Bezold's abscess arising with recurrent cholesteatoma 20 years after the first surgery: with a review of the 18 cases published in Japan since 1960

The classic Bezold's abscess was described as a deep neck abscess arising from an acute mastoiditis. With the pervasive use of antibiotics, the incidence of otitic suppurative complications including Bezold's abscess has dramatically decreased today. This decreased incidence has led to decreased familiarity and a subsequent increased delay in diagnosis. Otolaryngologists must recognize that intervening in benign processes such as cholesteatoma can lead to unforeseen serious complications. A case of Bezold's abscess arising in a 25-year-old man with recurrent cholesteatoma 20 years after his first surgery is presented. In this patient despite the prior canal wall down tympanoplasty, granulation tissue blocked the pathway from the mastoid to the external auditory meatus. A cholesteatoma formed in this obstructed space became secondarily infected and filled the mastoid cavity with pus. This recent clinical presentation of Bezold's abscess is described and the Japanese literature reviewed to renew familiarity with this rare complication.     

Aural cholesteatoma with upper neck extension

We report the case of a 32-year-old Chinese woman who presented with a large cholesteatoma in her right upper neck after a history of ipsilateral chronic otitis media since childhood. Intraoperatively, a cholesteatoma was found in the mastoid cavity, and the mass in her neck was attached to the mastoid cortex by a stalk. Direct erosion of the mastoid tip may have led the cholesteatoma epidermis to enter the deep surface of the sternocleidomastoid muscle, allowing debris accumulation to form the mass, similar to the propagation of pus in a Bezold's abscess. Neck cholesteatoma secondary to aural cholesteatoma is fairly rare. Only five reports were identified before 1989 followed by no reports in the past 20 years. The case we reported is a reminder to otolaryngologists that this unusual condition still occurs.     

Congenital cholesteatoma isolated to the mastoid presenting as stricture of the external auditory canal

Congenital cholesteatoma may originate at various sites in the temporal bone. Congenital cholesteatoma of the mastoid origin shows a variable clinical presentation, although the least common site is the mastoid process. We report an extremely rare case of congenital cholesteatoma isolated to the mastoid presenting as stricture of the external auditory canal. A 10-year-old boy presented with stricture of the left-sided external auditory canal caused by bulging of the posterior wall of the external auditory canal. Computed tomography showed destruction of the posterior wall of the external auditory canal by a lesion of soft tissue density in the left mastoid cells. At surgery, cholesteatoma was observed in the mastoid cavity. Although destruction of the posterior wall of the external auditory canal was identified, the external auditory canal skin and tympanic membrane were intact, and the aditus ad antrum mucosa was normal. Congenital cholesteatoma isolated to the mastoid was diagnosed. Diagnosis of congenital cholesteatoma isolated to the mastoid should be based on clinical examination, radiological evaluation, and surgical findings. In addition, the possibility of congenital cholesteatoma isolated to the mastoid should be considered in patients with stricture of the external auditory canal.     

外耳道胆脂瘤侵蚀乳突(附3例报告)

目的 :提高临床对外耳道胆脂瘤 (EACC)侵蚀乳突的认识。方法 :回顾性分析 3例EACC侵蚀乳突患者的临床资料。结果 :3例外耳道后壁破坏 ,并有外耳道后壁 乳突腔瘘形成 ;2例面神经骨管破坏 ,面神经及迷路完整 ;经手术治疗 ,随访 6个月～ 9年 ,无复发迹象。结论 :临床上易将外耳道栓塞性角化病 (KO)误诊为EACC ;EACC侵蚀乳突者临床并不多见 ;治疗原则是彻底清除胆脂瘤和死骨 ,并根据病变程度决定手术方式。     

Relationships between facial canal dehiscence and other intraoperative findings in chronic otitis media with cholesteatoma

ObjectiveWe investigated the relationship between facial canal dehiscence and intraoperative middle ear and mastoid findings in patients operated on for cholesteatoma.MethodsWe examined retrospectively 334 patients who had been operated on for cholesteatoma in Izmir Katip Celebi University, Ataturk Research and Training Hospital, ENT Clinic, between April 1997 and April 2010. The patients were examined for facial canal dehiscence according to age, gender, side of the ear, surgery type, first or revision surgery, localization of the facial canal dehiscence, spread of the cholesteatoma, with the presence of lateral semi-circular canal (LSCC) fistula and any defect in the ossicle chain, and destruction in the posterior wall of the external auditory canal(EAC).ResultsOf the patients, 23.6% had facial canal dehiscence and detected most commonly in the right ear 28.9% and tympanic segment, 83.5%. Facial canal dehiscence was found to be 24.2-fold more common in patients with LSCC fistula and 4.1-fold more common in patients with destruction in the posterior wall of the (EAC). In patients located cholesteatoma in tympanic cavity + antrum and the tympanic cavity + all mastoid cells and with incus and stapes defect, increased incidence of dehiscence. Age, first or revision operation and canal wall down tympanoplasty (CWDT) or canal wall up tympanoplasty (CWUT) did not affect the incidence of dehiscence.ConclusionsThat the likelihood of facial canal dehiscence occurrence is increased in patients with LSSC fistulas, destruction in the posterior wall of the EAC, or a stapes defect is important information for surgeons.     

