Cavernous hemangioma of the external ear canal

OBJECTIVE: To document the occurrence of a cavernous hemangioma of the external ear canal and to review the relevant literature.STUDY DESIGN Case report and literature review. METHODS: Review of a patient chart, imaging studies, operative report, and histologic findings. RESULTS: A cavernous hemangioma of the external ear canal not involving the tympanic membrane was surgically excised without complication. This is the third documented cavernous hemangioma of the external ear canal without tympanic membrane involvement in the English literature. Computed tomography scan is invaluable to narrow the differential diagnosis. Complete removal is curative. CONCLUSIONS: Cavernous hemangioma of the external ear canal with or without tympanic membrane involvement is a rare otologic entity amenable to surgical treatment. Temporal bone computed tomography scan imaging is an important preoperative diagnostic tool.     

角化细胞生长因子及受体在鼓膜穿孔邻近皮肤的研究

目的观察鼓膜穿孔部位邻近皮肤中角化细胞生长因子（keratinocyte growth factor,KGF）及其受体角化细胞生长因子受体（keratinocyte growth factor receptor,KGFR）的表达情况,分析其在慢性化脓性中耳炎不同转归中的作用。方法应用免疫组化SP染色方法和多媒体图像分析系统,观察20例继发性胆脂瘤型中耳炎鼓膜穿孔部位邻近皮肤、胆脂瘤上皮以及耳道深部正常皮肤的KGF和KGFR表达,并和20例非胆脂瘤型中耳炎鼓膜穿孔部位邻近皮肤作对比。结果胆脂瘤型中耳炎鼓膜穿孔邻近皮肤KGF和KGFR的阳性表达率分别为（33.135±6.364）%和（19.965±10.570）%,介于胆脂瘤上皮与耳道正常皮肤之间,明显高于非胆脂瘤型中耳炎患者相应部位（19.380±2.827）%和（13.145±7.935）%。结论KGF和KGFR在慢性化脓性中耳炎不同部位的表达依次上升,在胆脂瘤型中耳炎鼓膜穿孔邻近皮肤的表达明显高于非胆脂瘤型中耳炎,说明胆脂瘤型中耳炎该处皮肤增生更活跃。     

Cell shape in the migratory epidermis of the external auditory canal

The shapes adopted by cells migrating within tissues and in cell cultures are related to both the direction and mechanism of migration. The skin on the tympanic membrane and deep external auditory canal is unique in its ability to migrate from the tympanic membrane to the junction between the deep and superficial parts of the ear canal, where it desquamates. Observations on 24 surface preparations of skin, obtained from 17 human temporal bones, revealed that the basal cells of the epidermis were spindle-shaped, and their long axes were aligned in the direction of migration. This cellular asymmetry and orientation did not persist in the more superficial layers of the epidermis. These findings are important in the consideration of the mechanism of migration, and the level within the epidermis at which it occurs.     

Epidermal hyperplasia of the tympanic membrane and deep external ear canal: novel histo‐pathological features,embryological and clinical correlates

Objectives. To study the histology and developmental biology of epidermis of tympanic membrane and deep ear canal and to correlate the histo‐pathological features with clinical conditions. Method. Histo‐pathological and electron microscopic examination was performed of deep meatal skin, keratosis, keratosis obturans, external canal cholesteatoma, retraction pockets, acquired cholesteatoma and tympanic membrane perforations. Results. In some mature ears, a marked change in the normal flat thin epidermis to one resembling that of the fetus is seen in the presence of local inflammation. This hyperplastic epidermis is present in varying lengths on the tympanic membrane and deep ear canal and displayed as hyperplastic bands growing down into sub‐epidermal tissue and sometimes penetrated the collagen layer of the tympanic membrane to enter the middle ear. Keratosis was frequent on the surfaces of the tympanic membrane and deep ear canal, which may also be found in the invading bands, where they produced small keratin cysts. Conclusions. Severe chronic otitis media, with inflammatory exudates, glandular metaplasia or tympanosclerosis, may be associated with hyperplasia. This type of epidermal hyperplasia appeared to be pathogenic and was observed in several structurally distinct entities such as keratosis, keratosis obturans, retraction pockets, and cholesteatoma of the deep external canal. Invading epidermis in the middle ear, in some cases, is indistinguishable from acquired cholesteatoma. This reverse differentiation highlights a primordial property of auditory epithelium, which was not previously recognised. Furthermore, hyperplastic epidermis appears to be pathogenic and may be the cause of some specific conditions or their complications. References 1 Johnson A., Hawke M., Berger G. (1984) Hodge memorial Award‐surface wrinkles, cell ridges, and desquamation in the external auditory canal. J Otolaryngol. 13 , 345–354 2 Johnson A., Hawke M. (1985) Cell shape in the migratory epidermis of the external auditory canal. J Otolaryngol. 14 , 273–281     

