Canal Cholesteatoma Research Articles

External canal cholesteatoma: Clinical findings and modalities of management

Objective: to review our experience in patients with external auditory canal cholesteatoma.Study design: Retrospective chart reviewSetting: King Abdulaziz University Hospital and Prince Sultan Military Medical CityMethods: A retrospective wchart review of all patients between 2009 and 2012 with the diagnosis of external auditory canal cholesteatoma were included. The data included age, sex, presenting symptoms, duration of symptoms, clinical and radiological findings and modalities of management . Patients with incomplete data were excluded. A Microscoft Excel® program (Microsoft Corporation, Seattle, Washington) used for analysis and plotting charts and tables.Results: A total of thirteen patients with 15 ears found. Eight females and five male patients with age range between 12 and 50 years with a mean age of 31 years. The most common presenting symptom was otorrhea. Ten patients had a history of hearing loss. The duration symptoms varied between one to fifteen years. Three patients had history of trauma to temporal bone while seven patients had history of exposure to radiation therapy for nasopharyngeal carcinoma several years previously. In five patients no causes could be identified. Six patients underwent surgery and one of them had developed partial facial paralysis House-Brackmann grade III which recovered completely within six months.Conclusion: External auditory canal cholesteatoma can be easily missed if careful examination is not carried out. Early diagnosis and management is paramount if serious complications are to be prevented.

Clinical Study of Surgically Treated External Auditory Canal Cholesteatoma

Clinical Study of Surgically Treated External Auditory Canal Cholesteatoma

Facial Nerve Paralysis in Patients With Chronic Ear Infections: Surgical Outcomes and Radiologic Analysis.

ObjectivesThe purpose of this study was to investigate the clinical features, radiologic findings, and treatment outcomes in patients of facial nerve paralysis with chronic ear infections. And we also aimed to evaluate for radiologic sensitivities on facial canal, labyrinth and cranial fossa dehiscences in middle ear cholesteatomas.MethodsA total of 13 patients were enrolled in this study. Medical records were retrospectively reviewed for clinical features, radiologic findings, surgical findings, and recovery course. In addition, retrospective review of temporal bone computed tomography (CT) and operative records in 254 middle ear cholesteatoma patients were also performed.ResultsOf the 13 patients, eight had cholesteatomas in the middle ear, while two patients exhibited external auditory canal cholesteatomas. Chronic suppurative otitis media, petrous apex cholesteatoma and tuberculous otitis media were also observed in some patients. The prevalence of facial paralysis in middle ear cholesteatoma patients was 3.5%. The most common involved site of the facial nerve was the tympanic segment. Labyrinthine fistulas and destruction of cranial bases were more frequently observed in facial paralysis patients than nonfacial paralysis patients. The radiologic sensitivity for facial canal dehiscence was 91%. The surgical outcomes for facial paralysis were relatively satisfactory in all patients except in two patients who had petrous apex cholesteatoma and requiring conservative management.ConclusionFacial paralyses associated with chronic ear infections were observed in more advanced lesions and the surgical outcomes for facial paralysis were relatively satisfactory. Facial canal dehiscences can be anticipated preoperatively with high resolution CTs.

Clinical characteristics of keratosis obturans and external auditory canal cholesteatoma.

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. Retrospective case series. Academic medical center. 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. 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. 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.

Acquired ear canal cholesteatoma in congenital aural atresia/stenosis.

To estimate the prevalence of external auditory canal (EAC) stenosis in patients with congenital aural atresia (CAA) and the prevalence of acquired ear canal cholesteatoma in patients with EAC stenosis and to identify risk factors that may predict the presence of ear canal cholesteatoma in those patients. Retrospective chart review. University tertiary referral center. Patients with EAC stenosis with and without acquired ear canal cholesteatoma were identified from the medical records of 673 patients (770 ears) with CAA. Demographic data, symptoms at presentation, and audiometric data were compared between those with and those without cholesteatoma to identify the risk factors for the presence of ear canal cholesteatoma. Of the 770 ears evaluated, 101 (13.1%) were found to have at least 1 stenotic ear canal. Of this group of 101 ears with canal stenosis, 18 of 94 ears (7 ears were missing data; 19.1%) had a concurrent cholesteatoma, with 1 patient having bilateral cholesteatomas. Demographic, clinical, and audiometric parameters showed that only female sex was associated with a higher rate of ear canal cholesteatoma. Within the cholesteatoma group, right ears in female patients and left ears in male patients predominated. Approximately 1 in 5 patients with congenital aural stenosis were found to have ear canal cholesteatoma. Female sex is a risk factor; basic audiometric parameters provide no diagnostic utility in distinguishing ears with cholesteatoma from those without cholesteatoma.

