Keratosis obturans and external ear canal cholesteatoma: how and why we should distinguish between these conditions

Keratosis obturans and external ear canal cholesteatomas have been considered as separate entities for the last 20 years, after being regarded as variations of the same disease for at least 87 years. While both disorders are distinct, they do have some overlapping characteristics which may make it difficult to reach a definite diagnosis. This review explores the diagnostic dilemmas which may arise, and discusses the classification, aetiology, pathogenesis and management of these conditions. We concur that external ear canal cholesteatoma and keratosis obturans are different conditions and conclude that the presence of osteonecrosis and focal overlying epithelial loss are the most reliable features favouring the diagnosis of external ear canal cholesteatoma over keratosis obturans. Furthermore, whilst keratosis obturans can be managed successfully by regular aural toilet, external ear canal cholesteatoma may require surgical intervention depending on the extent of the disease.     

Middle ear foreign body causing cholesteatoma and external auditory canal granuloma: a case report

Objective Patients with unilateral ear discharge and hearing loss often have external or middle ear diseases. We present a 55-year-old man who suffered from persistent ear discharge and hearing loss in the left ear. Local findings showed that his left ear canal was filled with a large amount of granulation tissue, with purulent, foul-smelling discharge. Computed tomography indicated left middle ear cholesteatoma and mass shadow in the left external auditory canal. Modified radical mastoidectomy was performed. A piece of white plastic stick was found in the middle ear during the operation. Foreign body-induced cholesteatoma and external auditory canal granuloma in adults are very rare. We present this rare case so that these conditions can be better recognized and understood.     

先天性中耳畸形——听骨链畸形的治疗最新进展

先天性中耳畸形作为一种先天性疾病,是由第一咽囊发育障碍所致,可以与外耳畸形及内耳畸形相伴,也可以单独出现.中耳畸形中最主要的是听骨链畸形,主要表现为单侧或双侧传导性听力损失.存在听力损失的中耳畸形患者需要通过手术重建听力,传统的手术方式为外耳道和鼓室成形术,近十几年来,新的人工听觉植入技术不断兴起,为先天性中耳畸形患者...     

Keratosis obturans of the external auditory canal

Keratosis obturans is a rare condition of the bony part of external ear canal cased by hyperkeratosis of epiderm and disorders of migration process. Hyper-cumulation of desquamated epiderm in the external ear canal leads to hearing loss, earache and inflammation of ear canal skin. We present 2 cases of keratosis obturans as examples of epiderm migration disorders and difficulties in diagnosis and treatment of this disease. Keratosis obturans was diagnosed in both cases in histopathological and immunohistochemical examinations. Histopathological and molecular structure of keratosis obturans was discussed. In presented cases surgical, anti-inflammatory and keratinolytic treatment was applyied.     

Cholesteatoma of the external auditory canal and keratosis obturans

Keratosis obturans and external auditory canal cholesteatoma have often been regarded as a single entity. However, these are two distinct disorders with their own clinical presentations, physical and pathologic findings, and treatment. Keratosis obturans is an accumulation of obstructive desquamated keratin in the external auditory meatus. External auditory canal cholesteatoma is an invasion and erosion of squamous epithelium into a localized area of the bony ear canal. The origin of both entities remains obscure. The clinical symptoms, pathologic processes, and treatment are outlined and compared. Case reports are presented to illustrate the features of these two diseases.     

Thickness of the migratory epithelium of the external auditory canal

The migratory epithelium of the external ear has been the object of much study, and it has long been presumed to thicken in abnormal conditions of the external ear. In this study, normal values have been established for the thickness of the epithelium at various sites on horizontally sectioned normal temporal bones. Three sites, the umbo, the anterior annulus, and the posterior annulus are shown to have statistically significant thickening when compared with other contiguous sites on the same section. A study of temporal bones with various abnormalities of both external and middle ear showed a statistically significant thickening of the epithelium when compared with the normal bones. This difference was particularly marked at the umbo, anterior annulus, and posterior annulus. This would imply that these thickened areas may represent growth centers in the epithelium of the external ear.     

先天性外中耳畸形对儿童患者心理状况的影响

目的：本研究采用Achenbach儿童行为量表对先天性外中耳畸形患儿的心理状况进行测评,了解畸形对患儿心理有无影响及影响程度。方法：66例4~16岁先天性外中耳畸形患儿由家长根据其表现填写行为量表,计算心理行为异常检出率。同时收集一般资料、耳廓Marx分级,对患儿的心理异常检出率进行单因素及多因素分析。结果：外中耳畸形患儿心理异常检出率为21.21%,高于全国常模,差别有统计学意义。耳廓Marx分级及父母压力程度与心理异常检出率相关,多因素Logistic回归分析中Cox＆Snell系数为0.153。其中耳廓Marx分级Ⅲ级的患儿心理异常检出率高达36.4%,高于Ⅱ级畸形患儿。结论：先天性外中耳畸形这一事件对儿童患者心理确有影响,但仅是众多影响因素之一,其对患儿心理造成的影响在所有心理影响因素中的作用约占15%。但耳廓Marx分级Ⅲ级的患者是发生心理异常的高危人群。     