Solitary schwannoma of the tympanic membrane: a case report

The external ear canal may be occluded by a rare tumor of the tympanic membrane. We reported herein a case of solid schwannoma arising from the tympanic membrane of a 29-year-old man. It presented as a circumscribed and encapsulated tumor of the external ear canal. The definite diagnosis was based on a careful microscopic examination and pathological findings. A precise excision of the tumor together with part of the tympanic membrane, followed by a myringoplasty was performed. To the best of our knowledge, our case should be the first reported case of this entity in the world literature.     

Schwannoma of the tympanic membrane

Schwannoma arising from the tympanic membrane is a rare neoplasm. This report describes an external ear canal mass obscuring the tympanic membrane. A transcanal approach identified a tumour adhered to the tympanic membrane. The tumour was excised without myringoplasty. Pathology confirmed the diagnosis of schwannoma. Clinical examination revealed no evidence of recurrence during a follow-up period of one year. The possible origins of schwannoma of the tympanic membrane and lesion management are also discussed.     

Cavernous hemangioma of the tympanic membrane

Cavernous hemangioma seems to most frequently arise in the posterior portion of the external auditory canal. However, they rarely occur in the tympanic membrane. A 49-year-old male patient was referred for evaluation of right-sided pulsatile tinnitus that he'd experienced for the previous 2 years. Temporal bone computerized tomography showed an isolated soft tissue mass just lateral to the tympanic membrane. There was no evidence of bony erosion or middle ear invasion. The patient underwent excision of the mass using a postauricular approach. The mass was removed en bloc and the defect of the tympanic membrane was repaired by tympanoplasty type I. There was no recurrence after 1 year of follow-up.     

Cavernous haemangioma of the external auditory canal: clinical case and review of the literature

Although benign vascular lesions are frequent in the head and the neck region, clinical evidence of cavernous haemangioma of the external auditory canal is extremely rare; when present, the lesion invades the middle ear space. Herein, a rare case of a soft mass filling the external auditory canal, not involving the tympanic membrane, in a symptomatic 59-year-old male is described. Clinical and audiological characteristics, imaging studies and surgical treatment with histological evaluation are reported, which led to a diagnosis of a cavernous haemangioma. This is only the seventh case described in the literature, to date, not involving the tympanic membrane and the middle ear space. In addition, a review has been made of the relevant literature with respect to epidemiology, presentation, evaluation, pathology, and management options for haemangiomas arising in the external auditory canal.     

Incisions in tympanoplasty: anatomic considerations and indications

The endaural, postauricular and transmeatal incisions are the most commonly used surgical approaches for tympanoplasty. Each incision used in tympanoplasty has its own advantages and limitations so that no single approach is the best approach for all tympanic membrane perforations. The incision selected for tympanoplasty should be determined by the location and extent of disease. Forty adult temporal bones were studied to understand the limiting factors for each surgical approach used in tympanoplasty. The external endaural incision has been modified to permit easier visualization of the crescentic endomeatal canal incisions. The anterior external endaural incision allows direct exposure of temporalis fascia, the external meatus, bony canal and perforation involving the posterior tympanic membrane and ossicular chain. The postauricular incision gives direct exposure of the anterior tympanic membrane with preservation of the anterior canal wall skin. The transmeatal approach should be reserved for smaller central perforations with limited risk for squamous ingrowth into the middle ear. In the transmeatal tympanoplasty, the ear canal should permit the use of a speculum large enough to expose the entire perforation.     

Facial nerve paresis as the presenting symptom of leukemia

Leukemic involvement of the temporal bone is not uncommon and may present in a variety of ways including auricular or external canal skin lesions, red or thick tympanic membrane, middle ear effusions, otitis media, hearing loss or mastoiditis. Symptomatic facial nerve involvement, on the other hand, is extremely unusual. We discuss a pediatric patient whose sudden onset facial nerve paresis was the presenting symptom that led to her diagnosis of leukemia. At the time of mastoidectomy, a granulocytic sarcoma or chloroma was noted to be overlying the VIIth nerve.     

