External auditory canal cholesteatoma

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.

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.

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.

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.

Spontaneous cholesteatoma of the external auditory canal: the utility of CT

Spontaneous external auditory canal (EAC) cholesteatoma is a rare disease. The symptoms are nonspecific. It is diagnosed by clinical examination and radiological investigation. The clinical examination alone is often insufficient for accurately assessing spread of the cholesteatoma into the temporal bone, meaning cross-sectional imaging modalities are required, and specifically computed tomography. We report three cases of spontaneous cholesteatoma of the external auditory canal. All of our patients underwent surgery. In two cases, the cholesteatoma was restricted to the external auditory canal, while in one case, it was complicated by a fistula with the lateral semicircular canal. Good anatomical and functional results were obtained in all three cases, with the external auditory canal patent and a good calibre on completion.

Dilute vinegar therapy for the management of spontaneous external auditory canal cholesteatoma

The purpose of this study is to evaluate the efficiency of conservative dilute vinegar therapy in the management of spontaneous external auditory canal cholesteatoma (EACC). From 2000 to 2007, 19 patients presented to our clinic with spontaneous EACC. EACC was divided into four grades based on the temporal bone computed tomography: grade I with flattening of bony external canal, grade II with partial destruction of inferior bony canal, grade III with total destruction of inferior bony canal and grade IV with bony destruction into the middle ear and mastoid cavity. Clinical findings and treatment results were recorded. Microscopic local cleansing and dilute vinegar therapy was conducted in the ears with grades I, II and III. Combined mastoid surgery and dilute vinegar therapy was conducted in four ears with stage IV. There were no recurrences after average of 31 months follow-up. Spontaneous EACC can be effectively controlled with dilute vinegar therapy after microscopic local cleansing. However, surgery must be considered in the cases which have involved the mastoid and middle ear. Dilute vinegar therapy in combination with microscopic local cleansing was effective in the management of spontaneous EACC. Dilute vinegar therapy is an easy, cost-effective, and home-based cleansing method to prevent EACC and promotes healing. However, long-term follow-up may reveal frequent recurrence of cholesteatoma debris and involvement of middle ear or mastoid cavity, and then meticulous debridement with skin graft or surgical intervention should be considered.

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.

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.

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.

Keratosis obturans and external ear canal cholesteatoma: how and why we should distinguish between these conditions

Keratosis obturans and external ear canal cholesteatomas have been considered as separate entities for the last 20 years, after being regarded as variations of the same disease for at least 87 years. While both disorders are distinct, they do have some overlapping characteristics which may make it difficult to reach a definite diagnosis. This review explores the diagnostic dilemmas which may arise, and discusses the classification, aetiology, pathogenesis and management of these conditions. We concur that external ear canal cholesteatoma and keratosis obturans are different conditions and conclude that the presence of osteonecrosis and focal overlying epithelial loss are the most reliable features favouring the diagnosis of external ear canal cholesteatoma over keratosis obturans. Furthermore, whilst keratosis obturans can be managed successfully by regular aural toilet, external ear canal cholesteatoma may require surgical intervention depending on the extent of the disease.

Classification of the External Auditory Canal Cholesteatoma

OBJECTIVES/HYPOTHESIS

The external auditory canal cholesteatoma (EACC) is a rare disease in the field of otolaryngology. Only 1 in 1,000 new otologic patients present with this entity, which was first described by Toynbee. The aim of this article is to classify EACC by different histopathologic and clinical findings of patients presenting to the Department of Otolaryngology at the University of Mannheim, Germany.

METHODS

From 2000 to 2004, 17 patients presented to our clinic with EACC. The cholesteatoma were treated surgically, and the specimens were investigated histologically. Clinical findings were also recorded. We classified four stages: stage I with hyperplasia of the canal epithelium, stage II including periosteitis, Stage III including a defective bony canal, and stage IV showing an erosion of adjacent anatomic structure.

RESULTS

Eight patients presented with stage II, five patients with stage III, three with stage I, and only one patient presented with erosion of the mastoid cells, which was determined as stage IV.

CONCLUSION

In summary, our classification serves to describe the different histopathologic and clinical stages of EACC.

Cholesteatoma of external auditory canal: a case report

The authors present a case of cholesteatoma of external auditory canal (CEAC) with extensive invasion of mastoid; ossicle chain and tympanic membrane remained intact. The only symptom was chronic otorrhea. Diagnosis was based on clinical elements and CT scan was used to measure pathology and program surgery. Treatment was modified radical mastoidectomy associated with meatoplasty. Due to the insidious character of CEAC and the proximity with important structures of the external auditory canal, it must be always considered in differential diagnosis for lesions of external auditory canal. This case report intended to review clinical and surgical aspects of treatment of CEAC and present our approach in a case with severe lesions.

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.