Otorhinolaryngologische Erkrankungen beim Tauchen

The number of Germans practicing sea diving has grown, so doctors are increasingly confronted with questions pertaining to diving. They concern not only patient fitness but also prevention and therapy of associated disorders and disease. This article describes predisposing factors and otologic, rhinologic, and laryngologic problems associated with diving. The most common medical problem is inflammation of the external auditory canal; the most common -Barotrauma is to the middle ear. Case studies are used to demonstrate these and other disorders associated with diving.     

The surgical technique for implantation of the temporal bone stimulator (Audiant ABC)

Microsurgical techniques and modern hearing aids are very limited in providing hearing improvement to patients with a vast number of middle ear and external ear canal conditions. A new electromagnetic temporal bone stimulator (TBS), capable of direct stimulation of the cochlea, has been developed. Nothing is placed in the external ear canal. The internal portion of the device is placed in the mastoid portion of the temporal bone, thus completely bypassing the external canal, the ossicles, and the middle ear. This provides stimulation to the inner ear regardless of the condition of the external canal and the middle ear. Unilateral hearing losses may also be benefited by transfer of energy to the opposite ear. Selection of patients, the surgical technique, and the instrumental armamentarium are discussed. The pitfalls and expected results are described.     

Otorhinolaryngologic disorders associated with diving

The number of Germans practicing sea diving has grown, so doctors are increasingly confronted with questions pertaining to diving. They concern not only patient fitness but also prevention and therapy of associated disorders and disease. This article describes predisposing factors and otologic, rhinologic, and laryngologic problems associated with diving. The most common medical problem is inflammation of the external auditory canal; the most common -Barotrauma is to the middle ear. Case studies are used to demonstrate these and other disorders associated with diving.     

Autoimmunity in otology

Experimental and clinical studies over the past ten years have confirmed that immune-mediated disease can involve the external, middle, and/or inner ear. Autoimmune inner ear dysfunction can result from systemic or localized disease. The pathogenesis of autoimmunity and the responsible antigen(s) of the inner ear is not known at present. The clinical course, laboratory test results, and treatment response often follow a consistent pattern but in some cases may be highly variable. Empirical treatment of autoimmune inner ear disease has produced encouraging preliminary results, and further research should provide better understanding of these otoimmune disorders.     

Conductive hearing loss: investigation of possible inner ear origin in three cases studies

This is a report of three cases of mixed hearing loss that resulted from inner ear disorders. Two cases were unilateral and the third was bilateral. The diagnosis was based on the findings of normal middle and external ears in association with the absence of round window reflexes. The contralateral stapedial reflex was present in the two unilateral cases. This is the first documentation of conductive deafness due to inner ear abnormality. This diagnosis should be considered in cases of conductive hearing loss if the middle and external ears are normal. More studies are needed to establish the pathophysiology of this entity.     

中耳肌肉生理及病理

中耳肌肉是耳部“降噪系统”中最为关键的部分,其在持续监测声学输入和动态调节听觉灵敏度方面发挥着重要的保护作用。当中耳肌肉收缩时, 它们将镫骨推入卵圆窗, 并增加内耳膜迷路内液体的压力。如果中耳肌肉失去调节内耳压力的能力, 如强直、痉挛或肌张力障碍, 产生的异常压力将对内耳压力产生影响, 并导致许多问题, 如耳鸣、梅尼埃病和感音神经性听力损失等。综述中耳肌肉的生理构造及各自所起的作用,讨论中耳肌肉功能紊乱与耳部疾病的联系。     

Conductive hearing loss caused by third-window lesions of the inner ear.

