Ear psoriasis

Psoriasis of the ears occurs in approximately 18 percent of all patients at some time. Prevention by avoidance of picking and scratching and careful cleansing are helpful. Treatment with intralesional injection of triamcinolone acetonide is effective in patients resistant to other therapies.

Calcification of the auricular cartilage: a case report and literature review

We report a case of auricular calcification in an elderly man with a history of frostbite and normal serum calcium levels. The causes of calcification of the cartilage of the external ear are discussed.

Possible role of interleukin 1 alpha and interleukin 1 beta in the pathogenesis of cholesteatoma of the middle ear

Cholesteatoma of the middle ear is characterized by the presence of hyperproliferative keratinizing squamous epithelium in the middle ear cavity and destruction of adjacent bone. Interleukin 1 (IL-1) is an autocrine growth factor for normal keratinocytes and is capable of inducing bone degradation. The distribution of two molecular species of IL-1, IL-1 alpha and IL-1 beta, was investigated immunohistochemically in the hyperproliferative epithelium of cholesteatoma, in normal epidermis of the auditory canal and of the retroauricular region, and in nonkeratinizing tonsillar epithelium. In all squamous epithelia examined, IL-1 alpha and IL-1 beta were present in comparable amounts. The IL-1 content of cholesteatoma epithelium was clearly increased in relation to normal skin keratinocytes. All cellular layers of cholesteatoma epithelium stained strongly and uniformly for Il-1 alpha and IL-1 beta, whereas the keratin layer was negative for IL-1. No particularly strong reaction with basal cells was detected. In the connective tissue under the squamous epithelium of cholesteatoma, intensely positive cells were scattered between negative stromal cells. Our results suggest that IL-1 could be liberated from disintegrating keratinocytes and cells of the monocyte-macrophage lineage, stimulate the proliferation of the cholesteatoma epithelium in an autocrine manner, and contribute to the enhancement of bone destruction in the presence of cholesteatoma.

Extrusion rate of Shah and Shepard ventilation tubes in children

Shah and Shepard ventilation tubes are the two most commonly used ventilation tube in current practice. In some centres these two tubes are used interchangeably, in others the Shepard is often used as the first 'grommet' of insertion and the Shah for subsequent insertions. A study was undertaken of extrusion rate of these ventilation tubes in 180 children who had surgery for Serous otitis media in 1987. Extrusion time was found to be very significantly different between these tubes. The Shah ventilation tube remains in situ 3 months longer than the Shepard. A case is made for the use of Shah ventilation tubes as the first "grommet" of insertion. Otorrhoea following insertion of ventilation tube did not affect the extrusion rate of ventilation tubes in this study. Nor has otorrhoea a predilection for any particular ventilation tube.

Ear canal cholesteatoma

Although cholesteatomas are more commonly found in the middle ear and the mastoid, the disease can occur in the external ear canal. All cases of ear canal cholesteatoma treated by the author were reviewed. There were nine ears in seven patients, who had an average age of 62 years. The lesions ranged in size from a few millimeters to extensive mastoid destruction. Smaller lesions can be managed by frequent cleaning as an office procedure. Larger lesions require surgery, either canaloplasty or mastoidectomy. The otolaryngologist should suspect this disease in the elderly. Microscopic examination of the ear with meticulous cleaning of all wax, especially in elderly patients, is most useful in detecting early disease. Frequent applications of mineral oil to the canal should be used in the management of the disease and to prevent recurrence.

Histopathologic and ultrastructural changes in the temporal bones of HIV-infected human adults

Acquired immunodeficiency syndrome (AIDS) is a devastating disease that is affecting the human population in epidemic numbers. Patients with AIDS are known to have a significant incidence of otologic disease, including hearing loss, vertigo, tinnitus, otalgia, and infection with unusual pathogens. There has been no previous work on the histopathology of this disease. Ten temporal bones from five patients who were seropositive for the human immunodeficiency virus (HIV), the causative retrovirus of AIDS, were obtained. Seven specimens were analyzed using light microscopic techniques. Electron microscopy was performed on selected areas of pathology. A myriad of pathologic findings was seen, including severe petrositis with marrow replacement, mastoiditis, otitis media, ossicular destruction, precipitations in the perilymphatic and endolymphatic spaces of the vestibule and of the semicircular canals, and subepithelial elevation of the neurosensory epithelium of the saccule and utricle. The organ of Corti was relatively free of pathologic change. Many of the otologic symptoms encountered in these patients can be explained by the findings in this study. Further investigation using light and electron microscopy, and immunohistochemical techniques, is urged.

