Cholesteatoma of external ear - Clinicals, Diagnosis, and Management

Otorhinolaryngology

Clinicals - History

Fact Explanation
Introduction to the disease Cholesteatoma of external ear is a rare condition.Estimated incidence is about 1.2 per 1,000 among otological patients. disease may presents itself by an accumulation of epithelial debris in the ear canal.Most useful finding confirming an external ear canal cholesteatoma (EECC ) and differentiating it from keratosis obturans is focal osteonecrosis or the sequestration of bone lacking an epithelial covering.Based on pathogenetic theories there are classifications of EECC. One such classification is 1) primary EECC, 2) secondary EECC, and 3) cholesteatoma associated with congenital atresia of the ear canal.. Introduction to the disease
Cholesteatoma of external ear is a rare condition.Estimated incidence is about 1.2 per 1,000 among otological patients. disease may presents itself by an accumulation of epithelial debris in the ear canal.Most useful finding confirming an external ear canal cholesteatoma (EECC ) and differentiating it from keratosis obturans is focal osteonecrosis or the sequestration of bone lacking an epithelial covering.Based on pathogenetic theories there are classifications of EECC. One such classification is 1) primary EECC, 2) secondary EECC, and 3) cholesteatoma associated with congenital atresia of the ear canal..
Otorrhea Even some patients remain asymptomatic, one of the common presenting symptom EECC is otorrhea or so called ear discharge.. Otorrhea
Even some patients remain asymptomatic, one of the common presenting symptom EECC is otorrhea or so called ear discharge..
Otalgia It is also a common symptom. It is more vague or mild discomfort. But it also can be a chronic dull pain or a severe pain in some cases. Otalgia
It is also a common symptom. It is more vague or mild discomfort. But it also can be a chronic dull pain or a severe pain in some cases.
Fullnes It is a vague symptom. It is a subjective feeling in the ear canal which is neither otalgia nor occlusion.. Fullnes
It is a vague symptom. It is a subjective feeling in the ear canal which is neither otalgia nor occlusion..
Occlusion Found in some patients. It is a subjective feeling of having the ear canal occluded and frequently accompanied with conductive hearing loss.. Occlusion
Found in some patients. It is a subjective feeling of having the ear canal occluded and frequently accompanied with conductive hearing loss..
Tinnitus Tinnitus is ringing or humming of one or both ears without any stimulus. It is a manifestation of cholesteatoma of external ear.,. Tinnitus
Tinnitus is ringing or humming of one or both ears without any stimulus. It is a manifestation of cholesteatoma of external ear.,.
Hearing loss Some may present with conductive hearing loss. Most of the time it is due to occlusion of ear canal due to accumulation of debris. It is relieved following removal of debris. Hearing loss
Some may present with conductive hearing loss. Most of the time it is due to occlusion of ear canal due to accumulation of debris. It is relieved following removal of debris.
Vertigo Experienced by some patients. Extension of bony erosion with subsequent invasion of the adjacent structures of the temporal bone may leads to vertigo as well as facial nerve palsy.,. Vertigo
Experienced by some patients. Extension of bony erosion with subsequent invasion of the adjacent structures of the temporal bone may leads to vertigo as well as facial nerve palsy.,.
Disruption of balance Disruption of balance in the presence of a cholesteatoma raises the possibility of cholesteatoma is eroding the balance organs, which form part of the inner ear such as labyrinth.,. Disruption of balance
Disruption of balance in the presence of a cholesteatoma raises the possibility of cholesteatoma is eroding the balance organs, which form part of the inner ear such as labyrinth.,.
Mastoiditis and meningitis If left untreated,cholesteatoma will either grow or expand. It may further destructs the ear structures and leads to development of infections. In severe cases it may results mastoiditis or invasion of internal structures of the brain may result meningitis which may need urgent treatments.. Mastoiditis and meningitis
If left untreated,cholesteatoma will either grow or expand. It may further destructs the ear structures and leads to development of infections. In severe cases it may results mastoiditis or invasion of internal structures of the brain may result meningitis which may need urgent treatments..
History of surgery,recurrent inflammation and trauma Secondary EECC is found to be related to a variety of conditions mainly postoperative. Some of the other conditions are postinflammatory, recurrent inflammation, posttraumatic stenosis as well as atresia with ear canal obstruction.. History of surgery,recurrent inflammation and trauma
Secondary EECC is found to be related to a variety of conditions mainly postoperative. Some of the other conditions are postinflammatory, recurrent inflammation, posttraumatic stenosis as well as atresia with ear canal obstruction..
History of radiation therapy Radiation therapy incorporating the ear canal also found to be leads to EECC.. History of radiation therapy
Radiation therapy incorporating the ear canal also found to be leads to EECC..
Congenital abnormalities of the ear canal Studies found that cholesteatoma is also associated with congenital atresia of the ear canal.. Congenital abnormalities of the ear canal
Studies found that cholesteatoma is also associated with congenital atresia of the ear canal..
History of smoking Smoking also a contributory factor for this disease.Smoking induce hypoxia as well as tissue ischemia may predispose to above condition.. History of smoking
Smoking also a contributory factor for this disease.Smoking induce hypoxia as well as tissue ischemia may predispose to above condition..