Facial nerve schwannomas presenting as occluding external auditory canal masses: a therapeutic dilemma.

To present a series of patients with facial nerve schwannomas (FNSs) presenting as occluding external auditory canal (EAC) masses. Retrospective case series. Four patients were identified with mastoid segment FNSs occluding the EAC. Three patients presented with conductive hearing loss (CHL), and the fourth presented with facial paralysis, later developing CHL. One patient underwent conservative debulking, removing the EAC component only. Two patients were managed nonoperatively with periodic cleaning of entrapped keratin. The fourth patient received radiation therapy. Facial nerve function, canal cholesteatoma formation, and hearing. Among the patients managed with serial cleaning of entrapped keratin, one maintained normal facial function and one worsened to House-Brackmann II/VI. Facial function worsened to House-Brackmann II/VI in the patient who underwent surgical debulking. The fourth patient, who received radiation, developed complete facial paralysis. All patients accumulated keratin medial to the tumor, and all had CHL. When evaluating an EAC tumor, it is important to obtain imaging before biopsy because biopsy of a schwannoma can result in paralysis. EAC occlusion by a schwannoma presents a challenging management issue, particularly when cholesteatoma forms between the tumor and the tympanic membrane. The primary goal is maintaining normal facial function as long as possible and avoiding secondary ear canal complications. The presence of canal occlusion limits the choice of stereotactic radiation because this leads to a month-long period of tumor swelling and cutaneous sloughing. Resection and grafting are indicated when substantial facial weakness or twitch develops.

Favorable prognostic factors for long-term postoperative hearing results after canal tympanoplasty for congenital aural stenosis.

We aimed to determine favorable prognostic factors for long-term postoperative hearing results after canal tympanoplasty for congenital aural stenosis (CAS). Retrospective case review. Tertiary referral center. Canal tympanoplasty for CAS was performed in 25 ears. Primary repair of CAS. The influences of the following factors on the success of surgery were assessed by univariate and multivariate logistic regression analyses: modified Jahrsdoerfer grading system total score; age at surgery; patterns of presentation (whether sporadic or syndromic); presence of external auditory canal (EAC) cholesteatoma; presence of ossicular fixation, including the malleus bar; presence of a partial atretic plate; exposure of the facial nerve at the tympanic portion; type of tympanoplasty; and each component of the modified Jahrsdoerfer grading system. The univariate analysis revealed that the absence of EAC cholesteatoma (p = 0.029) and the presence of a partial atretic plate (p = 0.040) were significant predictive factors for favorable hearing prognosis, whereas the multivariate logistic regression analysis showed that an absence of EAC cholesteatoma was the most significant favorable predictive factor (p = 0.011), followed by anterolateral position of the malleus/incus complex with respect to the stapes as the second-most favorable factor (p = 0.021). The absence of EAC cholesteatoma and anterolateral position of the malleus/incus complex with respect to the stapes are considered useful in predicting long-term favorable hearing results after canal tympanoplasty for CAS.

External auditory canal and middle ear cholesteatoma and osteonecrosis in bisphosphonate-treated osteoporosis patients: a Danish national register-based cohort study and literature review

Long-term treatment with bisphosphonates against osteoporosis may cause atypical femur fractures and osteonecrosis of the jaw. Eight cases of bisphosphonate-associated osteonecrosis of the external auditory canal area are published. Based on Danish national registers, we report a time- and dose-dependent increased risk of cholesteatoma in osteoporosis patients treated with bisphosphonates. In the recent years, there has been a focus on possible rare side effects of bisphosphonates (BPs). Eight cases of BP-associated osteonecrosis of the external auditory canal have been reported in the world literature. Our aim was to describe the incidence of external auditory canal and middle ear diseases in Danish patients exposed to BPs in the treatment of osteoporosis. This register-based nationwide cohort study was conducted on the Danish population of approximately 5.6 million individuals. Patients who were prescribed BP for treatment of osteoporosis from 2003 to 2010 (n = 131,794) were included in the study and compared with the age- and gender-matched controls, unexposed to BP. The overall incidence of cholesteatoma in the ear was low. Only 350 events were seen in 527,176 cases and controls over 2,826,120.73 observation years. Totally, 119 events of cholesteatoma in the ear were recorded after initiation of BP therapy, 34 in the external auditory canal and 85 in the middle ear. Cholesteatoma in the external auditory canal was more frequent in the exposed than in the unexposed group (p < 0.0001). We found a significant dose-event relationship between incidence of cholesteatoma and dose of alendronate (p < 0.0001) and etidronate (p < 0.0001). Furthermore, we found an association between duration of treatment with alendronate and etidronate and risk of cholesteatoma in the external auditory ear canal (log rank, p = 0.002). No cases of bone destruction were observed during the 7-year observation period in either group. The use of oral BP is associated with an increased risk of cholesteatoma of the external auditory canal. The risk is small and associated with duration and dosage of BP.

