stage IV (p < 0.05). There was no significant difference in the median healing time between TEES and the canal wall up mastoidectomy for stage IV EACC (14 weeks) performed by the same surgeon over the same period (p > 0.05).

CONCLUSIONS

TEES is a feasible and safe technique for the exposure and eradication of advanced EACC. Some critical endoscopic techniques for resecting disease and reconstructing the defect in the EAC and middle ear should be mastered before performing this operation.

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.

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.

External Auditory Canal Cholesteatoma Causing Simultaneous Bezold Abscess and Sinus Thrombosis

Extra- and intracranial complications of cholesteatoma are rare in the new era of antibiotics. The rarity of the severe complications and the atypical symptoms cause difficulties to set up proper diagnosis and treatment. We report about a 76-year old patient with external auditory canal cholesteatoma causing Bezold abscess and sigmoid sinus thrombosis. The patient underwent canal wall up mastoidectomy and mastoid obliteration with abdominal fat and Bezold abscess drainage. Systemic antibiotic and anticoagulant therapy were applied. The treatment resulted in fast improvement in the general condition of the patient, and the control magnetic resonance imaging (MRI) showed no recurrence of the disease. Laryngoscope, 131:E1282-E1285, 2021.

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.

Incidence and Risk of Various Disorders of the External Ear in Patients With Hearing Aids Treated in ENT Practices in Germany

OBJECTIVE

The aim of the study was to investigate the relationship between the presence of a hearing aid (HA) and the occurrence of various disorders of the external ear, using data from ear, nose, and throat (ENT) practices in Germany from a nationwide, representative practice database.

METHODS

In the period between 2012 and 2016, the incidences of disorders of the external ear (ICD-10 groups H60 and H61) in patients with HA prescriptions were compared retrospectively with a control group without HA prescriptions (1:1 matching).

RESULTS

A total of 20,127 patients with HA prescriptions were compared with 20,127 controls. The highest 12-month incidences (HA vs. controls) were determined for "Impacted cerumen" (H61.2) (16.5% vs. 4.2%), "Unspecified otitis externa" (H60.9) (2.6% vs. 1.2%) and 'Acute noninfective otitis externa' (H60.5) (2.3% vs. 0.7%). The most significant risk increases for HA wearers were found for "Abscess of external ear' (H60.0, OR 10.03), "Other otitis externa' (H60.8, OR 6.00), and "Impacted cerumen' (H61.2, OR 4.55). A smaller risk increase was found for "Cholesteatoma of external ear' (H60.4, OR 2.26), among others.

CONCLUSION

In HA wearers, the risk of developing almost all of the diagnoses reviewed is significantly increased, especially for external auditory canal (EAC) furuncle, chronic otitis externa, and impacted cerumen. This study provides the first epidemiological evidence for HA as a risk factor for the rare EAC cholesteatoma.

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

INTRODUCTION

External auditory canal cholesteatomas (EACC) is insidious in nature and rare entity. There are only few case series on EACCs and surgical strategy is not standardized.

OBJECTIVES

1) To elucidate etiology of EACC and cardinal features. 2) To suggest a practical staging of EACC. 3) To enumerate surgical management according to stage of EACC.

STUDY DESIGN

Retrospective study in a quaternary referral center of 31 consecutive cases of EACC.

RESULTS

Thirty-one patients with EACC were reviewed. Unilateral otorrhea 19 (61.2%), hearing loss 22 (70.9%), and otalgia 8 (25.8%) are cardinal symptoms. Sixteen primary and 15 secondary EACCs were treated. Bone erosion was observed in 20 cases. In the present series, stage III = 12 (38.7%), stage II = 8 (25.8%), stage I = 11 (35.4%) underwent definitive treatment by surgery. Canalplasty with reconstruction was done in 19 cases of stages I and II. Of 12 cases in stage III, 3 cases underwent canalplasty with reconstruction. Subtotal petrosectomy was done in five cases. Intact canal wall mastoidectomy with canalplasty in two cases and radical mastoidectomy in two cases. Fascia, cartilage, muscle, and bone dust were used for reconstruction. Median follow-up period was 6 years and no recurrence of cholesteatoma was observed.

CONCLUSION

EACC is unique entity. Intraoperative and radiological findings assist in correct and practical staging of EACC. Late stage presentations of EACC are common. Definitive surgical treatment in our series avoided recurrence of cholesteatoma.

