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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 230-232

Outer auditory canal cholesteatoma


1 Department of Otorhinolaryngology and Head and Neck Surgery, AIIMS, New Delhi, India
2 Department of Otorhinolaryngology and Head and Neck Surgery, GMCH, Chandigarh, India

Date of Web Publication12-Dec-2017

Correspondence Address:
Dr. Hitesh Verma
Department of Otorhinolaryngology and Head and Neck Surgery, Fourth Floor, Teaching Block, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_156_16

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  Abstract 


Outer auditory canal cholesteatoma (OACC) is a rare form of cholesteatoma of temporal bone, and it accounts for 0.1%–0.5% of new patients at clinics of otolaryngologist. We are presenting here a rare case of cholesteatoma of OAC where excision was done with canal wall down mastoidectomy with preservation of tympanic membrane and structure medial to it and reconstruction of OAC with conchal cartilage. Complete disease removal with soft wall reconstruction is a viable method for OACC.

Keywords: Cholesteatoma, conchal cartilage, outer auditory canal


How to cite this article:
Verma H, Dass A, Singhal SK, Gupta N. Outer auditory canal cholesteatoma. Int J Health Allied Sci 2017;6:230-2

How to cite this URL:
Verma H, Dass A, Singhal SK, Gupta N. Outer auditory canal cholesteatoma. Int J Health Allied Sci [serial online] 2017 [cited 2019 Aug 22];6:230-2. Available from: http://www.ijhas.in/text.asp?2017/6/4/230/220519




  Introduction Top


Outer auditory canal cholesteatoma (OACC) is the rare form of cholesteatoma of temporal bone and it accounts 0.1%–0.5% of new patients at clinics of otolaryngologist.[1] This condition affects especially elderly people. The disease is slowly progressive, and patient may be symptom-free. So that it diagnoses late and with progressive bone destruction, affecting important circumjacent structures.[2],[3],[4] We are presenting here rare case of OACC in which excision was done by canal wall down mastoidectomy and reconstruction of OAC with conchal cartilage.


  Case Report Top


A 55-year-old male patient presented with a 5-year history of decreased hearing from the left ear. The hearing loss was progressive in nature. There was no other associated history. On examination, the bony part of canal was narrowed by cystic swelling (<1 cm diameter) in posterosuperior part, and it was filling <½ of canal. The swelling was smooth surface and soft in consistency. The part of tympanic membrane visible on otoscopy was normal. Fine-needle aspiration showed yellow color fluid with neutrophil-predominant inflammatory cells in it. High-resolution computed tomography temporal bone showed homogeneous soft tissue density in the left OAC with erosion of posterior canal wall and extension of mass in mastoid air cells [Figure 1]. Attic and mesotympanum are normal with normally ossicular chain. Pure tone audiometry showed AB gap of 30 dB, and it was conductive hearing loss. The canal malignancy and cholesteatoma were kept as differential diagnosis as the disease was unilateral in advance age without comorbidities. After informed consent, the patient was planned for exploration by postauricular approach under general anesthesia. Examination under microscope showed pale color cystic mass, and on palpation, the outer part of bony canal was eroded. The tympanic membrane was completely normal with normal adjoining canal wall. The disease was extending in lateral part mastoid cavity directly by erosion of canal wall. After disease excision tunnel was created in remaining part of posterior canal wall to fit conchal cartilage [Figure 2]. Conchal cartilage was harvested from the left pinna. The postoperative period was uneventful, and patient gained 15 dB hearing in the follow-up period. The final pure tone audiometery was 20/35 dB and no postoperative radiology was performed. The histopathology report reviling feature of squamous epithelium-lined matrix with granulation in perimatrix suggestive of cholesteatoma [Figure 3].
Figure 1: High-resolution computed tomography temporal bone showing soft tissue density in outer auditory canal with erosion of posterior canal wall and extension into mastoid cavity

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Figure 2: Conchal cartilage used for reconstruction of outer auditory canal with intact tympanic membrane of the left ear

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Figure 3: Histopathological picture reviling feature of squamous epithelium lined matrix with granulation in perimatrix suggestive of cholesteatoma

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  Discussion Top


Toynbee was described first and coined term “epidermal sheets” for cholesteatoma originates from the external auditory canal. Cholesteatoma can be congenital or acquired, and it is most commonly found in the middle ear cleft (98%).[5] OACC is acquired, and it is a rare entity. A cholesteatoma is a sac-like structure which is lined by stratified squamous keratinizing epithelium with associated inflammation and erosion of temporal bone.

Principle etiological factor for OACC is not clear. It may occur spontaneous or after accidental or surgical trauma of OAC.[6] Natural removal of keratin debris in outer ear is by normal outward migration of epithelium from tympanic membrane and OAC. The loss and reduced rate of self-cleaning property of EAC may be responsible for spontaneous OACC.[7] Patients may present with a history of otorrhea, dull pain, hearing loss, etc.[8],[9] The enzymatic proteolysis, pressure effect of accumulated keratin debris and superadded bacterial infection is thought to be the cause of bony erosion in OACC.[10] The differential diagnosis for OACC is keratosis obturans, postinflammatory medial canal fibrosis, malignant otitis externa, and squamous cell carcinoma. The history and physical examination are the basis of diagnosis and CT is done to the known extent of disease. The presence of soft-tissue mass with bony fragments and bony erosion is the CT presentation of an OACC.