BACKGROUND: Various authors have described conductive hearing loss (CHL), defined as an air-bone gap on audiometry, in patients without obvious middle ear pathologic findings. Recent investigations have suggested that many of these cases are due to disorders of the inner ear, resulting in pathologic third windows. OBJECTIVE: To provide an overview of lesions of the inner ear resulting in a CHL due to a third-window mechanism. The mechanism of the CHL is explained along with a classification scheme for these disorders. We also discuss methods for diagnosis of these disorders. DATA SOURCES: The data were compiled from a review of the literature and recent published research on middle and inner ear mechanics from our laboratory. CONCLUSION: A number of disparate disorders affecting the labyrinth can produce CHL by acting as a pathologic third window in the inner ear. The common denominator is that these conditions result in a mobile window on the scala vestibuli side of the cochlear partition. The CHL results by the dual mechanism of worsening of air conduction thresholds and improvement of bone conduction thresholds. Such lesions may be anatomically discrete or diffuse. Anatomically discrete lesions may be classified by location: semicircular canals (superior, lateral, or posterior canal dehiscence), bony vestibule (large vestibular aqueduct syndrome, other inner ear malformations), or the cochlea (carotid-cochlear dehiscence, X-linked deafness with stapes gusher, etc.). An example of an anatomically diffuse lesion is Paget disease, which may behave as a distributed or diffuse third window. Third-window lesions should be considered in the differential diagnosis of CHL in patients with an intact tympanic membrane and an aerated, otherwise healthy, middle ear. Clues to suspect such a lesion include a low-frequency air-bone gap with supranormal thresholds for bone conduction, and presence of acoustic reflexes, vestibular evoked myogenic responses, or otoacoustic emission responses despite the CHL. Imaging studies can help confirm the diagnosis.     

Myringitis: An update

Myringitis can be acute or chronic. Though they commonly present with ear discharge with or without pain, the etiology and the management principles differ. Granular myringitis generally is an external ear pathology extending to tympanic membrane and present as painless otorrhea, whereas the bullous myringitis is commonly associated with acute inflammation of middle ear cleft and present with severe ear pain. This literature review discusses the clinical as well as the therapeutic aspects of these inflammatory conditions.     

Chronic otitis media surgery and re-operation risk factor analysis: A nationwide retrospective cohort study of 18 895 patients

Conclusion: Patients with risk factors including younger age, mastoiditis, external ear disease, treatment by older surgeons, and concomitant mastoidectomy should receive detailed management to minimize the probability of re-operation for chronic otitis media (COM).

Objectives: Although COM remains a common ear disease requiring surgical intervention, its re-operation risks are less well-documented. This study aimed to compare patients with COM who underwent re-operation and those patients with no re-operation, and identify the risks of re-operation.

Method: This retrospective cohort study analyzed the trend of COM surgery from 1999–2009, and identified the re-operation risks of 18 895 patients with COM who underwent surgery from 2002–2006 using the National Health Insurance Research Database in Taiwan.

Results: Among the study population, 129 patients underwent revision surgery during a 5.5?±?1.5 year follow-up period. A univariate logistic regression analysis showed that the re-operation rate was significantly higher in patients under 18 years of age, those with mastoiditis, disorders of external ear, treatment by surgeons of 50–64 years of age, use of a very high volume surgeon, and combined surgery with mastoidectomy. A multivariate analysis further limited the re-operation risk factors to younger patients, those with mastoiditis, external ear disorders, treatment by older surgeons, and concomitant mastoidectomy.     

Otoacoustic emissions]

Spontaneous sound signals emitted from the inner ear were first recorded by Kumpf and Hoke in 1970. Kemp reported phenomena of sounds which were emitted by the ear responding to acoustic stimulation. These "otoacoustic emissions" are supposed to be generated in the outer hair cells. Active contractions of the actin and myosin in these cells produce a frequency specific cochlear amplifier mechanism. Although the clinical value of spontaneous otoacoustic emissions is yet unclear, as well as role in tinnitus, the recording of click-evoked otoacoustic emissions has now become diagnostic routine. Click-evoked otoacoustic emissions cannot be recorded in ears with cochlear mid-frequency hearing losses > or = 25 dB. However, the use of sinus tones or distortion products as stimuli promises more frequency-specific results. Most important for the quality of measurement is complete closure of the external ear canal, correct positioning of the recording probe, maximal suppression of background noise and sufficient compliance of the patient, especially when testing children. Middle ear effusions also prevent recording. Responses to a standard of 260 stimulations are averaged and identified as "true" emissions by their sufficient reproducibility and characteristic pattern in frequency analysis. Currently, the recording of click-evoked otoacoustic emissions can be used to detect early discrete lesions of the outer hair cells. Their use as a screening tool concerning cochlear hearing disorders is already possible in newborn children. Isolated central hearing disorders still cannot be detected by this diagnostic procedure.     

External granulation otitis

The authors repot two cases of successful treatment of external granulation otitis. Taken together, the difficulties encountered in diagnostics of this condition, concomitant disorders aggravating pathological changes in the ear, and the malignant clinical course of the disease hamper the adequate management of external granulation otitis.     

Surgery of the external ear canal

Diseases of the external ear canal are a frequent reason for consulting the otolaryngologist. Conservative treatment is sufficient in most cases. Chronic problems of the external ear canal, however, sometimes require surgical treatment. Enlargement of the external ear canal as well as the entrance of the external ear canal are often simultaneously performed together with tympanoplasties, in order to obtain good access to the middle ear and to facilitate postoperative care. In this review, we focus on surgical techniques for different pathologies such as exostosis, stenosis, fibrosis, and tumors of the external ear canal.