Tentative plan for classification of progression degree of external auditory canal cholesteatoma: EACC based on clinical evidence

Tentative plan for classification of progression degree of external auditory canal cholesteatoma: EACC based on clinical evidence

External auditory canal cholesteatoma with chronic renal failure or hemodialysis

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. 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.

Clinical characteristics of spontaneous cholesteatoma of the external auditory canal in children comparing with cholesteatoma in adults

The purpose of this study was to investigate the characteristics of external auditory canal cholesteatoma (EACC) in children through evaluation of the clinical and radiologic features as well as treatment outcomes. The clinical records were retrospectively reviewed for children under 15 years of age diagnosed with spontaneous EACC between March 2004 and December 2011. The clinical data of adults diagnosed with spontaneous EACC during the same period were evaluated to compare with EACC in children. Eight patients (3 males and 5 females) with pediatric EACC and 18 patients (7 males and 11 females, 20 ears) with adult EACC were included within the boundary of the study. The mean ages were 12.4 years (age range 9-15) for pediatric EACC and 49.8 years (age range 29-79) for adult EACC patients. Follow-up periods ranged from 8 to 86 months (mean 32.5 ± 8.62) in pediatric EACC and from 6 to 72 months (mean 22.2 ± 5.36) in adult EACC. Pediatric EACC, showed involvement most commonly in the posterior wall, while the inferior wall was most commonly involved in adult EACC. Pediatric EACC tended to show a more focal involvement and was not as extensive as adult EACC. Extension into the adjacent structures was similar in both groups, but bony destruction was more common in the adult group. Two children and eight adult patients were treated with surgery, but four adult cases needed more extensive surgical treatment because their disease was widely spread to included areas such as the mastoid segment of facial nerve and the temporomandibular joint. Six pediatric cases treated with conservative management showed no progression of disease on physical examination at the last visit, but two cases of adults progressed and required canaloplasty. Pediatric EACC shows less aggressive behavior compared to adult EACC. Adequate management may work better in pediatric than in adult EACC, even though the treatment modality is conservative management.

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

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. A retrospective review was carried out, comprising all patients with external auditory canal 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. 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.

Tympanomastoidectomy for cholesteatoma among Nigerians

The incidence of cholesteatoma among Nigerians is not well documented, as is the outcome of surgical treatment. A descriptive analysis of prospectively collected data of cases of cholesteatoma managed with tympanomastoidectomy at National Hospital Abuja between September 2005 and April 2012 is presented. Cases were analyzed for age, sex, type of cholesteatoma, intra-operative findings, and post-operative outcome after 6months of follow up. A total of 28 ears from 25 cases of cholesteatoma had tympanomastoidectomy. Age range was 6-73years (mean=34.4, SD=18.67). There were 13 females and 12 males. Primary acquired cholesteatoma was seen in 18 cases (20 ears), secondary acquired in 5 cases (six ears), and external auditory canal cholesteatoma was seen in 2 cases (two ears). The sites involved in middle ear cholesteatoma was attic, sinus and mesotympanum pars tensa (16/26), attic, sinus, antrum and mastoid cavity (5/26), attic, sinus, mesotympanum and mastoid antrum (4/26), and attic only (3/26).21/25 of cases (24 ears) managed had single stage intact canal wall (ICW) tympanomastoidectomy, while 4/25 (4 ears) had two-stage surgery with canal wall down tympanomastoidectomy in two of these, and revision surgery done within 12months of first surgeries. 2/25 cases (in the two stage revision group) had postoperative persistent mastoid cutaneous fistula and were treated with post-auricular advancement flap. The commonest cholesteatoma type seen at National Hospital Abuja, Nigeria was primary acquired type, and involved the attic, sinus and mesotympanum pars tensa mainly, and most can be managed by single stage tympanomastoidectomy.

Proteus Mirabilis Skull Base Osteomyelitis with Canal Cholesteatoma in an Immunocompetent Teenager: Surgical and Medical Management

Proteus Mirabilis Skull Base Osteomyelitis with Canal Cholesteatoma in an Immunocompetent Teenager: Surgical and Medical Management

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.

