Esophageal motor function in laryngopharyngeal reflux is superior to that in classic gastroesophageal reflux disease.

Laryngopharyngeal reflux (LPR) in otolaryngology patients appears to be different from classic gastroesophageal reflux disease (GERD). In particular, esophagitis and its principal symptom, heartburn, considered the diagnostic sine qua non of GERD, are often absent in LPR. It has therefore been postulated that LPR patients have superior esophageal function. Esophageal acid clearance (EAC) is a measure of the ability of the esophagus to restore neutral pH after reflux events have occurred. It is considered an excellent overall measure of esophageal function. The mean EAC can be calculated from 24-hour pH monitoring data. A comparison of EAC in patients with GERD and LPR has not been previously reported. To compare the EAC of 1) patients with LPR alone, 2) patients with GERD alone, 3) patients with both LPR and GERD, and 4) patients without either LPR or GERD, we studied 200 otolaryngological patients who had undergone 24-hour double-probe (simultaneous pharyngeal and distal esophageal) pH monitoring, 50 in each group. The subgrouping of each patient was determined by previously established pH monitoring criteria. We defined GERD as abnormal esophageal reflux and LPR as abnormal pharyngeal reflux. The patients with GERD had a mean (+/-SD) EAC of 1.44 +/- 1.2 minutes, and those with LPR had a mean EAC of 1.00 +/- 1.00 minutes (p < .05). The patients with both GERD and LPR had a mean EAC of 1.53 +/- 1.01 minutes. The patients without reflux had a mean EAC of 0.53 +/- 0.38 minutes. We conclude that patients with LPR have significantly better EAC than those with GERD. These data suggest that patients with LPR have superior esophageal function. This finding may clarify our understanding of the differences in mechanisms, symptoms, and incidence of esophagitis in patients with LPR and GERD.     

Morphological characteristics of external auditory canal in congenital aural stenosis patients

ObjectiveTo investigate characteristics of congenital aural stenosis (CAS) patients' external auditory canal (EAC) (position, length, orientation, etc.) and compare them with normal EAC.

Reconstruction of the external auditory canal using full-thickness rolled-up skin graft after lateral temporal bone resection for T1 and T2 external auditory canal cancer

ObjectiveTo present our results of the external auditory canal (EAC) reconstruction procedure using rolled-up full-thickness skin graft with tympanoplasty after lateral temporal bone resection (LTBR) for early-stage EAC carcinoma.Patients and MethodsA retrospective review of 15 patients who had undergone LTBR with reconstruction of the EAC for T1 and T2 EAC cancer between 2016 and 2020.ResultsPostoperative mean air-bone gap was 30.7 decibel hearing level. Although a few patients experienced chronic granulation, persistent otorrhea, and/or laterization of the tympanic membrane, most patients showed no serious complications related to the EAC reconstruction.ConclusionEAC reconstruction using a full-thickness skin graft in combination with tympanoplasty is useful for minimizing the hearing loss, maintaining the cosmetic appearance, and facilitating the observation into the ear cavity.     

Bilateral external auditory canal squamous cell carcinoma: a case report

Squamous cell carcinoma (SCC) of the external auditory canal (EAC) is an extremely rare malignant tumor with a prevalance between 1 and 6 cases per 1 million population. The incidence is higher in patients presenting with otological diseases (1 in 5,000 to 15,000). Certain associating factors have been described in the literature. This malignancy frequently presents with symptoms similar to a case of otitis externa or a chronic suppurative otitis media. In this paper, we present a patient who had bilateral SCC of EAC caused by radiotherapy for nasopharyngeal carcinoma. To our knowledge, our case is the fifth bilateral SCC of the EAC and the first bilateral radiotherapy related SCC of the EAC reported in the literature so far.     

