Bilateral Ear Canal Cholesteatoma with Underlying Type I First Branchial Cleft Anomalies

External Ear Disease: Keratinaceous Lesions of the External Auditory Canal

Keratosis obturans (KO) and external auditory canal cholesteatoma (EACC) are two distinct keratinaceous lesions of the external ear. This article reviews the signs, symptoms, pathophysiology, workup, and treatment of each. Patients with either pathology can often be managed in the clinic with debridement; however, EACC is more likely to involve osteonecrosis and require more extensive operative management if disease is not confined to the canal on account of the bony erosion characteristic of cholesteatoma. If required for extensive disease, surgical approaches to both pathologies are similar.

Congenital Anomalies of the Ear Canal

Congenital anomalies of the external auditory canal (EAC) are classically divided into congenital aural atresia (CAA) and congenital aural stenosis (CAS). CAA can present as an isolated anomaly, unilateral or bilateral, or in the setting of a craniofacial syndrome. Hearing testing (ABR with air and bone conduction thresholds for both ears) early in the perinatal period is important to document hearing thresholds. Hearing status thus informs parent counseling on options for hearing habilitation: Bone conducting technology is a must for children with bilateral CAA to support normal speech and language development. Bone conducting technology should be considered for children with unilateral CAA; benefits are unclear. In select candidates, atresia repair can provide improved hearing with a clean, dry, epithelialized ear canal. First branchial cleft cyst or sinus is rare; high index of suspicion is needed to diagnose along with high-resolution CT. Congenital aural stenosis (CAS) is a rare condition, and hearing testing should be similar to that in children with CAA. Early (age 4-5) CT imaging is recommended in the setting of a canal <2 mm or pinpoint canal to evaluate for trapped skin/ear canal cholesteatoma.

An Unusual Presentation of type-IV Second Branchial Cyst: A Case Report

Second branchial cleft cysts are a cystic dilatation of the remnant of the second branchial cleft that account for 95-percent of all branchial cleft malformations, along with second branchial fistulae and sinuses. Among them, the type-IV second branchial cyst is present against the pharyngeal wall in the parapharyngeal space and is rarest of all. Herein we report a rare presentation of type-IV second branchial cyst where MRI played a critical role for accurate preoperative diagnosis. The transcervical approach is a safe and effective technique for proper exposure and hence total surgical excision in such cases.

Unusual presentation of a first branchial arch fistula with maxillofacial infection: a case report

Background

First branchial cleft anomaly (FBCA) is a rare congenital defect that arises due to incomplete closure of the ventral portion of the first and second branchial arches. There are variable complex clinical manifestations for patients with FBCA, which are prone to misdiagnosis and inadequate treatment. FBCAs usually involve the facial nerve with a consequent increased risk of facial nerve damage. Here, we present an unusual case of FBCA presenting with two preauricular pits in association with an abnormal maxillofacial cyst.

Case presentation

A 10-month-old girl presented to our department due to recurrent maxillofacial infections accompanied by swelling or abscess of the left cheek and purulent discharge from the preauricular pit for 4 months. A 3D-computed tomography (CT) fistulogram and magnetic resonance imaging (MRI) revealed two conjunctive tract lesions: one tract arose from the skin surface anteroinferior to the external auditory canal (EAC), through the deep lobe of the left parotid, and anteriorly extended to the left masseter; the other extended from the superficial lobe of the left parotid to the intertragic notch. After the maxillofacial infection was controlled by intravenous antibiotic administration, surgery was performed. Intraoperative tools, such as facial nerve monitors, microscopes, and methylene blue dyes, were used to facilitate the complete dissection and protection of the facial nerve. On follow-up over one year, the patient recovered well without facial palsy or recurrence.

Conclusion

FBCA with maxillofacial cysts is rare and prone to misdiagnosis. Physicians should pay attention to this anatomic variant of FBCA with the fistula track located deep inside the facial nerve and projected medially to the masseter.

First branchial cleft cyst accompanied by external auditory canal atresia and middle ear malformation: A case report

BACKGROUND

We report a rare case of first branchial cleft anomaly (FBCA) accompanied by bony atresia of the external auditory canal, middle ear malformation, and location malformation of the facial nerve according to the intraoperative findings.

CASE SUMMARY

A 19-year-old male patient presented to our department with a mass behind the right earlobe and recurrent postauricular swelling and pain since childhood, he also had severe hearing loss in the right ear since birth. The patient underwent surgery including mass removal, mastoidectomy, and simultaneous meatoplasty and ossiculoplasty under microscopy. No facial palsy or recurrence was noted during postoperative follow-up.

CONCLUSION

FBCAs are rare, and to our knowledge, this is the first report of FBCA accompanied by external auditory canal bony atresia, middle ear malformation, and location malformation of the facial nerve. An effective postauricular approach under microscopy facilitated complete lesion removal and simultaneous otologic reconstruction.