Acute mastoid abscess and cholesteatoma

A 10-year review of acute mastoid abscess treated surgically in Belfast revealed a total of 24 cases, 12 of which were found to have an underlying cholesteatoma. The surgical management of these 12 cases is outlined but despite a desire to maintain an intact canal wall, 9 of them to date have ended up with an open cavity. The danger of conservative management and the possible association between acute mastoid abscess and cholesteatoma, especially in developed countries, is stressed.     

Dilute vinegar therapy for the management of spontaneous external auditory canal cholesteatoma

The purpose of this study is to evaluate the efficiency of conservative dilute vinegar therapy in the management of spontaneous external auditory canal cholesteatoma (EACC). From 2000 to 2007, 19 patients presented to our clinic with spontaneous EACC. EACC was divided into four grades based on the temporal bone computed tomography: grade I with flattening of bony external canal, grade II with partial destruction of inferior bony canal, grade III with total destruction of inferior bony canal and grade IV with bony destruction into the middle ear and mastoid cavity. Clinical findings and treatment results were recorded. Microscopic local cleansing and dilute vinegar therapy was conducted in the ears with grades I, II and III. Combined mastoid surgery and dilute vinegar therapy was conducted in four ears with stage IV. There were no recurrences after average of 31 months follow-up. Spontaneous EACC can be effectively controlled with dilute vinegar therapy after microscopic local cleansing. However, surgery must be considered in the cases which have involved the mastoid and middle ear. Dilute vinegar therapy in combination with microscopic local cleansing was effective in the management of spontaneous EACC. Dilute vinegar therapy is an easy, cost-effective, and home-based cleansing method to prevent EACC and promotes healing. However, long-term follow-up may reveal frequent recurrence of cholesteatoma debris and involvement of middle ear or mastoid cavity, and then meticulous debridement with skin graft or surgical intervention should be considered.     

Primary cholesteatoma of the mastoid presenting as cervical abscess

Primary cholesteatoma has been described in a number of sites within the temporal bone. We report an unusual case of primary cholesteatoma, confined to the mastoid, presenting with Bezold's abscess of the anterior cervical triangle, in an otherwise asymptomatic elderly man with normal hearing.     

侵及鼓室、乳突的外耳道胆脂瘤诊断和治疗

目的探讨侵及鼓室、乳突的外耳道胆脂瘤的临床表现、影像特点及其手术治疗方法.方法回顾性分析我科1998～2003年收治的侵及鼓室、乳突的外耳道胆脂瘤14例患者的临床资料.结果14例患者病变均不同程度破坏外耳道四壁并向后扩展至乳突腔.其中4例鼓膜松弛部穿孔,胆脂瘤侵入鼓室,听骨链受压、内移,或不同程度破坏.3例面神经垂直段骨质破坏.1例乳突广泛破坏,硬脑膜裸露.1例先天畸形外耳道狭窄.根据病变的范围,8例行改良乳突根治术,5例行开放式乳突根治术,1例行外耳道扩大成形术.10例听骨链未受累的,术后听力恢复正常,1例听骨链受压变形、移位,术后仍达到正常听力.3例听骨链中断,行听骨链重建术,语言频率气导平均听阈提高15 dB～20 dB.14例患者随访18个月至5年未见复发.结论外耳道胆脂瘤的病因目前尚不十分清楚.侵及鼓室乳突者临床表现不典型,诊断有一定难度,术前常规高分辨颞骨CT扫描,有助于原发部位的判断及确定病变范围,以选择合适的手术方式.     

外耳道胆脂瘤并发化脓性腮腺炎1例并文献复习

目的 探讨外耳道胆脂瘤并发化脓性腮腺炎病因及诊治经验,并进行外耳道胆脂瘤诊疗相关文献复习。 方法 回顾性分析1例外耳道胆脂瘤并发化脓性腮腺炎病例资料,主要症状为左耳听力下降伴流脓,左侧面部红肿疼痛。颞骨CT及耳部核磁示:左侧外耳道内胆脂瘤形成,累及乳突、鼓室、鼓窦、腮腺及咽旁间隙。临床诊断:外耳道胆脂瘤(左,Holt Ⅲ期)、化脓性腮腺炎(左)。手术方式为左耳外耳道胆脂瘤切除术、开放式乳突根治术、鼓室成形术、人工听骨植入术、耳甲腔成形术、腮腺脓肿清除术及腮腺瘘修补术。 结果 术中彻底清除外耳道及中耳内胆脂瘤及腮腺脓肿,并修复腮腺瘘。术后随访患者恢复良好,无胆脂瘤复发残留及腮腺炎复发相关症状出现。 结论 外耳道胆脂瘤具有骨质破坏的潜能。而HoltⅢ期外耳道胆脂瘤并发化脓性腮腺炎病例罕见,明确病因并依据病变侵袭范围选择个体化的治疗方案尤为关键。     