HRCT imaging of acquired cholesteatoma: a pictorial review

Chronically discharging ear is a common cause of morbidity in developing countries, and it is also associated with intratemporal and intracranial complications. The surgeon is often able to detect the disease. However, cholesteatoma in the "hidden areas" like anterior epitympanic recess and sinus tympani can be missed. Facial nerve involvement and cholesteatomatous erosion of the bony labyrinth are dreaded complications, the extent of which cannot be assessed completely on clinical examination. Adding to the complexity are the various variations in anatomy like high riding jugular bulb and aberrant internal carotid artery which could lead to catastrophic complications during surgery if left undetected preoperatively. HRCT temporal bone is useful to detect the extent of the disease, various complications, and guide the surgeon for pre-operative planning. In this review, we go through the various HRCT imaging features of acquired cholesteatoma, a reporting template, and a few words about imaging of the post-operative ear.

Clinical Characteristics and Treatment Outcomes for Patients With External Auditory Canal Cholesteatoma

OBJECTIVE

We aimed to evaluate the clinical features and treatment outcomes for patients with idiopathic and secondary external auditory canal cholesteatoma (EACC), and to validate the treatment strategy from the perspective of hearing as well as etiology and staging.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center and affiliated hospitals.

PATIENTS

Fifty-eight patients with idiopathic EACC and 14 patients with secondary EACC.

INTERVENTION

Conservative management and surgery.

MAIN OUTCOME MEASURE

Air conduction (AC) pure-tone averages (PTAs) and mean air-bone gaps (ABGs).

RESULTS

There were no significant differences between hearing values before and after conservative management for idiopathic EACC patients with stages I-III, indicating that hearing abilities were preserved. For idiopathic EACC patients with stage IV disease treated with surgery, the AC PTA threshold and mean ABG significantly improved from a preoperative value of 60.3 dB HL to a postoperative value of 32.4 dB HL (p = 0.013), and from 34.3 to 9.5 dB HL (p < 0.001), respectively. For secondary EACC, the AC PTA threshold and mean ABG significantly improved from a preoperative value of 49.5 dB HL to a postoperative value of 23.2 dB HL (p < 0.001), and from 31.4 to 6.7 dB HL (p < 0.001), respectively.

CONCLUSION

The treatment modalities should be selected based on the perspective of hearing as well as the extent of disease and etiology. The early lesions can be treated conservatively, whereas the advanced lesions or cases refractory to conservative management require complete surgical removal of EACC.

Clinical analysis of pediatric primary external auditory canal cholesteatoma

OBJECTIVE

Pediatric primary external auditory canal cholesteatoma (EACC) is a rare disease. The present study aimed to explore the clinical features and prognosis of this disease.

METHODS

Clinical data of 41 ears with pediatric primary EACC were collected, and the clinical characteristics and prognosis were analyzed in this retrospective study.

RESULTS

A total of 35 patients (median age of 13 years) were recruited in this study. Of these, 13 suffered on the left side and 16 on the other side, while 6 suffered on the bilateral ears. A total of 35 ears had hearing loss, 26 had otalgia, 15 had otorrhea, 12 had tinnitus, and 4 had pruritus. The median course of the disease was 1 month. The bone destruction of the external auditory canal (EAC) was located on the inferior wall of 20 ears, the posterior wall of 22 ears, the superior wall of 15 ears, and the anterior wall of 15 ears. According to Shin's stages, 24 ears were in stage I, 2 in stage II, 15 in stage III. A total of 40 ears underwent transcanal cholesteatoma removal (TCR) and 1 underwent both TCR and tympanoplasty. Finally, 33 ears were followed up postoperatively, and only 1 ear presented recurrence.

CONCLUSION

The posterior wall of the EAC is the most commonly affected wall, and the involvement of multiple walls is common. Due to the remodeling of the EAC bone in pediatric patients, the high stage lesions can be treated by minimally invasive surgical debridement combined with a close follow-up postoperatively.

Cross Sectional Imaging of the Ear and Temporal Bone

CT and MR imaging are essential cross-sectional imaging modalities for assessment of temporal bone anatomy and pathology. The choice of CT versus MR depends on the structures and the disease processes that require assessment, delineation, and characterization. A thorough knowledge of the two imaging modalities' capabilities and of temporal bone anatomy greatly facilitates imaging interpretation of pathologic conditions.