Predictors of residual-recurrent cholesteatoma in children

The aggressive nature of childhood cholesteatoma has generated much controversy regarding the optimal management of this challenging disorder. To identify potential predictors of residual-recurrent disease, we studied 232 children (244 ears) treated with 427 surgical procedures between 1973 and 1990. Cause of the primary cholesteatoma was congenital in 43 patients (18%), acquired in 83 (36%), and unknown in 106 (46%). Of 90 patients with residual-recurrent disease, 21 (23%) instances were detected during a second-look surgical exploration. The 3- and 5-year residual-recurrence rates were 48% and 57%, respectively. Development of residual-recurrent disease was associated with ossicular erosion (Cox regression) but not with status of the canal wall (up vs down) during tympanomastoidectomy. This study suggests a need for intense and prolonged postoperative follow-up of children with cholesteatoma, especially those with ossicular erosion.

Extranodal Rosai-Dorfman disease: an uncommon cause of persistent nodule in the ear

A 40-year-old woman presented with a nodule over the tragus of the right ear. A biopsy was initially reported as showing non-specific inflammation. In view of the persistence of the lesion, the histological material was reviewed, leading to revision of the diagnosis to Rosai-Dorfman disease, a diagnosis further confirmed by immunoreactivity of the histiocytes for S-100 protein. This case represented the extranodal form of Rosai-Dorfman disease in the absence of lymph node involvement.

Immunotype findings in macrophages in aural cholesteatomas

Since a heavy cellular infiltrate is seen in the stroma of most aural cholesteatomas, we attempted to characterize this cell population in more detail using monocyte/macrophage-specific monoclonal antibodies. KiM1 + (specific for CD11c antigen, the 150 kDa alpha-chain of a leukocyte integrin), and KiM6+ phagocytes were present in two- or fourfold higher numbers in the stroma of the six excised cholesteatomas than in the control tissues. Since the stroma of the cholesteatoma is devoid of microvessels, the typical perivascular localization of dermal macrophages was not seen in the cholesteatomas studied. The density of the macrophages in the normal ear skin was much higher in the upper dermis than in the lower dermis. In the cholesteatomatous specimens, the phagocytes were evenly scattered within the connective tissue and the cellular infiltrate. In contrast to diseased skin, no Mac 387+ macrophages were detected in the cholesteatomas. A great number of phagocytic cells closely resembling dermal macrophages was found in the stroma of the cholesteatomas and probably contributes to an active autoimmune process.

Optimum Management of the Discharging Ear

Discharge from the ear can be the result of many disease processes. The ear may discharge blood, pus, cerebrospinal fluid (CSF) or wax. Keratosis obturans, stenosis of the external meatus and benign tumours of the external meatus all lead to wax build-up, which may cause recurrent attacks of otitis externa. Malignant tumours, such as basal cell carcinoma, squamous cell carcinoma and tumours of ceruminous gland origin may also present with discharge. Tumours should be excluded by submitting all material removed from the external canal for histological examination. Single or multiple abscesses (known as furuncles) may occur in the hair follicles in the skin of the external acoustic meatus (EAM). Compulsive scratching, hearing aids and foreign bodies placed in the ear predispose to otitis externa, which is also often associated with infection by Pseudomonas aeruginosa, Staphylococcus aureus and faecal organisms. Management may be with aluminium acetate 14%, topical antibiotic/steroid drops, a gauze wick soaked with icthammol 10% in glycerin or polymyxin B sulphate--neomycin sulphate--hydrocortisone acetate cream placed into the EAM and replaced every 24 to 48 hours, or systemic antibiotics according to severity. Malignant (necrotising) otitis externa causes progressive destruction of the temporal bone, and cranial nerve palsies (usually facial first). Treatment is limited debridement of infected bone, accompanied by intravenous aminoglycosides, and local antibiotic treatment and aural cleanout or oral ciprofloxacin. Middle ear conditions causing discharge include acute otitis media, infected grommets, traumatic perforations and chronic suppurative otitis media, as well as tumours of the ear canal skin and middle ear, radiation-induced otitis externa and osteoradionecrosis of the temporal bone, tuberculosis, Langerhans cell histiocytosis, spontaneous or post-traumatic CSF leaks, Wegeners granulomatosis and immune deficiency states. Topical application of aminoglycoside antibiotics to the middle ear of laboratory animals such as rats, guinea pigs and chinchillas causes sensorineural hearing loss, an effect rarely seen clinically in humans. If the external acoustic meatus and tympanic membrane are obscured by discharge cotton buds, microsuction equipment or syringing are used to remove it. It is often useful to initiate treatment (usually with topical drops, wicks or an oral antibiotic) with a provisional diagnosis. A full examination and adequate visualisation of the tympanic membrane must eventually be performed, if necessary under anaesthesia, or else serious progressive conditions may be neglected. The most useful initial investigation is a swab sent for bacteriological assessment; other investigations are usually indicated by clinical findings and the provisional diagnosis.