肿瘤坏死因子-α在中耳胆脂瘤的表达及其对邻近骨质的作用

目的 :探讨肿瘤坏死因子 - α(TNF- α)在中耳胆脂瘤中的表达及其对邻近骨质的作用。方法 :应用TNF- α单克隆抗体对 18例中耳胆脂瘤组织和 8例正常外耳道、面部皮肤和鼓膜进行免疫定位检测。结果 :TNF-α定位于胆脂瘤组织的上皮及上皮下结缔组织 ,较正常外耳道及鼓膜的染色明显增强。结论 :TNF- α在中耳胆脂瘤组织中有较高表达并通过两条途径引起骨质吸收 :1TNF- α作为自分泌调节因子引起破骨性骨吸收 ;2 TNF-α作为中间信使 ,激活炎性细胞释放一系列生物酶引起骨组织脱钙 ,骨基质、骨蛋白溶解 ,最终导致骨质吸收。     

Immunohistochemical study of cell proliferation using BrdU labelling on tympanic membrane, external auditory canal and induced cholesteatoma in Mongolian gerbils

The Mongolian gerbil is a well-known animal model for induction of aural cholesteatomas. This animal model is useful for studying changes in the keratinizing epithelium. It is not known whether keratin accumulation can increase the proliferative activity of the keratinizing epithelium in tympanic membrane and meatal skin. In this study, we investigated the proliferative activity of the epidermis in induced aural cholesteatoma at various stages and in different areas of the tympanic membrane and meatal skin in normal gerbils. Anti-5-bromo-2- deoxyuridine (BrdU) was injected intraperitoneally to detect the proliferative activity of keratinizing epithelium. Immunohistochemistry with monoclonal BrdU antibody in the normal gerbil showed intense immunolabelled keratinocytes at the handle of malleus, and the superior parts of pars tensa and pars flaccida. Also, mitotic activity in the deep meatal skin was more active than in the lateral meatal skin. The induced aural cholesteatoma showed more active proliferation centre of the epithelial cell than eardrum and external ear canal of the normal gerbil. These observations suggest that the accumulation of the keratin debris might induce changes of the cellular proliferation in the external auditory meatus.     

Surgical treatment of acquired external auditory canal atresia

Acquired atresia of the external auditory canal is a relatively rare disease, that can be the result of the recurrent external otitis, chronic media otitis, ear trauma, neoplasms or iatrogenic complications. The surgical treatment results after operation in the 7 patients with acquired external auditory canal atresia were presented. The mean age of the patients was 34.1 and the female to male ratio was 2:5. In 6 cases we performed transcanal operation. The meatus atresia was removed and then the stenotic canal was widened by removing the skin and fibrous tissue. We especially focused our attention on the state of the anterior angle of the tympanic membrane. The bony canal was widened by burr in cases with bony overhangs. The bony canal walls were lined with pediculate or free skin grafts. In cases of tympanic membrane perforation we performed myringoplasty with temporal muscle fascia or tragus perichondrium. The follow-up period was from 8 to 39 months. The hearing improvement with primary closure of air bone gap within 20 dB was achieved in 43% of cases. In 28% of the patients recurrent atresia developed. The early surgical treatment is recommended in all the cases because cholesteatoma behind the atresia was found in 28% of patients.     

Surgical treatment of auditory canal exostoses

BACKGROUND: Although complications of surgical removal of external auditory canal exostoses are rare, reported surgical complications include tympanic membrane perforation, postoperative hearing loss, canal stenosis, and facial nerve injuries. PATIENTS AND METHODS: We report on our experience in exostosis surgery, consisting of 59 procedures in 48 patients. Preoperative and postoperative complaints and findings, intraoperative complications, and audiologic results are described and discussed. There has been a minimum of one year of follow-up in every case. RESULTS: Postoperative canal stenosis was seen in 2 cases of preoperative severe persistent external otitis. Temporary threshold shift was recorded in 6 patients. Persistent sensorineural hearing loss occurred in 4 patients. Six of the 10 patients with temporary or persistent hearing loss had already shown preoperative sensorineural hearing loss. Intraoperatively tympanic membrane perforation occurred in 3 cases, accidental opening of the mastoid in 1 case. CONCLUSIONS: Exostosis surgery should be reserved for uninfected ear canals. Meatal skin preservation without circular meatal flap incision is recommended to avoid postoperative canal stenosis. Especially in cases of preexisting sensorineural hearing loss, attention should be focused on the intraoperative noise reduction by tympanic membrane protection and pauses of noise exposition.     