External auditory canal cholesteatoma and benign necrotising otitis externa: clinical study of 95 cases in the Capital Region of Denmark

OBJECTIVE

To identify epidemiological and pathophysiological factors, and treatment strategies, in external auditory canal cholesteatoma and benign necrotising otitis externa.

METHODS

A retrospective case study was conducted of patients suffering from external auditory canal cholesteatoma and benign necrotising otitis externa admitted to tertiary hospitals, in the Capital Region of Denmark, over a five-year period.

RESULTS

Eighty-three patients (95 ears) with external auditory canal cholesteatoma or benign necrotising otitis externa were identified. A minimum incidence rate of 0.97 per 100 000 inhabitants per year was demonstrated. Sixty-eight per cent of cases had a history of smoking. Most lesions (74 per cent) were localised in the floor of the ear canal. Treatment time was 3.2 months for patients who had surgery and 6.0 months for those who received conservative treatment.

CONCLUSION

It is suggested that external auditory canal cholesteatoma and benign necrotising otitis externa are in fact the same disease, and therefore the diagnosis of external auditory canal cholesteatoma should be changed to benign necrotising otitis externa. Microangiopathy has a leading role in the aetiology. Surgery should be conducted in most cases.

Endoscopic Ear Surgery for External Auditory Canal Cholesteatoma

BACKGROUND

Treatment of external auditory canal cholesteatoma (EACC) has been a question of debate. To our knowledge and according to a systematic review of endoscopic ear surgery (EES) in 2015, this study describes for the first time the technique and outcome by solely transcanal EES for EACC.

STUDY METHOD

Retrospective case series, level of evidence IV.

METHODS

Between October 2014 and December 2016, nine patients with unilateral EACC have been treated by EES. Using a bimanual technique, canaloplasty has been performed using tragal perichondrium, cartilage, or artificial bone. Symptoms, signs, and reconstruction technique have been assessed and the primary endpoint: healing time was compared with benchmark values in the literature.

RESULTS

During the 26 months study period all of our nine Naim stage III EACCs were successfully treated by EES with median healing time of 23.8 days. EACC limited to the external auditory canal (Naim stage III) represented an ideal target for EES minimizing tissue damage and thus median healing time compared with retroauricular (42-56 d) or endaural (59 d) surgical techniques.

DISCUSSION

Shorter healing time helped to reduce skepticism toward a surgical treatment of EACC from the patient's perspective. Moreover, EES relied on reduced bulky equipment, dressing time, and complex maintenance compared with microscopic techniques.

CONCLUSION

Transcanal endoscopic surgery is a valid treatment option for EACC up to Naim stage III. Moreover, the described procedure fosters in our eyes the teaching of our residence to get familiar with the basic steps of EES.

Lyric hearing aid: a rare cause of benign necrotising otitis externa/external ear canal cholesteatoma

An 80-year-old Caucasian man presented with an incidental and asymptomatic lesion in his right ear thought to be secondary to his use of hearing aids for presbycusis. He used Lyric hearing aids, designed for 24 hours-a-day use for 4 months at a time and had no other previous otological problems. He underwent a bony meatoplasty and vascular flap reconstruction via a retroauricular approach to remove the lesion for histological analysis and regrafting of the area. The lesion was confirmed on histopathology as an ear canal cholesteatoma.

Reexamination of Etiology and Surgical Outcome in Patient With Advanced External Auditory Canal Cholesteatoma

OBJECTIVE

To describe the etiology of advanced cases of external auditory canal (EAC) cholesteatoma (EACC), and to report the surgical management and outcomes based on canalplasty depending on the extent of adjacent structures involvement around the EAC.

STUDY DESIGN

Retrospective case review.

SETTING

University hospital.

PATIENTS

Participants comprised 28 patients (12 males, 16 females) ranging in age from 9 to 86 years old. All patients presented with advanced-stage EACC (Naim's classification: stage III/IV).

INTERVENTION

Surgery ranged from simple bony meatoplasty with cartilage graft repair to more enlarged EAC canalplasty combined with tympanoplasty.

