External auditory canal wall cholesteatoma: a complication of ear surgery

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.

[External auditory canal cholesteatoma]

External auditory canal cholesteatoma is defined as an accumulation of keratin leading to osteolytic bony erosion. It is a rare or underdiagnosed otologic entity. Our study aims to illustrate one case of external auditory canal cholesteatoma. Hypertensive diabetic patient, 65 years of age, under therapy suffering from severe right earache, insomnia, hearing loss, small purulent otorrhea and right facial paralysis grade V since 3 months. Initially the diagnosis was malignant external otitis. The patient underwent antibiotic therapy without improvement. Otologic examination showed burgeoning ulcerative lesion of the posterior wall of the right external auditory meatus. Systematic lesion biopsy was performed and confirmed the diagnosis of cholesteatoma. The patient underwent open technique tympanoplasty. External auditory canal cholesteatoma is rare, clinical symptoms are not specific, coronal CT scan makes a major contribution to a positive diagnosis showing bony crater of external auditory meatus. Treatment depends on the extent of the lesions. It can be based on simple local cares or on open technique tympanoplasty. External auditory canal cholesteatoma may have multiple clinical aspects and lend to confusion with other pathologies of the external auditory meatus.

Bilateral primitive cholesteatoma of external auditory canal with congenital stenosis

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Primitive cholesteatoma of external auditory canal (EAC) is very rare and little known disease.

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There are no specific clinical symptoms which can lead to confusion with other EAC pathologies.

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Its diagnosis is clinical, but in case of stenosis, evaluation requires very close radiological analysis.

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The treatment is surgical and depends on the extent of the lesions.

[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.

Surgical results of external canal cholesteatoma

CONCLUSION

The treatment plan should be adapted in accordance with the individual cause for each patient with external canal cholesteatoma (EACC). Outpatient surgery with eradication of the cholesteatoma and canal reconstruction at an early stage to enable epithelial recovery and migration was proved to be the choice that was effective, low cost, and produced less suffering for the patient to achieve optimal results for most primary EACCs.

OBJECTIVES

To assess the indications, operation methods, and results of surgery for EACC.

PATIENTS AND METHODS

This retrospective case review was conducted in a tertiary referral center, Chi Mei Medical Center, from 1989 to 2007. Outpatient surgery to eradicate diseased canal epithelium and reconstruct a funnel-shaped canal was performed in the cases with primary EACC at an early stage, while inpatient surgery was conducted in the advanced cases. Assessments of cause and outcome were based on the combination of clinical history, physical examination, and radiographic appearance.

RESULTS

Clinical records of 45 patients (7 with bilateral lesions) were reviewed; 34 patients were noted with primary EACC and 11 patients with secondary EACC. Surgery was conducted in 42 ears to restore normal epithelial migration. Successful results on an outpatient basis were obtained in most patients.

Canal wall cholesteatoma following canalplasty

INTRODUCTION

Bony canalplasty is a common otological procedure performed to widen a narrow ear canal. The aim of this report is to describe two unusual patients who presented with a canal wall cholesteatoma many years after bony canalplasty.

CASES

Two patients, aged 28 and 52 years, are presented. Both underwent canalplasty, 14 and 17 years before re-presenting with cholesteatoma evident through posterior canal wall defects. Both patients underwent exploration of the mastoid cavities and cartilage reconstruction of the canal walls. There was no recurrence at 24 and three month follow-up examinations (variously), hearing was preserved in both cases, and the patients suffered no early complications.

CONCLUSIONS

The most frequent long-term complication of canalplasty is re-stenosis of the external auditory canal. The importance of sealing any inadvertently opened mastoid air cells, in order to avoid the late complication reported, is emphasised.

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

OBJECTIVE

External auditory canal cholesteatoma (EACC) is a rarity. Although there have been numerous case reports, there are only few systematic analyses of case series, and the pathogenesis of idiopathic EACC remains enigmatic.

STUDY DESIGN

In a tertiary referral center for a population of 1.5 million inhabitants, 34 patients with 35 EACC (13 idiopathic [1 bilateral] and 22 secondary) who were treated between 1994 and 2006 were included in the study.

RESULTS

EACC cardinal symptoms were longstanding otorrhea (65%) and dull otalgia (12%). Focal bone destruction in the external auditory canal with retained squamous debris and an intact tympanic membrane were characteristic. Only 27% of the patients showed conductive hearing loss exceeding 20 dB. Patients with idiopathic EACC had lesions typically located on the floor of the external auditory canal and were older, and the mean smoking intensity was also greater (p < 0.05) compared with patients with secondary EACC. The secondary lesions were assigned to categories (poststenotic [n = 6], postoperative [n = 6], and posttraumatic EACC [n = 4]) and rare categories (radiogenic [n = 2], postinflammatory [n = 1], and postobstructive EACC [n = 1]). In addition, we describe 2 patients with EACC secondary to the complete remission of a Langerhans cell histiocytosis of the external auditory canal. Thirty of 34 patients were treated surgically and became all free of recurrence, even after extensive disease.

