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Table of Contents
ORIGINAL ARTICLE
Year : 2015  |  Volume : 17  |  Issue : 2  |  Page : 40-43

External canal cholesteatoma: Clinical findings and modalities of management


1 Department of Otolaryngology Head & Neck Surgery, King, Abdulaziz University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Date of Web Publication2-Jan-2020

Correspondence Address:
MD Abdulrahman Alsanosi
King Abdulaziz University Hospital King Saud University PO.Box 245,Riyadh 11411
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.274655

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  Abstract 


Objective: to review our experience in patients with external auditory canal cholesteatoma.
Study design: Retrospective chart review
Setting: King Abdulaziz University Hospital and Prince Sultan Military Medical City
Methods: 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.

Keywords: external auditory canal, cholesteatoma, radiotherapy, otorrhea


How to cite this article:
Alsanosi A, Alshehri H, Alqatani M. External canal cholesteatoma: Clinical findings and modalities of management. Saudi J Otorhinolaryngol Head Neck Surg 2015;17:40-3

How to cite this URL:
Alsanosi A, Alshehri H, Alqatani M. External canal cholesteatoma: Clinical findings and modalities of management. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2015 [cited 2022 Dec 9];17:40-3. Available from: https://www.sjohns.org/text.asp?2015/17/2/40/274655




  Introduction Top


Cholesteatomas are benign erosive lesions that involve the temporal bone. The lesion is lined by stratified squamous epithelium and contains desquamated epithelialdebris. It is common in the middle ear, but is relatively uncommon in the external auditory canal [1]. The incidence of external auditory canal cholesteatoma (EACC) is 0.3 of 100,000 of population per year. Possible causes for EACC include occlusion or narrowing of the external auditory, implantation of squamous epithelium and subsequent erosion of the bone canal [2]. Other causative factors of EACC such as temporal bone trauma, tympanomastoid surgery, and post radiation therapy, have been implicated [3],[4]. Otalgia and otorrhea have been described as the most common presenting symptoms. Other symptoms such as pruritis, hearing loss and facial weakness have also been described [5].

The diagnosis of EACC is established when there are focal skin disruption, osteonecrosis, and varying degrees of bone sequestration. The middle ear and tympanic membrane are usually normal unless there is secondary invasion by the EACC [6],[7].

Complications of EACC are rare. The site and the extent of EACC determine its management whichvaries from simple curettage to a canal wall down mastoidectomy [2]. Healing in the post operative period can be hastenedby lining the cavity with temporalis fascia, andsecondary healing occurs within 10 weeks in most cases [2],[8].

This paper discusses our experience with diagnosis and managements of EACC.


  Materials and Methods Top


Between January 2009 and December 2012, a retrospective chart review was studied for all patients with diagnosis of EACC. The data collected included the age, sex, presenting symptoms, clinical, radiological findings and modalities of management were included .charts with incomplete data were excluded. A total of 13 patients (15 ears) with diagnosis of EACC were found. The research was approved by the institutional review board at King Saud University. A Microscoft Excel® program (Microsoft Corporation, Seattle, Washington) was used for analysis and plotting charts and tables.


  Results Top


Patient’s ages ranged from 12 to 50 years, patient was classified into two groups according to there ages, first group less than 18 years (31%) and the second more than 18 years (69%). The male to female ratio was 1:1.6.

Otorrhea was the most common presenting symptom (93%), followed by hearing loss (67%). Otalgia occurred in 27% of patients and tinnitus was the least common complaint occurring in 14% of patients(27%), and tinnitus is the least(14%) [Figure 1].There was no significant difference between right and left ears (53% vs 47%). The duration of symptoms prior to diagnosis varied between 1and 15 years. Patients who had symptoms for less than 4 years were 54%, those who had symptoms between 4 and 8 years was 31%, and those with symptoms for greater than 8 years comprised 15% of the subjects [Figure 2].
Figure 1: Most common presenting symptoms of patients with EACC.

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Figure 2: Duration before presenting to hospital.

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Granulation tissue was the commonest clinical finding, which was observed in 67% of patients, followed by a bony canal wall defect in 60% [Figure 1], and facial nerve exposure and adhesion in one ear representing 7%. During surgery,earcanal erosion was found in 63% of patients, [Figure 3], facial nerve exposure in 28%, ossicular disruptions in 21% and temporomandibular joint exposure in 7%.
Figure 3: Defect of inferior canal wall black arrow pointing to inferior part tympanic membrane.

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Etiology included both primary and secondary EACC. Secondary EACC was the most common type and represented 67% (10 ears) while primary where the cause was unknown included 33% (5 ears). The most common etiology associated with secondary EACC was radiation therapy which represented 7 ears (70%) (7 ears), while temporal bone trauma was thought to be the etiology in 3 out of 10 ears (30%).

Most of ears 53.8% were stage I-III according to Naim’s classifications treated with only debridement in an outpatient clinic.

Six patients (46.2%) all were stage IV underwent surgical intervention in the form of Canal wall down mastoidectomy. There was no complication except one patient who had partial facial nerve palsy House-Brackmann grade III which recovered completely within six months.


  Discussion Top


Cholesteatomacan be found in the middle ear or external ear canal or both. While it is common in middle ear but is uncommon in the external ear canal [1]. It can affect any age group. In some studies authors found that EACC affected mainly the middle age groups, others found it more commonly in an older age group with age of 57 years as the mean for this group [5].

In our study group we found that the middle age group representedthe majority of patients with EACC which was comparable to the published articles, however the mean age in our study was younger when compared to other studies [5].

Owen et al [5] found almost no difference between females and males, but in our study femal.eswere almost twice as frequently affected as males. Otalgia and otorrhea were the most common symptoms in our study group which was similar to published articles [5].