Two cases of intratemporal facial nerve neurilemmomas

The patients with neurilemmomas of the facial nerve within the temporal bone were treated. Although most of cases of the facial nerve neurilemmoma in the temporal bone present with a facial palsy, a few cases have normal facial nerve function and are especially difficult to diagnose preoperatively because of few symptoms. Case 1, a 31-year-old man, developed progressive left facial palsy with protrusion of the posterior wall of the external auditory meatus over a five-month period. Case 2, a 64-year-old man, complained of only fullness and tinnitus of the right ear without any facial nerve symptoms. Polytomography of the temporal bone demonstrated no abnormal findings in both cases. However, computed tomography revealed a soft-tissue density area in the left mastoid cavity with destruction of the posterior wall of the external auditory meatus in case 1. A similar soft-tissue density mass was found in the right tympanic cavity in case 2, suggesting the presence of the tumor in the temporal bone. At operation, the tumors were found to originate from the vertical portion of the facial nerve in both cases. It was assumed that normally existing dehiscences of fallopian canal might account for why some patients have normal facial nerve function.     

Tympanoplasty with mastoid obliteration using hydroxyapatite granules for aural cholesteatoma--a clinical and experimental study]

Hydroxyapatite granules were employed for mastoid obliteration in cases of aural cholesteatoma. After eradicating a cholesteatoma by the canal-down technique, the canal wall was reconstructed with cortical bone chips, and the mastoid cavity was obliterated with hydroxyapatite granules. Tympanoplasty by this technique was performed on 48 ears with aural cholesteatoma. There was no recurrence of cholesteatoma during the follow-up period of two years after surgery. One case of residual cholesteatoma was found in the mesotympanum. There were two cases in which the hydroxyapatite granules became exposed through the posterior canal skin. An air-bone gap of less than 20 dB was achieved in 73% of all the patients. Experimental studies in guinea pigs have demonstrated that hydroxyapatite granules do not undergo morphological changes in and are tightly interdigitated with newly formed bone tissue growing from bulla bone one year after hydroxyapatite implantation in the temporal bullae. The newly-formed bone showed incomplete osteon structures. Excellent biocompatibility and bone adaptability of hydroxyapatite granules were demonstrated experimentally. It is concluded that tympanoplasty with mastoid obliteration using hydroxyapatite is safe and useful for avoiding mastoid cavity problems and for preventing the recurrence of cholesteatoma.     

Conservative tympanomastoidectomy

The objectives of tympanomastoid surgery are elimination of irreversible middle ear and mastoid disease, usually cholesteatoma, and maintenance or restoration of serviceable unaided hearing. There are a surprising number of techniques described in the literature but in essence they break down into two schools of thought, those who favor an intact posterior canal wall technique in most cases and those who feel that the possibly improved hearing results obtained with an intact posterior canal wall technique do not warrant the additional risks involved. Sheehy recently has reported an incidence of 35 percent persistence or regrowth of cholesteatoma found in mastoid re-explorations following the intact posterior canal wall technique for management of epitympanic and mastoid cholesteatoma. We believe there are excellent reasons for removing the posterior canal wall routinely in dealing with mastoid cholesteatoma. This technique is far superior in obtaining permanent control of the disease process, usually results in a small trouble-free mastoid cavity, and does not seriously interfere with reconstruction of a serviceable sound conducting mechanism in the majority of cases. In analyzing the results of 100 consecutive mastoid operations for the period from 1970 through 1972, it was possible to maintain or reconstruct the sound conducting mechanism in 94 percent. In those cases which had preoperative bone conduction of 35 db ISO or better for the speech frequencies, the type and percentage hearing results obtained are presented. Endaural modified radical mastoidectomy combined with tympanoplastic repair at the time of definitive surgery permits maximum visualization of the middle ear space. Because most mastoids which harbor cholesteatoma are sclerotic, small trouble-free mastoid cavities result from this type of surgery and the open mastoid technique offers the best prospects to the patient for obtaining a dry safe ear without danger of persistent or recurrent cholesteatoma in the mastoid segment. It does not seriously preclude tympanoplastic reconstruction of a functioning sound conduction mechanism. When feasible, tympanoplastic repair should be done at the same time definitive mastoid surgery is done. This can usually be accomplished in one brief hospitalization and a minimum of postoperative visits to the physician's office.     