RESULT

EACC was categorized as idiopathic in 22 patients and secondary EACC in six patients. Six patients with idiopathic EACC were receiving hemodialysis, one of whom showed bilateral pathology. Particularly in cases with epithelial invasion into the hypotympanum immediately adjacent to the jugular bulb, multi-layered repair including bone paste, post-auricular pedicled musculo-periosteal flap, auto cartilage, and temporalis muscle fascia were required. Five patients required revision surgery (17%), including one case of recurrent (reconstructed) cholesteatoma and three cases of perforation of the tympanic membrane.

CONCLUSION

In the majority of our series, underlying diseases followed with microangiopathy and angiogenesis could be possible candidates in the etiology of EACC. Enlarged bony meatoplasty and multilayered reconstruction surgery brought about self-cleaning and dried the EAC in advanced-stage EACC.

Cholesteatoma as a complication of Langerhans Cell Histiocytosis of the temporal bone: A nationwide cross-sectional analysis

OBJECTIVE

To determine if patients with Langerhans Cell Histiocytosis (LCH) of the temporal bone have a higher risk of developing cholesteatoma.

METHODS

Review of literature and cross-sectional weighted analysis of patients under 19 with a diagnosis of LCH from the National Inpatient Sample (NIS) and Kids' Inpatient Database (KID) from 2000 to 2013. ICD-9 codes and demographics were analyzed; pairwise comparisons and multivariate analyses were performed.

RESULTS

Only seven cases of cholesteatoma after the treatment for LCH of the temporal bone have been documented in the literature. No significant association between cholesteatoma and LCH was seen (OR 0.747 [0.149-3.751]). Patients with LCH did have a higher incidence of chronic otitis media, chronic otitis externa, chronic sinusitis, hearing loss, and otitis media with effusion.

CONCLUSION

Our results show that patients with Langerhans Cell Histiocytosis do not appear to have a higher risk of developing cholesteatoma. However they are more likely to be diagnosed with chronic otitis externa which should be differentiated from cholesteatoma or recurrence of LCH.

A Rare Case Report and Literature Review of External Auditory Canal Cholesteatoma with Circumferential Destruction of Canal Wall Exposing Facial Nerve

External auditory canal cholesteatoma (EACC) is a rare condition with an estimated incidence of 1.2 per 1000 new otological patients. It is often mistaken with keratosis obturans. We discuss an extensive primary EACC with an aural polyp in a male which was managed by modified radical mastoidectomy.

Clinical analysis on surgical management of type III external auditory canal cholesteatoma: a report of 12 cases

OBJECTIVE

To investigate surgical management of type III EACC with lesions involving the posterior external auditory canal and mastoid.

METHODS

This retrospective case review was conducted in 12 patients with type III EACC who underwent intact canal wall mastoidectomy with tympanoplasty and canal wall reconstruction with autologous cortical bone.

RESULTS

During the follow-up, all patients obtained successful results on external auditory canal structures and hearing improvement, except for one patient who needed a revision operation for the fistula between the reconstructed wall and the mastoid.

CONCLUSION

Intact canal wall mastoidectomy with tympanoplasty and canal wall reconstruction with autologous cortical bone was proved to be an effective and inexpensive choice for the patients with type III external auditory canal cholesteatoma (EACC) to achieve optimal outcomes.

Radiology of external ear: indications, normal anatomy, and pathological processes

The external ear is accessible to direct examination; the clinical history and otoscopy are sufficient to diagnose and treat most diseases of the external ear. We aim to describe the normal anatomy of the external ear, specify the indications for imaging tests, and review the clinical and radiological manifestations of the most common diseases affecting the external ear. We classify these diseases according to their origin into congenital, inflammatory, infectious, or traumatic disease or benign bone tumors or malignant tumors. Imaging does not play an important role in diseases of the external ear, but in certain clinical scenarios it can be crucial for reaching a concrete diagnosis and establishing the best treatment. Computed tomography is the first-choice technique for most diseases. Magnetic resonance imaging complements computed tomography and makes it possible to differentiate among different tissue types and to evaluate the extension of disease accurately.

Clinical Characteristics of Keratosis Obturans and External Auditory Canal Cholesteatoma

Objective

Keratosis obturans (KO) and external auditory canal cholesteatoma (EACC) have been considered separate entities. While the disorders are distinct, they share many overlapping characteristics, making a correct diagnosis difficult. In the present study, we compared their clinical characteristics and radiological features to clarify the diagnostic criteria.

Study Design

Retrospective case series.

Setting

Academic medical center.