Myringitis bullosa haemorrhagica: clinical course influenced by tympanosclerosis

Observations based on two contrasting cases of myringitis bullosa haemorrhagica indicate that tympanosclerosis involving the tympanic membrane may have a significant effect on the clinical course of the disease. The evidence suggests that the bullae associated with the condition arise from the epidermal layer of the eardrum.

Medical management of pseudocyst of the auricle

Four male patients with pseudocyst of the auricle were successfully treated with oral corticosteroids. This condition is an asymptomatic, non-inflammatory, cystic swelling, usually located in the scaphoid or triangular fossa of the anti-helix which if untreated, leads to deformity of the pinna. All successful methods of treatment described in the literature so far have been invasive. All four patients in the above series responded to oral steroid therapy alone.

Plasma cell granuloma of the middle ear and mastoid. Case report

We present the case of a 37-year-old man with plasma cell granuloma affecting the middle ear and mastoid. At magnetic resonance imaging scan, the lesion appeared as a homogeneously enhancing mass of soft tissue replacing the majority of the mastoid bone and causing vascular compression. After surgical resection, microscopic examination showed predominantly plasmacytes, and histochemical studies confirmed a polyclonal origin consistent with nonneoplastic plasma cell granuloma. We believe this is the first case report of plasma cell granuloma affecting the middle ear and mastoid.

Autograft ossiculoplasty in cholesteatoma

Although using autogenous ossicles in reconstruction offers stable hearing results with good tendency for healing and minimal extrusion, their use in cholesteatomatous ears has been criticized for the possibility of progressive osteitis, bone resorption and cholesteatoma recurrence. In the present study we have been investigating a way which affords safe re-implantation of such ossicles. Treatment by burring followed by autoclaving seems to offer an implant that is safe both bacteriologically and pathologically. We have found no evidence that cholesteatoma could develop from such treated ossicles.

Incidence and progression of myringo-incudo-pexy after secretory otitis

A cohort of originally 327 healthy children born in 1975 was followed by repeated otomicroscopies and tympanometries from age 5 to age 16 years, in total 9 otomicroscopies. Prevalence of drum pathology, especially myringo-incudo-pexy was investigated. Prevalence of myringo-incudo-pexy was 0.5% at age 5 years, 2.5% at age 7 and 4.2% at age 16. Forty percent of pexies were stable; 36% fluctuated and 26% disappeared. Hearing was surprisingly good at age 16, but the pexy represents a risk for progression.

[Human monocytes show chemotaxis in response to cholesteatoma debris]

Using a microchamber technique, we tested cholesteatoma debris and certain of its constituents for effects on the migration of human peripheral blood monocytes and polymorphonuclear leukocytes. Cholesteatoma debris induced significant migration of monocytes. When the individual constituents of cholesteatoma debris, i.e., alpha-keratin, cholesterol, lauric acid and lipopolysaccharides, were tested for monocyte chemotaxis, only alpha-keratin induced significant monocyte migration. alpha-keratin extracted from the cholesteatoma debris with 8 M urea also induced migration of monocytes with a bell-shaped dose-response curve, which is frequently encountered with chemoattractants. Therefore, cholesteatoma debris and one of its components, alpha-keratin, are potent chemoattractants for human monocytes. On the other hand, cholesteatoma debris showed no significant chemotactic effect on polymorphonuclear leukocytes. Based on the present and our previous results, cholesteatoma debris acts on monocytes/macrophages as a strong chemotactant, a potent activating (priming) factor, and an inducer of production of tumor necrosis factor, which is a bone-resorbing cytokine. Therefore, we concluded that macrophages induced by cholesteatoma debris may play an important role in the pathogenesis of bone resorption in cholesteatoma otitis.

[Contralateral ear in cholesteatoma]

The authors examine 224 contralateral files of patients suffering from cholesteatoma. They record that the systematic study of the opposite ear can prove to be of interest, given the numerous anomalies found. One ear in two has a contralateral pathology. In 32% of the cases, there is a retraction pocket, and in 14% a cholesteatoma. The mean time for a cholesteatoma to appear from a retraction pocket varies by 24 months in 44% of the cases, thus demonstrating the necessity of examining the opposite ear, as a dynamic evolution exists. Of these pockets, 2% in fact evolved, these statistics, to a true cholesteatoma.