Osteonecrosis of the External Auditory Canal Associated With Oral Bisphosphonate Therapy

To present the first case of a patient with oral bisphosphonates-associated ear canal osteonecrosis (BPECO), review previously published cases, and suggest a definition of BPECO. A 79-year-old woman with left otorrhea and earache was treated for otitis externa for 2 months. The examination revealed a deep floor of the left ear canal defect. The bisphosphonates were discontinued. By the end of the 6-week-course of intravenous antibiotics, the bone defect progression ceased. Already a month later, the defect was lined from approximately 50%. Unfortunately, the patient was lost to follow-up at this stage. She was on oral bisphosphonates for 10 years for severe osteoporosis. She had never been exposed to radiotherapy or had any surgery in the left ear. She admitted to be a habitual cotton bud user for aural toilet. A CT scan showed an aggressive lobulated mass consistent with carcinoma. A biopsy suggested osteomyelitis with no evidence of malignancy. The final diagnosis was agreed to be the first case of oral BPECO. Debridement, intravenous antibiotics, and cessation of bisphosphonates The BPECO is not very well-known clinical diagnosis among ENT surgeons and, therefore, often misdiagnosed for ear canal cholesteatoma, malignant otitis externa, or temporal bone malignancies. It seems reasonable to re-review patient's medical history with focus on BP medication in cases with negative biopsy. Although the BP osteonecrosis is a rare phenomenon, the large volume of BP prescription makes the number of patients at risk significant.

Surgical management of external auditory canal lesions

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

Primary external auditory canal cholesteatoma presenting as cerebellar abscess

External auditory canal cholesteatoma (EACC) is an uncommon disease and its pathogenesis remains unclear. Clinically, patients usually present with symptoms like chronic dull pain and otorrhea, but many patients can be astonishingly silent or even asymptomatic. The intracranial complication with extensive mastoid cavity from primary EACC is extremely rare. Early diagnosis is imperative to facilitate best possible intervention and to relieve patient symptoms and to prevent further complications. We present the first report in the English literature of a case of primary EACC presenting as cerebellar abscess. We experienced a rare case of a 55-year-old female patient admitted in our hospital with cerebellar abscess complicated by a cholesteatoma in the external auditory canal. The patient was first managed conservatively with systemic antibiotics by neurosurgeon, and then the disease was removed successfully by canal wall down mastoidectomy and no recurrence had occurred in the first 4 months post-operatively.

A Comparison of Patterns of Disease Extension in Keratosis Obturans and External Auditory Canal Cholesteatoma

To investigate the different pathways of progression to the middle ear in keratosis obturans (KO) and external auditory canal cholesteatoma (EACC). Retrospective case review. Referral hospital otolaryngology department. Patients with KO or EACC and middle ear disease who underwent surgical management were included. Four ears of 4 patients (mean age, 41.25 yr) were the KO group, and 5 ears of 4 patients (mean age, 49.5 yr) were the EACC group. Intraoperative findings of the middle ear cavity were investigated in KO and EACC groups. In the KO group, 3 patients had a perforated tympanic membrane and cholesteatoma in the tympanic cavity. The other patient had preoperative right facial palsy. Removal of the keratin plug revealed an adherent tympanic membrane. In intraoperative findings, the tympanic segment of the fallopian canal was found to be eroded because of inflammation. No case initially progressed to the mastoid cavity. Four patients had external auditory canal cholesteatoma with middle ear disease. In EACC group, all patients had initial progression to the mastoid cavity. KO tends to progress initially to the tympanic cavity via a diseased tympanic membrane. EACC tends to progress to the mastoid cavity via destruction of the posterior bony canal. This is the first report to investigate differences in pathway of progression to the middle ear cavity in these 2 diseases.

The misdiagnosis of external auditory canal carcinoma

External auditory canal (EAC) carcinomas are frequently misdiagnosed. The aim of this study was to conduct a review of misdiagnosed cases and analyze the factors involved. This study was a retrospective assessment. Eighteen of 44 EAC carcinoma cases seen at the Eye and ENT Hospital were misdiagnosed. All medical records were retrospectively analyzed for the age, sex, presenting symptoms, type of misdiagnosis, computed tomographic (CT) or magnetic resonance imaging (MRI) findings, stage of the cancer, surgical approach, histopathological examination, adjunctive therapy (postoperative radiotherapy) and outcomes of treatment. Six cases were misdiagnosed as otitis media, five cases were misdiagnosed as otitis externa, and two cases were misdiagnosed as external auditory canal cholesteatomas. Other misdiagnoses were stenosis of the EAC, ear neuralgia, furuncle of the EAC, benign neoplasm of the EAC and pre-auricular fistula. Our analyses suggest that a biopsy should be conducted to obtain a histopathological diagnosis if an EAC carcinoma is suspected, in case otitis media or otitis externa does not respond to routine anti-bacterials. Head and neck MRI should be used to explore the involvement of soft tissues. Patients with bloody ear discharge and otalgia, particularly with temporal bone erosion seen in a CT scan, are highly likely to have a malignant carcinoma of the temporal bone.