AN UNUSUAL IATROGENIC CHOLESTEATOMA OF THE EXTERNAL AUDITORY CANAL: A CASE REPORT

Evren Erkul, Engin Cekin, Murat Salihoglu, Enver Cesmeci

Gulhane Military Medical Academy Haydarpasa Training Hospital Department of Otorhinolaryngology, Istanbul, Turkey

Case report

We present a patient with unusual, huge external auditory canal cholesteatoma (EACC) that developed during a three-year period after tympanoplasty. The patient suffered from otalgia and slight hearing loss and these symptoms started six months after the surgery. Ear discharge was not present. During the otoscopic examination, a sub-epithelial mass obliterating the left side of the external auditory canal was seen (Fig. 1). The patient’s history revealed that otalgia and slight hearing loss began to develop six months after surgery. EACC excision and myringoplasty was performed (Fig. 2).

Discussion

External auditory canal cholesteatoma is an uncommon form of cholesteatoma originating from the external auditory canal extending into surrounding structures, including the mastoid and middle ear. It is first described by Toynbee.1 There are no sufficient data about incidence of EACC; although there are authors who reported the incidence of EACC to be one in 1000 new otologic patients.2,3 EACC is described as a late complication of temporal-bone trauma, tympanomastoid surgery, and radiation therapy. The potential for development of EACC in congenital and acquired aural stenosis is well recognized.2 Chronic inflammatory disorders may also stimulate development. Depending on the etiology, EACC has been classified into six types: congenital, post-traumatic, iatrogenic, post-obstructive, post-inflammatory and spontaneous. There is little information on the incidence of ECC according to cause. Earlier literature on this topic suffers from an uncertain definition of the process and confusion with other disorders of the external auditory canal, mainly keratosis obturans.3 An accurate description of each process by Piepergerdes and colleagues4 was important in the resolution of this dilemma. They recognized that EACC develops secondary to a disorder of the canal bone, in many instances caused by a local osteitis. The diagnosis of ECC is based on history and physical examination. Radiographic assessment is useful to define the extent of the lesion and delineate its proximity to the middle ear and neu-rovascular structures. Presenting symptoms, physical findings, radiographic appearance, and management will vary according to the cause of the lesion.

Iatrogenic EACC develops as a late complication of tympanomastoid surgery. The lesion can present as invagination of skin through a defect in the posterior canal wall or as a subepithelial mass lesion.5 Imaging reveals destruction of the canal wall lateral to the scutum and a normally aerated middle-ear space if the initial operation was successful. Hearing loss is variable, being dependent on the initial operation.

image

Fig. 1. Pre-operative view of subepithelial mass that is obliterating the left external auditory canal.

image

Fig. 2. Post-operative view of the left external auditory canal after surgery.

Conclusion

As seen in our case, we should be very aware not to implant squamous epithelium into deep tissue of mastoid cavity, tympanic cavity and external auditory canal during ear surgery.

References

1.Toynbee JA. Specimen of molluscum contagiosum developed in the external auditory meatus. Lond Med Gaz 46:261–264, 1850

2.Holt JJ. Ear canal cholesteatoma. Laryngoscope 102:608–613, 1992

3.Vrabec JT, Chaljub G. External canal cholesteatoma. Am J Otol 21:608–614, 2000

4.Piepergerdes MC, Kramer BM, Behnke EE. Keratosis obturans and external auditory canal cholesteatoma. Laryngoscope 90:383–391, 1980

5.Vrabec JT, Chaljub G.Am J Otol. External canal cholesteatoma 21(5):608–614, 2000

Address for correspondence: Evren Erkul, Gülhane Askeri Tıp Akademisi Haydarpaşa Eğitim Hastanesi KBB Hastalıkları Servisi, 34668, Üsküdar, İstanbul, Türkiye. evrenerkul@yahoo.com

Cholesteatoma and Ear Surgery - An Update, pp. 391–392

Edited by Haruo Takahashi

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