[Congenital cholesteatoma of the middle ear in children]

In a series of 16 middle ear cholesteatomas of a congenital type are reported in children; the youngest (18 months) presented with a bilateral case. Whereas a simple tympanoplasty could cure a localized pearl, typically anterosuperior in the mesotympanum, the stapes is fast eroded (7 cases) if progression goes on. Intact canal wall technique in 2 stages was the typical procedure. Good hearing results were generally achieved (except in one case of fixed footplate): 9 cases/14 with an ABG within 20 dB and an AC level within 30 dB.

Sialomucin in middle ear cholesteatoma perimatrix

Mucosubstance histochemistry of human middle ear cholesteatoma revealed that sialomucins are abundant and sulfomucins present in small amounts in the glandlike structures of the cholesteatoma perimatrix. Based on the study, various glycoproteins were injected into the dermis of the external ear canal and infiltrated into the tympanic membranes of guinea pigs. Tympanic membranes were obtained 7 days later and light- and electron-microscopically studied. Injection of a sialomucin from bovine submaxillary gland resulted in marked proliferation of epidermis and degeneration of the lamina propria. Asialomucin prepared from sialomucin by hydrolysis produced mild thickening of the epidermis but the lamina propria was not degenerated. Fetuin and bovine serum albumin did not cause proliferation of the epidermis. Cholesterol granuloma formed in some of the specimens injected with sialomucin. The presence of sialomucin in cholesteatoma perimatrix and these experimental studies using tympanic membranes of guinea pigs suggests that sialomucins participate in the proliferation of epidermis and degeneration of subepidermal connective tissue in human middle ear cholesteatoma.

Congenital cholesteatoma

We present a British series of eleven patients with primary cholesteatoma, including one patient with bilateral disease. Eight children presented with a history of hearing loss, while one child had had recurrent otitis media and another had had earache. Operative findings were: in five ears, cholesteatoma confined to the antero-superior segment with intact ossicles, in a further four, cholesteatomas extending throughout the mesotympanum with ossicular erosion in one, and in two ears posterior disease throughout the middle ear and mastoid, which had eroded the ossicles in both cases. The five cases of antero-superior cholesteatoma lend most support to Michaels' concept of epidermoid formation as a possible source of congenital cholesteatoma. With a greater awareness of the problem and careful examination of the antero-superior quadrant of the tympanic membrane, earlier diagnosis may be possible enabling removal of small intact cholesteatoma sacs and preserving the structures of the middle ear and therefore the hearing. A screening programme for infants included as part of their routine examination which would be undertaken by examiners who are trained to be more aware of the problem and skilled at otoscopy, would help in the earlier detection of such cases as is shown by reports from the U.S.A.

Cochlear bone erosion: effects on cochlear hair cells. A scanning electron microscopy study

Cochleae from gerbils with normal middle ears were compared with cochleae from gerbils with experimentally induced cholesteatomas that were in contact with the cochlear wall (stage III cholesteatomas). Cochleae from gerbils with stage III cholesteatomas were further divided into two groups: one without erosion of cochlear bone, and one with cholesteatoma-induced bone erosion but without cochlear fistulae. The cochleae with bone erosion showed significant loss of outer hair cells in the middle and apical turns, but not in the basal turn. The cochleae with stage III cholesteatomas but without bone erosion did not differ from normal controls. These results suggest that an ototoxic agent, involved in the process of bone erosion, acts through the bony cochlear wall.

[Clinical studies on attic retraction]

Attic retraction was studied in 327 ears of 264 patients in whom photographs of the tympanic membrane were taken from 1983 to 1989. Attic retraction was investigated clinically on the basis of findings of the tympanic membrane in reference to the photographs and ear X-ray findings, including CT. Attic retraction was also observed in 4.5% of cases without inflammation, but its severity was mild. The incidence of attic retraction in cases of adhesive otitis media was 42.7% in mild adhesive otitis media (adhesive grade I) and 60.8% in severe adhesive otitis media (adhesive grade II), both incidences were significantly higher than the incidence of 23.8% in cases of otitis media with effusion. Thus, the incidence of attic retraction increased as the grade of adhesion became severer. In cases of otitis media with effusion, the incidence was significantly higher in the adult group (32.3%) than in the child group (17.4%). In many of the ears with otitis media with effusion, adhesive grade I and chronic otitis media, the severity of attic retraction was mild. There were more cases of milder retraction in the child group than in the adult group. Attic retraction underwent change with time in 2.8% of cases, and cholesteatoma occurred in 1.8% of cases. No improvement in attic retraction was achieved by insertion of a ventilation tube. Bilateral attic retraction was observed in 56.9% of the child group and 30.2% of the adult group, and the difference was statistically significant. Ear X-ray findings by Schüller's method revealed many ears with poorly developed mastoid cells and poor pneumatization.(ABSTRACT TRUNCATED AT 250 WORDS)