Clinicals - Examination

Fact Explanation
Ear discharge Initial inspection may reveals ear canal full of discharge. Accumulation of debris can be seen.. A foul smelling discharge which contain blood is detected in case of associated infection.. Ear discharge
Initial inspection may reveals ear canal full of discharge. Accumulation of debris can be seen.. A foul smelling discharge which contain blood is detected in case of associated infection..
Swelling behind the ear Even though infective features can be seen seldom, some may present with pain and swelling behind the ear which may detect on examination, indicative of ongoing infection.. Swelling behind the ear
Even though infective features can be seen seldom, some may present with pain and swelling behind the ear which may detect on examination, indicative of ongoing infection..
Bony erosion Extension of bony erosion is seen in some cases. Invasion of the adjacent structures of the temporal bone such as mastoid bone, middle ear cavity as well as exposure of the temporomandibular joint can be identified. . Bony erosion
Extension of bony erosion is seen in some cases. Invasion of the adjacent structures of the temporal bone such as mastoid bone, middle ear cavity as well as exposure of the temporomandibular joint can be identified. .
Facial nerve palsy A rare presentation. Dehiscence of the facial nerve due to extension of bony erosion may leads to this manifestation.. Facial nerve palsy
A rare presentation. Dehiscence of the facial nerve due to extension of bony erosion may leads to this manifestation..
Hearing loss Examination of cranial nerves may reveals conductive hearing loss either due to accumulation of debris or ossicular disruption.. Hearing loss
Examination of cranial nerves may reveals conductive hearing loss either due to accumulation of debris or ossicular disruption..

Investigations - Diagnosis

Fact Explanation
CT scan Diagnosis is mainly clinical with the help of imaging, such as CT. Non contrast CT and HRCT also used. It will show hypodense areas in EAC and involvement of tympanic membrane, mastoid air cells as well extension to the middle ear structures. Not only diagnosis but also it may helpful to exclude most of other conditions mentioned under differential diagnosis.. CT scan
Diagnosis is mainly clinical with the help of imaging, such as CT. Non contrast CT and HRCT also used. It will show hypodense areas in EAC and involvement of tympanic membrane, mastoid air cells as well extension to the middle ear structures. Not only diagnosis but also it may helpful to exclude most of other conditions mentioned under differential diagnosis..
MRI Diffusion MRI imaging is found to be helped in tricky situations. EACC will show prompt diffusion restriction where it may helpful to differentiate from malignancy because malignant otitis externa does not show restriction on diffusion.. MRI
Diffusion MRI imaging is found to be helped in tricky situations. EACC will show prompt diffusion restriction where it may helpful to differentiate from malignancy because malignant otitis externa does not show restriction on diffusion..
Plain X ray Even it may play a minimum role due to the use of advance imaging such as CT and MRI, plain x ray may helpful in conditions where the disease associated with skull fractures.. Plain X ray
Even it may play a minimum role due to the use of advance imaging such as CT and MRI, plain x ray may helpful in conditions where the disease associated with skull fractures..
Audiometry Performed for hearing assessment since patients are complained of hearing loss.,. Audiometry
Performed for hearing assessment since patients are complained of hearing loss.,.
FBC Performed as a basic investigation to detect ongoing infection.. FBC
Performed as a basic investigation to detect ongoing infection..
ESR Also can performed as a baseline investigation in suspected cases of associated infection.. ESR
Also can performed as a baseline investigation in suspected cases of associated infection..

Investigations - Management

Fact Explanation
Full blood count (FBC) Carried out to detect Hb and platelet levels. It is performed to assess the fitness for surgery.,. Full blood count (FBC)
Carried out to detect Hb and platelet levels. It is performed to assess the fitness for surgery.,.
Fasting blood sugar (FBS) It is also performed to assess the fitness before surgery since it is done under GA to assess the blood glucose level .,. Fasting blood sugar (FBS)
It is also performed to assess the fitness before surgery since it is done under GA to assess the blood glucose level .,.
ESR Also perform as a routine investigation since recurrent inflammation and post inflammatory conditions act as an etiological factors for the disease. . ESR
Also perform as a routine investigation since recurrent inflammation and post inflammatory conditions act as an etiological factors for the disease. .
CT and MRI Useful to assessment of involved other adjacent structures in ear such as middle ear, mastoid cavity, labyrinth, facial nerve and ossicles. It may helpful in deciding the type of surgery.. CT and MRI
Useful to assessment of involved other adjacent structures in ear such as middle ear, mastoid cavity, labyrinth, facial nerve and ossicles. It may helpful in deciding the type of surgery..
CT scan Classification of EAC cholesteatoma mainly depend on CT scan and clinical findings.Stage I cholesteatoma is found to be limited to the EAC.Stage II cholesteatoma involves the tympanic membrane and also the middle ear. If EAC involves the mastoid air cells it is called stage III.Lesion extends beyond the temporal bone is seen in In stage IV cholestetoma.,. CT scan
Classification of EAC cholesteatoma mainly depend on CT scan and clinical findings.Stage I cholesteatoma is found to be limited to the EAC.Stage II cholesteatoma involves the tympanic membrane and also the middle ear. If EAC involves the mastoid air cells it is called stage III.Lesion extends beyond the temporal bone is seen in In stage IV cholestetoma.,.