The treatment options may be conservative or surgical. In patients where lesion is completely visualized and in patient with no chronic pain, treatment is conservative in the form of frequent cleaning and local wound debridement. Surgical treatment is indicated in patients with persistent chronic pain despite medical management, frequent infection, in complicated ear, progression during follow-up, and in immunocompromised.[11],[12] Extension of disease in mastoid air cells, modified radical mastoidectomy may be indicated, with the tympanic membrane and ossicles left intact[13] as we did in our case. Various methods mentioned in literature to reconstruct OAC whereas we choose conchal cartilage.[14],[15],[16],[17]


  Conclusion Top


Canal wall down mastoidectomy with reconstruction with cartilage is effective choice to evade cavity problem.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Anthony PF, Anthony WP. Surgical treatment of external auditory canal cholesteatoma. Laryngoscope 1982;92:70-5.  Back to cited text no. 1
    
2.
Zanini FD, Ameno ES, Magaldi SO, Ruben A, Lamar RA. Cholesteatoma of external auditory canal: A case report. Rev Bras Otorrinolaringol 2005;71:91-3.  Back to cited text no. 2
    
3.
Malcolm PN, Francis IS, Wareing MJ, Cox TC. CT appearances of external ear canal cholesteatoma. Br J Radiol 1997;70:959-60.  Back to cited text no. 3
    
4.
Garin P, Degols JC, Delos M. External auditory canal cholesteatoma. Arch Otolaryngol Head Neck Surg 1997;123:62-5.  Back to cited text no. 4
    
5.
Aswani Y, Varma R, Achuthan G. Spontaneous external auditory canal cholesteatoma in a young male: Imaging findings and differential diagnoses. Indian J Radiol Imaging 2016;26:237-40.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Holt JJ. Ear canal cholesteatoma. Laryngoscope 1992;102:608-13.  Back to cited text no. 6
    
7.
Makino K, Amatsu M. Epithelial migration on the tympanic membrane and external canal. Arch Otorhinolaryngol 1986;243:39-42.  Back to cited text no. 7
    
8.
Tran LP, Grundfast KM, Selesnick SH. Benign lesions of the external auditory canal. Otolaryngol Clin North Am 1996;29:807-25.  Back to cited text no. 8
    
9.
Bhagat S, Varshney S, Bist SS, Mishra S, Kabdwal N, Kumar R. Primary external auditory canal cholesteatoma presenting as cerebeller abscess. Indian J Otolaryngol 2013;19:88-91.  Back to cited text no. 9
    
10.
Applebaum EL, Duff BE. Ear and temporal bone, I: Clinical considerations for non-neoplastic lesions of the ear and temporal bone. In: Fu YS, Wenig BM, Abemayor E, Wenig BL, editors. Head and Neck Pathology with Clinical Correlations. Philadelphia: Churchill Livingstone; 2001. p. 668-78.  Back to cited text no. 10
    
11.
Coelho LB, Delegido RM, Finamore CM, Rodrigues J, Secchi MM. Cholesteatoma of external auditory canal. Rev Bras Otorrinolaringol 2000;66:285-8.  Back to cited text no. 11
    
12.
Vrabec JT, Chaljub G. External canal cholesteatoma. Am J Otol 2000;21:608-14.  Back to cited text no. 12
    
13.
Yan Y, Dong S, Hao Q, Liu R, Xu G, Zhao H, et al. Clinical analysis on surgical management of type III external auditory canal cholesteatoma: A report of 12 cases. Acta Otolaryngol 2016;136:1006-10.  Back to cited text no. 13
    
14.
Sun K, Guan G, Jin C, Liu Y, Zhang D, Hao Y, et al. Tympanoplasty with soft-wall reconstruction of ear canal. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2011;25:744-6.  Back to cited text no. 14
    
15.
Sudhoff H, Brors D, Al-Lawati A, Gimenez E, Dazert S, Hildmann H, et al. Posterior canal wall reconstruction with a composite cartilage titanium mesh graft in canal wall down tympanoplasty and revision surgery for radical cavities. J Laryngol Otol 2006;120:832-6.  Back to cited text no. 15
    
16.
Yu F. A novel technique for reconstruction of the posterior wall of the external auditory canal and tympanum using pedicled temporalis myofascia. Acta Otolaryngol 2013;133:699-707.  Back to cited text no. 16
    
17.
Lee HJ, Chao JR, Yeon YK, Kumar V, Park CH, Kim HJ, et al. Canal reconstruction and mastoid obliteration using floating cartilages and musculoperiosteal flaps. Laryngoscope 2017;127:1153-60.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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