CLINICAL CHARACTERS OF PATIENTS WITH EXTERNAL AUDITORY CANAL CHOLESTEATOMA SURGERY
Introduction
External auditory canal cholesteatoma (EACC) is relatively rare in comparison to middle-ear cholesteatoma. Patients with EACC often present with otorrhea and otalgia due to bone erosion, but many cases can be remarkably unnoticed. If the bone erosion progresses, serious complications, like facial palsy, may occur. Accordingly, the surgical indication should be decided upon taking into consideration the patient’s age, severity of symptoms, extent of bone destruction, and compliance of cleaning in the outpatient clinic.
EACC is classified according to the cause. EACC of unknown origin has been classified as primary EACC, and EACC due to a known cause has been classified as secondary EACC. Moreover, primary EACC has been divided into strict primary EACC, which shows an accumulation of keratin debris and bone destruction in a localized area of the external auditory canal, and keratosis obturans, which shows accumulation of keratin debris and bone erosion. These two diseases are differentiated from each other by pathophysiology and clinical features. Secondary EACC follows after injury or congenital auditory canal stenosis.
In this study, we investigate the clinical features of patients undergoing surgery for strict primary EACC and the results of surgery.
Methods
The clinical records of all patients diagnosed with primary EACC undergoing surgery in our hospital from 2002 to 2011 were retrospectively reviewed. We evaluated their clinical characteristics, including gender, age, symptoms, complications, invaded area, and the results of surgery from their charts.
Results
There were seven males and five females. All of them had unilateral lesions. The mean age was 29.6 years, with a range of 10 to 63 years. The patients were mostly teenagers (Fig. 1). The most common symptom was otalgia, which occurred in eight cases. The other symptoms were hearing loss, otorrhea, and ear fullness, which occurred in seven, six, and four cases, respectively. Facial-nerve palsy was found in only one case. The most common complaint which was the reason why they underwent surgery was otalgia, accounting for six of 12 cases (Fig. 2). Two cases required urgent surgery because of uncontrollable otalgia. The most common area invaded by EACC was the inferior canal wall (Table 1). EACC extended into the mastoid cavity in only one case, which was treated with tympanoplasty with mastoid obliteration using bone chips and pedicled periostium flap. The vertical portion of the facial nerve was exposed in four ears intra-operatively. In one case where facial palsy was found before surgery, facial movement could not be elicited by electrostimulation. Tympanic cavity invasion was found in only one case. In this case, the inferior part of the tympanic
Fig. 1. Patients’ age and gender. There were seven males and five females and all of them had unilateral lesions. The mean age was 29.6 years, ranging from ten to 63 years.
Fig. 2. Distribution of symptoms.
Table 1. Invaded area by EACC.
membrane was adhered to the promontory. Tympanic membrane perforation was also seen in two cases. Canalplasty was performed in all cases, and enlargement of the external auditory canal was performed in six cases. Tympanoplasty type 1 was also performed in three cases with tympanic membrane abnormalities. In one case of extended invasion into the mastoid cavity, mastoid obliteration using bone chips and a pedicled periosteal flap were also performed. After one year follow up of surgery, ten cases obtained a self-cleaning auditory canal without maintenance. In only one case, residual cholesteatoma arose under the generated canal and repeat surgery was needed. One case dropped out before within one year of follow up. The case with facial nerve palsy completely recovered within a few months post-operatively.
The cases of EACC that require surgery are relatively rare. We have applied surgery mainly to young people. We have considered that as patients’ age increases, they become less suitable for surgery. In the decision-making process before surgery for EACC, age may be a strong factor in deciding who can undergo this surgery. There were no differences in the gender of patients for EACC surgery.1 Our results were consistent with previous reports of gender distribution of EACC.
The most common symptoms are otalgia and otorrhea. Otalgia is usually a chronic, dull pain, but sometimes becomes uncontrollably severe and needs urgent surgery.2,3 We encountered two patients with severe otalgia, and performed urgent surgery. Facial palsy is rare, however, urgent surgery will help the patient to recover completely.
In our patients, the most common area invaded by EACC was the inferior wall. In the literature, a lower migratory rate of epithelium in the inferior canal wall has been described.4 It may influence the migration speed of the external auditory canal skin. Tympanic-membrane perforation was also seen in two cases. In one case, the history of tympanic-membrane perforation was unclear, and EACC and tympanic-membrane perforation were incidentally found together. However, in another case, EACC arose first, then myringitis occurred in the follow-up period of EACC, and, finally, tympanic-membrane perforation occurred. Although there may be no relationship between EACC and tympanic-membrane perforation, chronic inflammation or skin migration may have an influence on both conditions.
The results of surgery after one year follow up were good in this study. Although we do need a longer follow-up period, we can apply surgery more frequently for young people as well as elderly people to improve their quality of life by creating a self-cleaning external auditory canal that does not require any maintenance.
Conclusion
The cases of EACC that require surgery are relatively rare. The cases with consistent otalgia, otorrhea, and facial nerve palsy and the cases with progressive extension to the middle-ear cavity should be indicated for surgery. However, it is necessary to consider the patient’s status and compliance for cleaning in an outpatient clinic. We have applied surgery mainly to young people with uncontrollable symptoms and reached excellent results with surgery for EACC. We conclude that it should be applied more frequently, also on elderly people.
References
1.Owen HH, Rosborg J, Gaihede M. Cholesteatoma of the external ear canal: etiological factors, symptoms and clinical findings in a series of 48 cases. BMC Ear Nose Throat Disord 6, 2006
2.Piepergerdes MC, Kramer BM, Behnke EE. Keratosis obturans and external auditory canal cholesteatoma. Laryngoscope 90:383–391, 1980
3.Smith MF, Falk S. External auditory canal cholesteatoma. Clin Otolaryngol Allied Sci 3:297–300, 1978
4.Makino K, Amatsu M. Epithelial migration on the tympanic membrane and external canal. Arch Otorhinolaryngol 243:39–42, 1986
Address for correspondence: Kuniyuki Takahashi, MD, PhD, Department of Otolaryngology, Niigata University Faculty of Medicine, 1 Asahi-machi, Niigata 951–8510, Japan. kuniyuki.ent@gmail.com
Cholesteatoma and Ear Surgery – An Update, pp. 237–239
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands