Extensive external auditory canal cholesteatoma in the infratemporal area wit...

Jun Ho Lee; Sang Ho Jung; Chan Hum Park; Seok Min Hong
Ear, Nose & Throat Journal; Sep 2010; 89, 9; ProQuest Medical Library
pg. 438

ORIGINAL

ARTICLE

Extensive external auditory canal

cholesteatoma in the infratemporal
area without mastoid involvement:
Use of a new surgical technique
Iun Ho Lee, MD; Sang Ho lung, MD; Chan Hum Park, MD; Seok Min Hong, MD

Abstract
The external auditory canal (EAC) is nn unusual location
fora cholesteatoma. We present the casesof2 patients with
EAC cholesteatoma who experienced extensive damage that
extended from the inferior EAC wall to the infratemporal
area; there was no mastoid involvement. In both cases, the
cholesteatomas were removed under local anesthesia and
the inferior canal wall was reconstructed with a technique
that involved the placement oja pedicled musculoperiosteal
flap, a cartilage graft, and a full-thickness skin graft.
This simple procedure preserves n normal fAC contour,
middle ear space, and mastoid cavity.
Introduction
External auditory canal (EAC) cholesteatoma
is an
uncommon form of the disease, When it does occur, it
usually affects older patients, who typically present with
chronic otorrhea and dull otalgia. Various treatmen ts for
EAC cholesteatoma have been previously reported.':' If
the bony defect in the EAC is small, the erosive bone can
be saucerized with a diamond bur, and the area of the
defect can be filled with a soft-tissue graft, cartilage, and
temporalis fascia. J If the adjacent anatomic structures
(i.e., the mastoid, skull base, temporomandibular
joint,
and/or facial nerve) are damaged, a canal-wall-down
mastoidectomy and obliteration are preferred.'

From the Department of Otorhinofaryngology-Head and Neck Surgery,

Hnllym University College of Medicine, Chuncheon, Soulh Korea
(Dr. Lee, Dr. Park, and Dr. Hong), and the Department of Otorhinolaryngology-Head and Neck Surgery, Yonsei University Wonju
College of Medicine, wonju, South Korea (Dr. lung).
Corresponding author: jun 1-10 Lee, MD, Department of Ororhinolaryngology-Head and Neck Surgery, Hallym University College of
Medicine, 153 Kyo-Dong,Chuncbeon, Kangwon, Republic ofKorea.
E-mail: zoonoxrsnnte.corn
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We report the cases of 2 patients with EAC cholesteatoma who were treated with an inferior canal waJJ
reconstruction technique that involved the placement
of a pedicled musculoperiosteal
flap, a cartilage graft,
and a full-thickness skin graft.
Case reports
Patient 1. A 67-year-old woman visited our hospital
for evaluation of intermittent
right-sided otorrhea
that had developed over the preceding month. She
also complained of mild hearing impairment on the
affected side, She was receiving medical treatment for
hypertension.
On physical examination, a large defect in the inferior
wall of the EAC was observed; the tympanic membrane was normal (figure l, A). Methicillin-resistant
Staphylococcus at/reus was cultured from the draining
otorrhea. Computed tomography (CT) of the temporal
bone showed destruction of the inferior wall of the
right EAC by a lesion with a soft-tissue density, but
the aeration of the mastoid air cell and the middle ear
space was normal.
The patient was taken for surgery under local anesthesia. Following exposure of the EAC via a retroauricular
approach, the inferior wall of the EAC was found to be
destroyed by the cholesteatoma. After removal of the
cholesteatoma sac, a huge dead space was seen on the
inferior EAC (figure l, B). The muscular fascias of the
infratemporal area were palpated th rough this dead space.
A mastoidectomy was not necessary because the mastoid
cavity was apparently normal and because the removal
of the EACcholesteatoma was relatively easy and did not
require canal widening to reach the mastoid area.
Using an inferior pedicled rnusculoperiosreal
nap
(figure I, C), we covered the dead space (figure l, D).
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LEE, .lUNG, PARK, HONG

Because the harvested flap was

rotated in an anterornedial
inferior direction, the remaining
lateroinferior portion of the bony
EAC was saucerized to create a flap
pathway. To maintain the stability
of the inferior EAC, the rotated
nap was covered by the cartilages
(figure 1, E). Because the defect
in the inferior EAC was severe, we
used several pieces of tragal and
conchal cartilage. Thesecartilages
were sliced along the horizontal
plane to maximize the area of
cartilage used. A full-thickness
skin graft from the postauricular
area was covered with grafted
cartilage.
At the 3-week postoperative
follow-up, the lateral portion of
the skin graft was found to be
defective. We believethatthecause
of this defect was an insufficient
amount
of full-thickness
skin
graft to cover the EAC defect. We
obtained another skin graft from
the rerroauricular area and per-