Subjects and Methods

The clinical data of 23 cases of EACC and KO were retrospectively reviewed. The following clinical characteristics were compared between the 2 groups: sex, age, onset of symptoms, follow-up period, audiometric results, and imaging findings on temporal bone computed tomography including bilaterality, location, and the presence of extension to adjacent tissue.

Results

The mean age of the EACC group was significantly older than that of the KO group. All of the cases of EACC occurred unilaterally, and bilateral occurrences of KO were observed in 4 of 9 cases. All of the lesions in the KO group were circumferential, and no lesion in the EACC group invaded the superior canal wall. No significant differences in symptoms, such as acute otalgia, otorrhea, and hearing loss, were noted between the 2 groups. The incidence of conductive hearing impairment more than 10 dB was higher in the KO group than in the EACC group.

Conclusion

Thus, KO and EACC are 2 distinct disease entities that share common features in clinical characteristics except for predominant age and bilaterality. Conservative treatment with meticulous cleaning of the lesion was successful in most cases with a long-term follow-up.

[External auditory canal cholesteatoma with chronic renal failure or hemodialysis]

BACKGROUND

External auditory canal cholesteatoma (EACC) is a rare otologic disease, characterized by focal osteonecrosis, sequestration and overlying epithelial loss of the bony external auditory canal (EAC). The etiology and pathogenesis of EACC remain controversial. There are only 2 reports on the association between EACC and chronic renal failure (CRF)/hemodialysis (HD). METHOD & RESULT: (1) This study reviewed seven EACC cases with CRF. The mean age was 68.4 years (range: 56 -81 years), and the male-female ratio was 5:2. There were 12 ears with EACC (5 cases were bilateral and 2 cases were unilateral). The EACCs were found in the inferior or posterior inferior part of the EAC in 11 ears. The number of the ears in stage III or IV was 6. Five cases were on HD. (2) Seventy-six cases with CRF on HD were examined for EACC, and 2 out of those 70 cases were diagnosed as having EACC. (3) A comparative study of the 7 EACC cases on HD and 68 non-EACC cases on HD revealed no significant differences in the sex, age, period on CRF/HD, complications (diabetes mellitus or skin disease), smoking, ear cleaning and the use of an earphone or a hearing aid.

CONCLUSION & DISCUSSION

Six out of all 9 EACC cases with CRF developed bilaterally, and in the inferior or posterior inferior part of the EAC, which implies a common pathological condition that contributes to the development of EACC. The mean age of 9 patients with EACC was relatively older (66.7 years), therefore age-related changes in the EAC are suspected in the cases with CRF on HD. The patients with CRF on HD have a high incidence of EACC. This strongly suggests the association between EACC and CRF/HD, but the mechanism of this pathogenesis has not been revealed.

External auditory canal cholesteatoma in patients given radiotherapy for nasopharyngeal carcinoma

BACKGROUND

Patients who undergo radiotherapy (RT) for nasopharyngeal carcinoma (NPC) may develop external auditory canal cholesteatoma (EACC).

METHODS

The records of patients with newly diagnosed NPC who had received concomitant chemotherapy and RT in a tertiary referral center from 1997 January to 2012 July were retrospectively reviewed.

RESULTS

RT-related external auditory canal cholesteatoma (RT-related EACC) was identified in 15 of 833 patients given RT for NPC. Three patients had EACC in both ears. The interval from completion of RT to the diagnosis of EACC ranged from 0.5 to 15.4 years (mean, 5.6 years). RT-related EACC commonly (75%) invaded the anterior and inferior parts of the external canal wall. Canaloplasty was used in 12 patients to surgically remove cholesteatoma. There was no recurrence of RT-related EACC during the study period.

CONCLUSION

Patients with NPC might contract RT-related EACC a few years after RT. We hypothesize that a fraction dose of 200 cGy or more induces RT-related EACC.

Regenerative treatment for soft tissue defects of the external auditory meatus

OBJECTIVE

To establish a regenerative treatment for soft tissue defects of the external auditory meatus (EAM) without conventional surgical therapy.

STUDY DESIGN

Controlled clinical pilot study.

SETTING

General hospitals.

PATIENTS

Sixty-five patients with new or old EAM defects without active inflammation were selected. Ages ranged from 12 to 87 years (average age of 58 yr).