Quantity of aerobic bacteria in the bony portion of the external auditory canal of children

OBJECTIVE: the human external auditory canal (EAC) hosts a commensal bacterial flora of mainly non-pathogens, but bacterial pathogens may also be present. The latter are important in the aetiopathogenesis of external otitis and middle ear cholesteatoma with discharge. The purpose of this study was to quantify the bacteria normally harboured in the healthy EAC and on a well-defined region of the cavum conchae (CC) of children. METHODS: bacterial samples were collected from the CC and bony portion of the EAC of 32 children (18 boys, 14 girls; median age 5 years). Prior to sampling, the EACs were either left untreated, anaesthetized with Bonain's solution, or washed with 70% alcoholic solution. The samples were incubated at 37 degrees C and evaluated regarding bacterial species and number. RESULTS: the predominant bacterial non-pathogens were coagulase-negative Staphylococci and coryneforms (diphtheroids) and pathogens Staphylococcus aureus and Pseudomonas aeruginosa. Total bacterial counts of the CC ranged between 2 x 10(3) and 4.6 x 10(4) CFU/cm(2) (median value 7 x 10(3); n = 14). Total bacterial counts from the bony portion of the EAC ranged between 0 and 5.7 x 10(7) CFU/EAC (median value 8 x 10(3); n = 32). Pre-treatment of the EACs with Bonain's solution containing the highly bactericidal substance phenol or with 70% alcoholic solution did not sterilize the EAC. CONCLUSIONS: small numbers of bacterial non-pathogens (and sometimes pathogens) are found in the EAC of children. Neither phenol nor 70% alcoholic solution can inhibit or eradicate all these microorganisms.     

The role of the external auditory canal in the development of the malleal manubrium in humans

OBJECTIVE: To determine if the external auditory canal (EAC) plays a role in the induction and proper positioning of the malleal manubrium in humans. STUDY DESIGN: Retrospective study between 1994 and 2002. SETTING: Academic, tertiary care referral medical center.Patients Fifty-five ears of 50 patients with congenital atresia (n = 47) or stenosis (n = 8) of the EAC, for which meatoplasty was performed at the University hospital between 1994 and 2002. MAIN OUTCOME MEASURES: The presence of the manubrium was examined during surgery, and the corre-lation between the presence of the manubrium and the grade of the microtia was evaluated. RESULTS: The manubrium was identified in all ears with EAC stenosis, whereas it was absent in all ears with EAC atresia. No correlation was observed between manubrium formation and auricular deformity. CONCLUSIONS: Our results demonstrated a close relationship between the formation of the EAC and that of the malleal manubrium in humans. This is consistent with the recent findings in knockout mice. This information is useful for surgical intervention in cases of congenital EAC anomalies.     

Presence of hBD-1 and hBD-2 in human cerumen and external auditory canal skin

CONCLUSION: Human beta-defensin-1 (hBD-1) and human beta-defensin-2 (hBD-2) antimicrobial peptides present in the cerumen, which is composed of exfoliated epithelial keratin and gland secretion, might provide the first line of defense against microbes in external auditory canal (EAC) skin. OBJECTIVES: Cerumen (earwax) plays a primary role in protecting the EAC skin and tympanic membrane. Even though the protection by antimicrobial peptides present in the skin secretion has been well established, little is known about the intrinsic role of the peptides in the EAC skin and cerumen. The aim of this study was to examine the presence of important antimicrobial peptides, hBD-1 and hBD-2, in the cerumen and EAC skin. MATERIALS AND METHODS: Cerumen was collected from 20 healthy adults, and the EAC skins were obtained from 12 patients who underwent middle ear surgery with canaloplasty. The presence of hBD-1 and hBD-2 was analyzed using immunohistochemistry and Western blotting. RESULTS: In the immunohistochemical study of the EAC skin, expression of hBD-1 and hBD-2 was observed in both the epithelium and the glands. The presence of hBD-1 and hBD-2 peptides in the cerumen was confirmed by Western blotting.     

Spontaneous temporomandibular joint herniation into the external auditory canal: a case report and review of the literature

OBJECTIVES: Case report of a man presenting with spontaneous temporomandibular joint (TMJ) herniation into the external auditory canal (EAC). STUDY DESIGN: Case report and literature review. METHODS: A case report of a patient with spontaneous TMJ herniation into the EAC is presented. RESULTS: The patient was a 41-year-old man complaining of tinnitus in his right ear. Examination revealed that the anterior wall of the bony EAC moved backward when the patient's mouth was closed and forward when opened, causing the resultant discomfort. In this case, surgery was performed, resulting in a good outcome with no complications. Thirteen other cases of spontaneous TMJ herniation into the EAC were found in the literature. CONCLUSION: Few cases of spontaneous TMJ herniation into the EAC have been reported; however, if surgical treatment is desired, we should comply with the patient's request.     