Keratosis of the tympanic membrane and deep external auditory canal

Summary We have previously described the pathways of movement of epithelium on the tympanic membrane, showing that there are two discrete and separate zones. Four cases of keratosis of the tympanic membrane and deep external auditory canal are here reported. All patients complained of tinnitus and other aural symptoms. Sequences of otoscopic photography of daubs of dye placed on the tympanic membrane showed an abnormal anterior movement over the whole tympanic membrane in two cases and complete paralysis of movement in the two others. These findings suggest that the disorder arises from damage to basal epidermal cells caused by inflammation, which is probably due to infection. Treatment is by suction-stripping of keratin from the eardrum. Careful examination of the eardrum under magnification is required in all cases of tinnitus so as to detect this condition. Correspondence to: S. Soucek     

The spatial organisation of keratinocytes in acquired middle ear cholesteatoma resembles that of external auditory canal skin and pars flaccida

A scanning electron microscopic study of acquired middle ear cholesteatoma was undertaken in order to compare morphological findings with those of keratinising squamous epithelium of the tympanic membrane and external auditory meatus. Analysis of results confirms a highly ordered vertical architecture, with cell stacking, in the stratum corneum of cholesteatoma, similar to that found in the skin of the deep external auditory meatus and the pars flaccida of the tympanic membrane. These findings support the notion that acquired cholesteatoma originates by immigration of epithelium from the pars flaccida and external meatus rather than by metaplasia of middle ear mucosa.     

The pathologic features of keratosis obturans and cholesteatoma of the external auditory canal

The presence of a keratin plug occluding the deep external auditory canal was first noted and documented in the 19th century. It has subsequently been proposed that two different diseases can be responsible for the presence of this type of obstruction within the deep meatus: keratosis obturans and external auditory canal cholesteatoma. Keratosis obturans is characterized by a dense plug of keratin debris located primarily within the deep meatus. There is an associated hyperplasia of the underlying epithelium and evidence of chronic inflammation within the subepithelial tissue. There is no evidence of erosion or necrosis of the underlying bone. In external auditory canal cholesteatoma the significant finding is extensive erosion of the bony external auditory canal by a wide-mouthed sac, lined with stratified squamous keratinizing epithelium, that arises lateral to the tympanic membrane and is located in the inferior portion of the bony external canal. There is frequently evidence of sequestration of the underlying bone.     

Biology of cholesteatoma

Acquired cholesteatoma is a disease of the posterior superior part of the middle ear cleft that may arise from the external epithelium of the tympanic membrane. Three distinct epithelial zones of differing thicknesses characterize the development of this latter epithelium, and the thickness differences and their distribution in the eardrum and deep external canal, which delineate the zones, are found at all stages of life, including the mature ear. It is postulated that epithelial migratory activity follows the pathways of early development, the flow occurring through the three zones. The detailed validity of this model was confirmed by otoscopic photography of dye movements on the tympanic membrane. Cholesteatoma may develop from the earliest and most active of these zones situated on the pars flaccida. The pathologic anatomy of cholesteatoma suggests vigorous growth. Retraction pockets provide a source for bands of squamous epithelium growing into the middle ear. Cholesteatoma and tympanic membrane epithelium move en masse in tissue culture, a property not shown by any other stratified squamous epithelium.     

Catastrophic otologic injury from oral jet irrigation of the external auditory canal

Jet irrigation is an accepted method for removal of cerumen from the external auditory canal. Even at a submaximal power setting, oral jet irrigators can generate enough force to rupture the tympanic membrane. Parameters for safe use of these irrigators have never been established. Three cases are reported in which, in addition to tympanic membrane rupture, oral jet irrigators caused ossicular disruption, round and oval window fistulae, and subluxation of the stapedial footplate. A prospective study performed on 25 fresh cadavers demonstrated a 6% incidence of tympanic membrane perforation when the power setting was one-third full power or greater. Recommendations are made for safe use of oral jet irrigators for removal of external auditory canal cerumen.     

Sweet's syndrome affecting the external auditory canal and tympanic membrane

We report a patient who developed left ear pain, dry cough, and fever. The external auditory canal was tender, swollen, erythematous and full of debris. Later the patient developed widespread tender and red skin nodules and pustules that subsequently coalesced to form plaques. Identical lesions developed also in the external auditory canal and the tympanic membrane of the affected ear. Skin biopsy showed dermal neutrophilia, compatible with the diagnosis of Sweet's syndrome. Rapid improvement was achieved with prednisone after the failure of antibiotics.