DISCUSSION

For the development of idiopathic EACC, repeated microtrauma (e.g., microtrauma resulting from cotton-tipped applicator abuse or from hearing aids) and diminished microcirculation (e.g., from smoking) might be risk factors. A location other than in the inferior portion of the external auditory canal indicates a secondary form of the disease, as in the case of 2 patients with atypically located EACC after years of complete remission of Langerhans cell histiocytosis, which we consider as a new posttumorous category and specific late complication of this rare disease.

Cholesteatoma of the external ear canal: etiological factors, symptoms and clinical findings in a series of 48 cases

BACKGROUND

To evaluate symptoms, clinical findings, and etiological factors in external ear canal cholesteatoma (EECC).

METHOD

Retrospective evaluation of clinical records of all consecutive patients with EECC in the period 1979 to 2005 in a tertiary referral centre. Main outcome measures were incidence rates, classification according to causes, symptoms, extensions in the ear canal including adjacent structures, and possible etiological factors.

RESULTS

Forty-five patients were identified with 48 EECC. Overall incidence rate was 0.30 cases per year per 100,000 inhabitants. Twenty-five cases were primary, while 23 cases were secondary: postoperative (n = 9), postinflammatory (n = 5), postirradiatory (n = 7), and posttraumatic (n = 2). Primary EECC showed a right/left ratio of 12/13 and presented with otalgia (n = 15), itching (n = 5), occlusion (n = 4), hearing loss (n = 3), fullness (n = 2), and otorrhea (n = 1). Similar symptoms were found in secondary EECC, but less pronounced. In total the temporomandibular joint was exposed in 11 cases, while the mastoid and middle ear was invaded in six and three cases, respectively. In one primary case the facial nerve was exposed and in a posttraumatic case the atticus and antrum were invaded. In primary EECC 48% of cases reported mechanical trauma.

CONCLUSION

EECC is a rare condition with inconsistent and silent symptoms, whereas the extent of destruction may be pronounced. Otalgia was the predominant symptom and often related to extension into nearby structures. Whereas the aetiology of secondary EECC can be explained, the origin of primary EECC remains uncertain; smoking and minor trauma of the ear canal may predispose.

[External auditory canal cholesteatoma as a complication of ear surgery]

External auditory canal cholesteatomas are a rare disease. Their usual clinical appearance is a mass eroding the bony external auditory canal, normally in the inferior or anterior parts, with an intact tympanic membrane and a normal middle ear. A case of this uncommon disease with a review of the scientific literature is presented. Guidelines for the prevention, diagnosis and management are examined.

Pediatric external canal cholesteatoma with extensive invasion into the mastoid cavity

Cholesteatoma in the external auditory canal (EAC) is an uncommon situation, and is especially rare in pediatric patients. We report two pediatric cases of external canal cholesteatoma with extensive invasion into mastoid cavity. Both cases had otalgia and poor hearing as the initial symptoms, and received operation according to the extent of the lesions. Since external canal cholesteatoma with extensive invasion into the mastoid cavity has the propensity to involve the vertical segment of the facial nerve, extreme care should be taken when performing any procedure in this area. Through thorough pre-operative evaluation and adequate surgical procedures, good outcomes can be achieved and hearing as well as facial nerve function can be preserved.

Regulation of Apoptosis in External Auditory Canal Cholesteatoma by Hepatocyte Growth Factor/Scatter Factor

OBJECTIVES

External auditory canal cholesteatomas (EACC) are characterized by focal invasion of squamous cell epithelium and accumulation of keratin debris in the apical part of the matrix. Apoptosis appears to be important in understanding the pathogenesis of EACC. Here the possible regulatory effect of the apoptosis mediated by hepatocyte growth factor (HGF)/scatter factor (SF)-c-Met-Fas in EACC is discussed.

METHODS

We examined 17 EACC specimens for immunohistochemical expression of HGF/SF, c-Met, caspase 3 and Fas. The staining reaction was evaluated semiquantitatively.

RESULTS

HGF/SF was detected in mesenchymal tissue below the EACC epithelium. c-Met was expressed throughout the epithelium. Fas and caspase 3 were detected at increasing levels towards the apical layers of the EACC matrix.

CONCLUSIONS

High levels of HGF/SF result in binding of HGF/SF to c-Met, releasing Fas to aggregate and bind to its death-inducing signaling complex. The result is apoptosis, marked by formation of dead squamous cells and sequestered keratin debris on the apical side of the cholesteatoma.

Congenital cholesteatoma of external auditory canal

A 7-month-old male child is reported with congenital cholesteatoma of the external auditory canal. We describe the clinical features, computed tomography finding and surgical treatment. Congenital cholesteatomas can occur within the temporal bone. There are six places of location: (1) petrous apex, (2) mastoid, (3) middle ear, (4) both middle ear and mastoid, (5) external ear canal and (6) within the squamous portion of the temporal bone. Congenital cholesteatoma of the external auditory canal is rare. Generally, it appears in the canal floor without lesions in the tympanic membrane. Computed tomography completes the study. Treatment consists of excision of the mass.