The misdiagnosis of external auditory canal carcinoma

External auditory canal (EAC) carcinomas are frequently misdiagnosed. The aim of this study was to conduct a review of misdiagnosed cases and analyze the factors involved. This study was a retrospective assessment. Eighteen of 44 EAC carcinoma cases seen at the Eye and ENT Hospital were misdiagnosed. All medical records were retrospectively analyzed for the age, sex, presenting symptoms, type of misdiagnosis, computed tomographic (CT) or magnetic resonance imaging (MRI) findings, stage of the cancer, surgical approach, histopathological examination, adjunctive therapy (postoperative radiotherapy) and outcomes of treatment. Six cases were misdiagnosed as otitis media, five cases were misdiagnosed as otitis externa, and two cases were misdiagnosed as external auditory canal cholesteatomas. Other misdiagnoses were stenosis of the EAC, ear neuralgia, furuncle of the EAC, benign neoplasm of the EAC and pre-auricular fistula. Our analyses suggest that a biopsy should be conducted to obtain a histopathological diagnosis if an EAC carcinoma is suspected, in case otitis media or otitis externa does not respond to routine anti-bacterials. Head and neck MRI should be used to explore the involvement of soft tissues. Patients with bloody ear discharge and otalgia, particularly with temporal bone erosion seen in a CT scan, are highly likely to have a malignant carcinoma of the temporal bone.     

Pseudoepitheliomatous Hyperplasia Versus Squamous Cell Carcinoma of the External Auditory Canal

Four case reports are presented to demonstrate the clinical and histopathologic similarity of pseudoepitheliomatous hyperplasia (PH) to squamous cell carcinoma (SCC) in the external auditory canal (EAC). In all four cases the original report of SCC on a biopsy specimen of an EAC lesion was corrected on review to PH. In one patient conservative management resulted in resolution of the EAC lesion. A second patient underwent radiation therapy and partial temporal bone resection with no SCC found in the surgical specimen. A third patient's ear canal had healed with conservative treatment and repeated biopsy revealed no malignancy. After a 6-year symptom-free interval, she developed invasive SCC with bone involvement that required surgery and radiation treatment. A fourth patient underwent a sleeve resection of the skin of the EAC that proved to be PH, and no evidence of SCC was found. A thoughtful clinical history, careful physical examination, response to conservative treatment, and close communication with the pathologist should be exercised in the evaluation of EAC lesions.     

The use of a custom earmold to prevent recurrent external auditory canal stenosis

The treatment of external auditory canal (EAC) stenoses often requires the prolonged use of a stent or splint. Traditional stents often occlude the EAC, resulting in a temporary conductive hearing loss. This case report describes a custom canal earmold with a large bore used as a stent in a patient with EAC stenosis. The customized earmold stent successfully prevented restenosis, while the large bore provided ventilation and improved hearing subjectively during the stenting phase.     

Comparative evaluation of Transient Evoked Oto-acoustic Emissions and Brainstem Evoked Response Audiometry as screening modality for hearing impairment in neonates

Objective This study was designed to evaluate Transient Evoked Oto-acoustic Emission (TEOAE) as screening modality for hearing impairment in neonates. Brainstem Evoked Response Auditometry (BERA) was used as gold standard diagnostic tool in this study. The factors affecting the specificity of TEOAE were also studied. Methods The study group of 200 randomly selected neonates was subjected to TEOAE and BERA (400 ears). Oto-endoscopy was done in all TEOAE failures and a repeat test was done after suction cleaning of blocked external auditory canal (EAC). Results Otoscopic evaluation of all 52 TEOAE failures was done. EAC obstruction was noticed in 31 ears and 4 ears showed collapsible EAC. TEOAE was repeated after suction cleaning of the obstructed EAC and using long probe tips for collapsible EAC. This improved the Pass rate of TEOAE from 87% to 92%. EAC obstruction and collapsible EAC were the two factors identified in this study that significantly affected the specificity of TEOAE as a screening test. Pass rate of TEOAE in <48 hrs age group was found to be 55.5%, which was nearly half of over-all pass rate. This was because of high prevalence of obstructed EAC in this age group. TEOAE was found to be a rapid screening tool as average time taken for BERA was 35 min/neonate and for TEOAE was 17.4 min/neonate. Acceptability of TEOAE was found to be higher as compared to BERA. Conclusions TEOAE is a simple and rapid test with relatively higher acceptability. But, the low sensitivity and specificity are the main shortcomings that take away from TEOAE, the status of independent screening modality for hearing impairment in neonates. TEOAE cannot completely replace BERA as screening modality for hearing impairment in neonates, however can complement it.     