Pediatric external canal cholesteatoma with extensive invasion into the mastoid cavity

Cholesteatoma in the external auditory canal (EAC) is an uncommon situation, and is especially rare in pediatric patients. We report two pediatric cases of external canal cholesteatoma with extensive invasion into mastoid cavity. Both cases had otalgia and poor hearing as the initial symptoms, and received operation according to the extent of the lesions. Since external canal cholesteatoma with extensive invasion into the mastoid cavity has the propensity to involve the vertical segment of the facial nerve, extreme care should be taken when performing any procedure in this area. Through thorough pre-operative evaluation and adequate surgical procedures, good outcomes can be achieved and hearing as well as facial nerve function can be preserved.     

Otogenic facial paralysis

Summary The histopathological changes of the facial canal and nerve in facial paralysis due to chronic suppurative otitis madia are described in six temporal bones. Bony destruction of the facial canal was found in its tympanic segment and in its upper mastoid part in all cases, but it was particularly notable in the labyrinthine segment as well. The pathological process, cholesteatoma or granulation tissue surrounding the exposed facial nerve was inflamed in all cases. The affected facial nerve showed degenerative and inflammatory changes throughout its tympanic segment in all cases, but its mastoid segment appeared to be relatively normal. Our findings suggest that facial paralysis occurs us chronic suppurative otitis when the inflammatory process specifically involves the facial nerve trunk.     

Sinus tympani in surgery of the middle ear and skull base

Tympanic sinus is located at the medial wall of the tympanic cavity. It's visualisation is difficult from most of approaches. Tympanic sinus is often filled with cholesteatoma in course of chronic otitis. Intraoperative assessment of tympanic sinus was performed in 29 patients with facial recess cholesteatoma, and in 20 patients with acoustic neuroma operated with translabyrinthine approach. In the group of patients with cholesteatoma four patients underwent canal wall up tympanoplasty with posterior tympanotomy, 25 underwent canal wall down tympanoplasty. Tympanic sinus was assessed during surgery with 30 degrees endoscope. In all cases depth of the sinus was measured with the use of calibrated hook. In 11 patients depth of the sinus exceeded 4 mm. In 6 among these features of bone destruction was found.     

Can recurrent cholesteatoma be avoided?*

After closed operation techniques recurrences of cholesteatoma are often caused by retraction of squamous epithelium under the bony annulus, under which it spreads into the attic or the mastoid cavity. Consequently, retractions under the bony annulus can be avoided, if the annulus is removed. An endaural operation technique is described in which the superior and posterior bony ear canal wall is completely removed and the posterior wall is reconstructed by means of a meatal skin flap. As the oval window is often partly hidden by the frame of the tympanic membrane it is more favourable for the restoration of the sound conducting mechanism if the frame and surface of the tympanic membrane are extended backwards. This can be done by repositioning the posterior cutaneous ear canal wall and grafting the tympanic membrane with fascia. By doing this, the attic is incorporated into the ear canal. Should the factors which originally induced the development of the cholesteatoma remain effective and cause a new retraction, the full breadth of the posterior ear canal skin will retract into the exenterated mastoid cavity. An easily accesible open cavity and not a recurrence will be the result. In a follow-up study of 112 patients it was found that 67 of them had developed such an open cavity, which caused no serious problems.     

Echinococcosis presenting as an otogenic brain abscess: an unusual lesion of the middle ear cleft and temporal lobe

This paper presents a case of a 28-year-old male with a seizure episode and a 4-year history of intermittent tinnitus on the left ear. On computed tomography and magnetic resonance imaging, a density with rim enhancement was found at the temporal lobe, associated with mastoid tegmen destruction and middle ear mass, indicating cholesteatoma with complicating brain abscess. Evacuation of the brain abscess was performed with a combined otolaryngologic and neurosurgical procedures (canal wall-down mastoidectomy and temporal craniotomy). The pathology turned out to be infestation with Echinococcus granulosus.     

Bezold's abscess following chronic mastoiditis in a newborn

Despite the availability of antibiotics, acute otitis media can still lead to major complications. Bezold's abscesses are very rare complications and are usually found only in adults with well-pneumatized mastoid bones. We present the case of a 10-week-old newborn with a Bezold's abscess. It is stressed that acute otitis media can be silent and undetected in infants and can lead to major complications such as Bezold's abscess.     

Fibrous dysplasia of the temporal bone

A 38-year-old woman with fibrous dysplasia of the entire right half of the mandible and the right temporal bone is presented. She had a unilateral progressive conductive hearing loss and stenosis of the auditory canal complicated by a chronic external otitis, a hidden cholesteatoma, destruction of the ossicles and an impending facial palsy. Surgery was performed to create a new auditory canal, to eradicate the cholesteatoma and to decompress the facial nerve from the surrounding fibrous dysplasia.