Tos suggested a classification for EACC. He classified the lesion into primary, secondary and cholesteatoma associated with congenital atresia of the ear canal. In primary EACC the etiology is unknown, while secondary EACC is related to other conditions such as postoperative, post inflammatory, post traumatic and post radiation [9]. In some studies primary EACC affects a wide range of ages including younger adults [5]. On the other hand some found that the number of patients with primary EACC almost equaled those with secondary [9]. Congenital type of EACC was not seen in our cases, but primary lesions were seen in one third of patients while two thirds had secondary EACC. Secondary EACC might be due to different etiological factors such as trauma, inflammatory, post-surgery and after radiotherapy. The most common etiology was post-surgical [4],[9] while we found in our study the radiation was the most common cause and involved both ears as well.

Right and left ears are equally affected by EACC in literature as well as in our study [5].

Naim classified EACC pathologically into four stages on the basis of histopathology and clinical finding: stage I demonstrated hyperplasia of the canal epithelium; stage II showed periosteitis; stage III demonstrated defective bony canaland; stage IV demonstrated erosion into adjacent anatomic structure [10]. Recently, Shin et al., and others proposed a new staging for EACC based upon CT scan and they recommended different procedures for each stage. In stage I the lesion was confined to the external auditory canal. In stage II, the lesion invaded the middle ear, and in stage III, the lesion invaded the mastoid process while in stage IVthe lesion extended beyond the temporal bone [11].

The nature and severity of the symptoms determine the treatment of EACC. The principle of treatment should include eradication of the cholesteatoma and maintain normal epithelial migration of external canal by canaloplasty. Such an attempt is easy to achieve if surgery is performed before stage IV [12]. Majority of our patients were early staged and managed well with debridement and application of topical treatment in outpatient clinic. Late presentation may lead to extension of disease and erosion of adjacent anatomic structure. The surgical procedure chosen depends on the site and extent of bone destruction. Disease limited to floor or anterior wall of external canal with no extension to mastoid ear cells can be managed well with canaloplasty. In most of cases small area of canal skin defect does not require skin grafting, however big skin defect may heal well with skin grafting [13].

Canal–wall-down mastoidectomy is the procedure of choice in Patient with erosion of external canal and extension of disease to mastoid cortex with middle ear involvement . All of cases required surgery in our study presented with advance disease where it was not possible do any thing except canal down mastoidectomy. Some authers advocate canal wall mastoidectomy up in cases when there is limited erosion of posterior canal wall and no Involvement of the middle ear [14].


  Conclusion Top


ECC is a rare condition but must be kept in mind in patients presenting with logorrhea. Care must be taken to follow closely patient who have had radiation therapy around the temporal bone for the management of head and neck tumors. Delaying of intervention may lead to serious complications including facial nerve involvement.



 
  References Top

1.
Piepergerdes MC, Kramer BM, Behnke EE. Keratosis obturans and external auditory canal cholesteatoma. Laryngoscope. 1980;90:383-91.  Back to cited text no. 1
    
2.
Anthony PF, Anthony WP. Surgical treatment of external auditory canal cholesteatoma. Laryngoscope. 1982;92:70-5.  Back to cited text no. 2
    
3.
Owen Jr. HH, Gaihede M.Cholesteatoma of the external ear canal: etiological factors, symptoms and clinical findings in a series of 48 cases. BMC Ear, Nose and Throat Disorders. 2006; 6 (16): 1-9.  Back to cited text no. 3
    
4.
Brookes GB, Graham MD. Post-traumatic cholesteatoma of the external auditory canal. Laryngoscope. 1984; 94:667-670.  Back to cited text no. 4
    
5.
Adler M, Hawke M, Berger G, Harwood A. Radiation effects on the external auditory canal. J Otolaryngol. 1985; 14(4):226-32.  Back to cited text no. 5
    
6.
Fábio D, Everton Ameno, Sidney O,Ruben A. Cholesteatoma of external auditory canal: a case report. Revista Brasileira De Otorrinolaringología. V.71, n.1: 91-93.  Back to cited text no. 6
    
7.
Heilbrun ME, Salzman KL, Glastonbury CM, et al. External Auditory Canal Cholesteatoma: Clinical and Imaging Spectrum. AJNR. 2003; 24(4): 751-6.  Back to cited text no. 7
    
8.
McCary WS, Kryzer TC, Lambert PR. Application of split-thickness skin grafts for acquired diseases of the external auditory canal. Am J Otol. 1995;16:801-5.  Back to cited text no. 8
    
9.
Tos M. Cholesteatoma of the external acoustic canal. In Manual of middle ear surgery vol. 3: Surgery of the external auditory canal. Thieme; 1997:205-209  Back to cited text no. 9
    
10.
Naim R, Linthicum F Jr.,Shen T, Bran G,Hormann K. Classification of the external auditory canal cholesteatoma. Laryngoscope. 2005;115:455-60.  Back to cited text no. 10
    
11.
Shin SH,Shim JH, Lee HK.Classification of External Auditory Canal Cholesteatoma by Computed Tomography. Clin Exp Otorhinolaryngol. 2010 ;3(1):24-6.  Back to cited text no. 11
    
12.
Yung -Song Lin .Surgical results of external canal cholesteatoma. ActaOto-Laryngologica. 2009; 129: 615-623  Back to cited text no. 12
    
13.
McCary WS, Kryzer TC, Lambert PR. Application of split thickness skin grafts for acquired diseases of the external auditory canal. Am J Otol. 1995;16:801-5.  Back to cited text no. 13
    
14.
Jeffrey T. Vrabec, Gregory Chaljub. External Canal Cholesteatoma. Am J Otol. 2000 Sep;2 1(5):608-14.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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