Presence of hBD-1 and hBD-2 in human cerumen and external auditory canal skin

Conclusion. Human β-defensin-1 (hBD-1) and human β-defensin-2 (hBD-2) antimicrobial peptides present in the cerumen, which is composed of exfoliated epithelial keratin and gland secretion, might provide the first line of defense against microbes in external auditory canal (EAC) skin. Objectives. Cerumen (earwax) plays a primary role in protecting the EAC skin and tympanic membrane. Even though the protection by antimicrobial peptides present in the skin secretion has been well established, little is known about the intrinsic role of the peptides in the EAC skin and cerumen. The aim of this study was to examine the presence of important antimicrobial peptides, hBD-1 and hBD-2, in the cerumen and EAC skin. Materials and methods. Cerumen was collected from 20 healthy adults, and the EAC skins were obtained from 12 patients who underwent middle ear surgery with canaloplasty. The presence of hBD-1 and hBD-2 was analyzed using immunohistochemistry and Western blotting. Results. In the immunohistochemical study of the EAC skin, expression of hBD-1 and hBD-2 was observed in both the epithelium and the glands. The presence of hBD-1 and hBD-2 peptides in the cerumen was confirmed by Western blotting.     

Anticipating real-ear insertion response using an external auditory canal model

ObjectivesThis study aimed to determine the acoustic characteristics of the external auditory canal (EAC) and predict the real-ear aided response (REAR) using an EAC model that includes the standing wave effect.MethodsThe EAC transfer function equations were derived by summing the incoming and outgoing waves. First, we investigated the real-ear unaided gain (REUG). Second, seven patients (eight ears) wearing hearing aids (HAs) were enrolled as subjects to examine the REAR. We conducted wideband tympanometry (WBT) to measure the absorbance, the frequency response at 65 dB (65dB-FR) of the HAs, and the measured REAR for an international speech test signal (ISTS) at 65 dB.ResultsThe EAC model that includes the standing-wave effect is considered to be valid from examination of the REUG. A significant correlation was found between the measured and calculated REARs at 900 Hz, 1000 Hz, 2000 Hz, and 3000 Hz in an uncorrelated test. A two-way analysis of variance (ANOVA) found significant differences in the 65dB-FR and the measured REARs at 800, 900, 1000, and 2000 Hz, but this difference disappeared after correction of the calculated acoustic characteristics of the EAC.ConclusionsBy measuring the WBT characteristics and correcting them with an EAC model, the in-situ REAR can be determined from the HA characteristics in the mid-frequency range. There is a risk of insufficient HA amplification in the mid-frequency range when no real-ear measurements are performed.     

Cavernous hemangioma of the tympanic membrane and external ear canal

OBJECTIVES: The aims of this study are to document the occurrence of a cavernous hemangioma of the tympanic membrane (TM) and external auditory canal (EAC) that invaded the middle ear spaces and to review the relevant literature. METHODS: The clinical presentation, imaging studies, operative report, and histologic findings of this new case of cavernous hemangioma are reviewed. RESULTS: A cavernous hemangioma of the TM and EAC involving the middle ear spaces was surgically excised without complications. The pulsatile tinnitus, which affected our patient at the same ear where the lesion was situated, disappeared after surgery. Our case represents the first documented cavernous hemangioma of the TM and EAC that invaded the middle ear spaces and the eighth case of cavernous hemangioma of the EAC/TM. Computed tomography is the method of choice in evaluating this lesion. CONCLUSIONS: Hemangiomas of the EAC and/or TM are extremely rare entities amenable to surgical excision. With magnetic resonance imaging, there is difficulty in defining the exact location of the tumor and degree of soft tissue involvement.     