Management - Supportive

Fact Explanation
Patient education Patient / family should be educate regarding the disease, and what consequences resulted in if left untreated. Then doctor should explain the available surgical methods to them. After that should inform the possible surgical complications and take written consent for the surgery. Those possible complications are hearing loss which can be complete and permanent,Dizziness which may resolves within a day of surgery,partial or complete facial nerve paralysis, Tinnitus and taste abnormalities. And also possible complications of anesthesia since this is performed under GA, bleeding, infection and other more remote operative problems should be informed to the patient.. Patient education
Patient / family should be educate regarding the disease, and what consequences resulted in if left untreated. Then doctor should explain the available surgical methods to them. After that should inform the possible surgical complications and take written consent for the surgery. Those possible complications are hearing loss which can be complete and permanent,Dizziness which may resolves within a day of surgery,partial or complete facial nerve paralysis, Tinnitus and taste abnormalities. And also possible complications of anesthesia since this is performed under GA, bleeding, infection and other more remote operative problems should be informed to the patient..

Management - Specific

Fact Explanation
Local care and canaloplasty The main goal of treatment for EACC is preservation of the normal external auditory canal skin as well as surgical removal of the cholesteatoma and necrotic bone tissue thereby prevent disease progression and bone destruction. Degree of bone necrosis , bony erosion as well as the surgeon's judgment may play a role in deciding limit of surgical removal. Treatments depend on the stage of disease.Local care or canaloplasty can be consider in management of stage I disease.. Local care and canaloplasty
The main goal of treatment for EACC is preservation of the normal external auditory canal skin as well as surgical removal of the cholesteatoma and necrotic bone tissue thereby prevent disease progression and bone destruction. Degree of bone necrosis , bony erosion as well as the surgeon's judgment may play a role in deciding limit of surgical removal. Treatments depend on the stage of disease.Local care or canaloplasty can be consider in management of stage I disease..
Canaloplasty and tympanoplasty Canaloplasty and tympanoplasty are used in management of stage II disease.. Tympanoplasty involves the tympanum. The tympanum is the area of the ear which is behind the ear drum where the ossicles are located.. Canaloplasty and tympanoplasty
Canaloplasty and tympanoplasty are used in management of stage II disease.. Tympanoplasty involves the tympanum. The tympanum is the area of the ear which is behind the ear drum where the ossicles are located..
Canaloplasty and mastoidectomy Canaloplasty and tympanoplasty are used in management of stage II disease.. Tympanoplasty involves the tympanum. The tympanum is the area of the ear which is behind the ear drum where the ossicles are located.. Canaloplasty and mastoidectomy
Canaloplasty and tympanoplasty are used in management of stage II disease.. Tympanoplasty involves the tympanum. The tympanum is the area of the ear which is behind the ear drum where the ossicles are located..
Removal of cholesteatoma via middle fossa approach or the transzygomatic approach In case of lesion progresses beyond the temporal bone where we called stage IV, cholesteatoma have to be removed via various approaches. Some of those methods are the middle fossa approach or the transzygomatic approach. However there are two basic surgical approaches to the ear. They are transcanal where performed through the ear canal and Postauricular where the surgery is performed by making an incision behind the ear then moving the ear forward to allow exposure of the mastoid and middle ear.. Removal of cholesteatoma via middle fossa approach or the transzygomatic approach
In case of lesion progresses beyond the temporal bone where we called stage IV, cholesteatoma have to be removed via various approaches. Some of those methods are the middle fossa approach or the transzygomatic approach. However there are two basic surgical approaches to the ear. They are transcanal where performed through the ear canal and Postauricular where the surgery is performed by making an incision behind the ear then moving the ear forward to allow exposure of the mastoid and middle ear..
Ossiculoplasty It is performed to repair or reconstruct the ossicles to improve hearing. Several techniques as well as prostheses can be used for the reconstruction.. Ossiculoplasty
It is performed to repair or reconstruct the ossicles to improve hearing. Several techniques as well as prostheses can be used for the reconstruction..

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