INTERVENTION

Therapeutic nonsurgical treatment of EAM defects. Gelatin sponge, basic fibroblast growth factor (b-FGF), fibrin glue, and water proof transparent dressing were used in the repair procedure. Patients were divided into 2 groups: treatment with (n = 54) and without (n = 11) b-FGF. After mechanically disrupting the edge of the EAM defect, gelatin sponge immersed in b-FGF was placed over the defect and covered with fibrin glue. In cases of extensive EAM defects, the EAM was filled with gelatin sponge/b-FGF, and the auricle was wrapped in water proof dressing. Two or 3 weeks postprocedure, crust over the defect was removed. If complete defect closure was not achieved after 1 treatment course, the treatment was repeated.

MAIN OUTCOME MEASURE

Evaluation of complete closure of EAM defects 3 months posttreatment.

RESULTS

Complete closure of the EAM defect was achieved within 3 treatment courses in 92.6% (50/54) and 18.2% (2/11) of the patients with or without b-FGF, respectively. No inflammation/infection or severe sequelae were observed.

CONCLUSION

This study demonstrated the effectiveness of combining gelatin sponge, b-FGF, and fibrin glue for EAM defect regeneration. This innovative regenerative therapy is an easy, simple, cost-effective and minimally invasive method for treating EAM defects.

Imaging review of the temporal bone: part I. Anatomy and inflammatory and neoplastic processes

From a clinical-radiologic standpoint, there are a limited number of structures and disease entities in the temporal bone with which one must be familiar in order to proficiently interpret a computed tomographic or magnetic resonance imaging study of the temporal bone. It is helpful to examine the region in an organized and systematic fashion, going through the same checklist of key structures each time. This is the first of a two-part review that provides a practical approach to understanding temporal bone anatomy, localizing a pathologic process with a focus on inflammatory and neoplastic processes, identifying pertinent positives and negatives, and formulating a differential diagnosis.

Operative management of external auditory canal cholesteatoma: case series and literature review

Objectives:

To describe the clinical features of external auditory canal cholesteatoma, and to assess the outcome following bony meatoplasty with tragal cartilage and perichondrium graft repair.

Methods:

A retrospective review was carried out, comprising all patients with external auditory canal cholesteatoma who presented between January 2007 and December 2011. Patients underwent pre-operative audiometry and computed tomography imaging of the temporal bones, before undergoing bony meatoplasty via a postauricular incision. Pre- and post-operative comparisons were made of patients' otological symptoms and the otoscopic appearance of the external ear canal.

Results and conclusion:

Eight patients were included in the analyses. The median age of patients was 46.5 years (range 14–68 years), with a male to female ratio of 1:1. The median length of follow up was 16 months. The most common presenting features were unilateral otalgia and purulent otorrhoea. All patients had relatively advanced disease at presentation, with erosion of the temporal bone. All patients underwent bony meatoplasty via a postauricular approach to eradicate the disease. Bony meatoplasty was successful in the definitive management of external ear canal cholesteatoma.

Surgical management of external auditory canal lesions

Background:

Lesions arising in the external auditory canal that require surgical excision are uncommon. They are associated with a range of pathologies, including bony abnormalities, infections, benign and malignant neoplasms, and epithelial disorders.

Methods:

This paper describes a 10-year personal case series of external auditory canal lesions with chart, imaging and histopathology review.

Results:

In total, 48 lesions required surgical management, consisting of: 13 bony lesions; 14 infective lesions; 14 neoplasms with 11 histological types (including ceruminous adenoma and the extremely rare cavernous haemangioma); 3 epithelial abnormalities; and 4 other benign lesions. The surgical management is described.

Conclusion:

This study emphasises the diagnostic differences between exostoses and osteomas, and between external auditory canal cholesteatoma and keratosis obturans. It also discusses the management of aural polyps, and highlights the need to excise external auditory canal masses for histology in order to guide subsequent treatment.

Therapeutic approaches to complicated cholesteatoma of the external auditory canal: a case of associated facial paresis

Spontaneous cholesteatoma of the external auditory canal (EAC) is an uncommon condition that is difficult to diagnose. In a patient with such a possibility, serious clinical investigation along with radiologic and histologic exploration should be performed early on because a delay in treatment can lead to severe complications. Given the rarity of EAC cholesteatoma, no therapeutic consensus has emerged. The type of management depends on the extensiveness of invasion and bone erosion and the status of the neighboring structures. The primary therapeutic objectives are to eradicate the cholesteatoma and then to fill in the residual cavity, which in our opinion can be best accomplished with a muscle flap and EAC reconstruction. Postoperative follow-up should be carried out to look for infections, stenosis, and recurrence. We report a new case of spontaneous EAC cholesteatoma, and we review its diagnostic and therapeutic challenges.