Pleomorphic adenoma of the external auditory canal complicated by hearing loss secondary to chronic otitis media

Pleomorphic adenoma (PA) rarely occurs in the external auditory canal (EAC). A case of PA complicated with chronic otitis media is reported. The patient was a 36-year-old male who began to experience a hearing loss in the left ear in 1996. He sought medical attention only after ear pain developed in April 2003. At the initial examination, a tumor covered by smooth skin was seen filling the left EAC. Pure-tone audiometry showed residual hearing at low frequencies and scale-out across middle to high frequency range. The CT and MRI findings led to a diagnosis of a tumor of the left EAC complicated with an inflammatory middle-ear lesion. The tumor was excised en bloc with the overlying skin, and tympanoplasty was performed. The pathological diagnosis was PA of the left EAC and inflammatory granuloma of the middle ear.     

Resection of carcinoma of the external auditory canal in a patient with a high jugular bulb using temporal craniotomy

External auditory canal (EAC) carcinoma is a rare and unusual malignancy. The complex anatomy and relationship between the tumor and surrounding tissues in a limited space render it difficult to attain safe resection margins during surgery. A high jugular bulb (HJB) is one such anatomical variation that has important surgical implications that complicate the surgical procedure for EAC carcinoma. A 73-year-old woman presented with a 3-month history of right ear pain. Pathological findings and computed tomography (CT) revealed EAC carcinoma, which was expanding to the middle ear (ME). Although there was no cavity inside the ME, an HJB was detected. Surgical treatment using a temporal incision for temporal craniotomy achieved complete resection of the tumor and preserved facial nerve function. The patient recovered without complications and was discharged 17 days after the operation. Temporal incision and temporal craniotomy is a useful approach for EAC carcinoma with HJB.     

Microbiology of otorrhea in children with tympanostomy tubes: implications for therapy

OBJECTIVE: Based on the prevalence of children with tympanostomy tubes who develop otorrhea, an analysis was performed to identify specific prognostic indicators in this population to enable clinicians to determine the likelihood of specific pathogens and select the best empiric therapy. METHODS: Data from two multicenter clinical trials of ofloxacin otic solution 0.3% (OFLX) trials in pediatric patients 1-12 years of age were used to develop a statistical model to predict the likelihood of external auditory canal (EAC) or nasopharyngeal (NPG) pathogens. Data were available for 283 microbiologically evaluable patients. Potential indicators included subject age, season of enrollment, ear aspiration, cleaning, otorrhea, and granulation tissue. The model used a stepwise logistic regression analysis relating the occurrence of NPG or EAC pathogens to the potential prognostic indicators. RESULTS: Among the total study population, 42.8 and 61.5% had NPG and EAC pathogens, respectively; 10.6% had both. The most frequently isolated valid pathogens were Streptococcus pneumoniae and Haemophilus influenzae. Significant prognostic indicators for NPG pathogens were subject age, season of enrollment, and presence of ear odor. Although these indicators were similar for EAC and NPG pathogens, the correlation was reversed, i.e. older subjects had EAC pathogens, and younger ones (< 2 years) had NPG pathogens; EAC pathogens were associated with presence of ear odor and NPG pathogens, with absence of ear odor. CONCLUSIONS: A statistically and clinically valid model has been developed that has prognostic value for the clinician treating children with otorrhea and tympanostomy tubes and serves as an aid in the appropriate choice of empiric therapy.     

A case of compound nevus of the external auditory canal in a child

Compound nevus is one of the subtypes of melanocytic nevus. The occurrence of melanocytic nevus within the external auditory canal (EAC) is very uncommon. In the cases of melanocytic nevus of the EAC, intradermal nevus occurs most frequently between the fifth and seventh decades of life. Compound nevus of the EAC in preschool-aged child is extremely rare. In a 6 year old girl, a 4 mm size, dome shaped and pigmented mass arose from the inferior wall of the cartilaginous portion of the EAC. This mass was treated with excision and a defatting full thickness skin graft by the transmeatal approach. Histopathology confirmed a compound nevus.