[Burow's solution treatment for external auditory canal and mastoid cavity cholesteatoma]

Burow's solution, 13% aluminum acetate dissolved in water developed as ear drops by German Dr. Karl August Burow in the mid-1800s, was confirmed by Mahoney (1980) and Thorp et al. (2000) to act on chronic suppurative otitis media without ototoxicity. We have found it satisfactory in treating otitis media and other intractable inflammation and fungal infection of the external auditory canal. We report its potent effect in 2 cases of external auditory canal cholesteatoma (EACC) and 1 of mastoid cavity cholesteatoma (MCC)-the first such report insofar as we knew. Case 1 of EACC involved an 8-year-old boy with cholesteatoma debris in a bony groove evidencing defective skin just posteroinferior to the left tympanic membrane. EACC was cured after a single Burow's solution instillation. Case 2 of EACC was a 31-year-old woman whose left ear canal was filled by a keratin mass with pus positive for methicillin-resistant staphylococcus aureus (MRSA) and granulation and experiencing otalgia and dysgeusia. Computed tomography (CT) showed that the bony anterior and posterosuperior wall of the external auditory canal had been destroyed. The EACC was removed and Burow's solution instilled once a week, effecting a cure about one month later, leaving the bony groove of the anterior and inferior wall intact and recovering gustatory sensation. Case 3 of MCC was a 47-year-old man undergoing right canal wall down tympanoplasty three times. One year after the last surgery, the mastoid cavity and posterior external canal wall was covered by a cholesteatoma matrix with granulation and pus. Instilling Burow's solution for 5 months resulted in a completely dry cholesteatoma-free cavity. All three subjects had intact tympanic membranes. Burow's solution alone proving effective against EACC and MCC suggests its great usefulness as first-choice conservative therapy. Although this usually cannot completely cure middle-ear and attic cholesteatoma, its effectiveness in cases of EACC and MCC should be recognized in infection and inflammation with cholesteatoma.

Neuroradiology of cholesteatomas

The relevant aspects of cholesteatomas are reviewed with the emphasis on their diagnosis by using cross-sectional imaging. The indications and limitations of CT and MR imaging and the use of novel MR imaging techniques in the diagnosis of cholesteatomas are described. HRCT of the temporal bone has an excellent spatial resolution, thus even small soft-tissue lesions can be accurately delineated (high sensitivity). However, CT has poor specificity (ie, soft-tissue structures cannot be differentiated). MR imaging with the conventional sequences (T1WI, T2WI, postcontrast T1WI) provides additional information for distinguishing different pathologic entities and for accurately diagnosing primary (nonsurgical) and residual/recurrent (surgical) cholesteatomas. Higher diagnostic specificity is achieved by introducing DW-EPI, delayed postcontrast imaging, DW-non-EPI, and DWI-PROPELLER techniques. Studies using DW-non-EPI and DWI-PROPELLER sequences show promising results related to improved diagnostic sensitivity and specificity for even small (<5 mm) cholesteatomas, thus allowing avoidance of second-look surgery in the future.

Conservative management of advanced external auditory canal cholesteatoma

OBJECTIVE

To investigate the spectrum of disease presentation and clinical management of primary external auditory canal cholesteatoma (EACC).

STUDY DESIGN

Case series with chart review.

SETTING

Specialty teaching hospital.

SUBJECTS AND METHODS

Ten cases of primary EACC were identified in nine patients treated over 14 years (1995-2009). Cases were reviewed with regard to demographics, presentation, physical examination, CT findings, and clinical management.

RESULTS

The most common symptoms were otalgia and hearing loss, followed by otorrhea and tinnitus. Erosion was present in the mastoid air cells in seven patients, middle ear in six, temporomandibular joint in two, otic capsule in two, and fallopian canal in one patient. Eight of nine patients were managed with serial debridement.

CONCLUSIONS

EACC is associated with adjacent bony erosion, most often involving the inferior EAC. Despite the potentially destructive nature of these lesions, most cases can be successfully managed with serial debridement.