Figure 1. Patient /. A: The extensive destruction of the illferior EAC is seen (/1 presentation.
The tympanic membrane is relatively /"/0/"11"11T1h1e. exposed il/ferior /JOIIYall/llIlus
shadow ((/rrol\l) is seen. B: Irl/(jge snows she denr/ space (nrrowhear/) resulting from the
remove! of the cholesteatoma soc. C: All inferior pedicled niuscntoperioueai j7np is
lmrvested. D: Tile IWl"vestedj7np;s rotnted;1I nil antennnediai il/ferior direction 1.0 cover the
dead spnce. E: The rotated flap is covered by the tragal and concha! cortiiage, and a [utlshickness skill graft [mm t"he postauricuior aren is covered by cnrtilage. F: Five weeks
foflolVillg the revision gmtt/ the BAC is neavly 110I"IIlCdand the ly/ll/)(1l1ic druin ((//"1"01\1)
remains nommi.

formed a revision procedure via a transcanal approach.

an anteriorly exposed mastoid segment of the facial
Five weeks later) the EAC was nearly normal and the nerve (Agure 2, A). We covered the dead space and the
tympanic drum remained normal (figure 1, F).
exposed facial nerve with an inferior pedicled rnusPatient 2. A 46-year-old man presented with a mild
culoperiosteal flap, cartilage, and a full-thickness skin
left-sided bearing impairment of 1 year's duration.Irngraft (figure 2, B).
pacted earwax was observed on physical examination.
Postoperatively, the contour of the inferior EAC was
Following removal of a large amount of keratinous
nearly normal and the rympanic drurn remained normal
material, a huge defect was noted in the inferior EAC. (figure2,C).At the 6-111011th follow-up, the reconstrucWe did not perform a bacterial culture because the chotion was well maintained (figure 2, D).
lesteatoma sac was apparently not
infected. The mastoid cavity was
not involved in the cholesteatoma
sac, and the eardrum had a norma!
tympanic shadow) so we did not
obtain temporal bone CT.
Two weeks after removal of
the impacted wax, surgery was
performed with local anesthesia.
Intraoperatively, the narure of the
mastoid seglllcllt
[acia! nerve ((II"I"OIV) is
EAC destruction was found to Figure 2. Patient 2. A: The (ll/feriorly
seen following removal of the choiesteatsnna. B: The dead space and the exposed [acini
be almost the same as that seen
nerve ore covered lVitll Il11 injeriorpeaided IIIl1scll/operiostenlj7np. C: /11 the immediote
in patient 1; the only significant
postopemsive period, the il/ferior fAe appears (a be well reconstructed. D: At tue 6~ll/olllh
difference was that patient 2 had fo/lolV~lIp, lite reconstructed il/ferior EAC is maintnined.
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LEE. JUNG, PARK, HONG

portion to cover the dead space

and the pedicled portion to cover
the cartilaginous part of the EAC
and the lateroinferior portion of
the bony part of the EAC. The
bony part of the lateroinferior
EACshould be saucerized to make
a pathway for this pedicle.
Jahnke and Lieberum
suggested that the decision to place
a soft-tissue graft must be based
primarily on the surgeon's satisfaction that no epithelial fragrnents remain hidden
ill the
bony defect.' Fortunately, in our
D
2 cases, the operating field was
Figure J. This simple technique preserves (/ lIonnal EAC COlltOI.lI~ middle eM space, and mastoid not blocked by normal structures.
cavity. A: Tile dotted lines indicate tile borders of the i/'lJeTior EAC defect. The defect should be Thus, complete removal of the
saucerized at the tateroirferict portion of tire bony EAC in order to mnke a pathway for cholesteatoma sac and grafting
the injerior pedicled muscuioperiosteai flap (arrow). B: The harvested flap is rotated ill an over the dead space were easily
(111- teromedial il/ferior direction (arrows) to cover the dead space. C: Tragal and cOI'lehal
performed.
cartilage is used to cover the rouned flap (arrowhead). D: The full-thickness skin gmft is
Makino and Arnatsu wrote
covered with cnrtilnge [arrow}.
that normal epithelial migration
Discussion
from the tympanic membrane and EAC is an important
In this report, we present a new technique for managing
self-cleansing function of the outer ear." OUf technique
in feriorlyexrensive EACcholesteatomas withal! t mastoid
involvement (figu re 3). Several other surgical techniques
for EAC cholesteatoma have been reported. Nairn er al
based their choice of procedure on the severityofthecase;
they recommended a rranscanal or endaural approach
for a minimally invasive condition and a postauricular
approach and canal-wall-down technique in cases of
mastoid involvement.' Others have recommended the
obliteration of large defects with several materials.':'
In both of our cases, the cholesteatoma caused extreme damage that extended from the inferior EAC wall
to the infratemporal region. Fortunately, the mastoid
area was not involved. In most patients, if the inferior
bony canal is almost destroyed, the mastoid cavity is
invaded by the cholesteatoma. Under such conditions,
the canal-wall-down mastoidectomy and meatoplasty
are essential procedures, but since the mastoid cavity
was not invaded in our patients, the canal-wall-down
mastoidectomy was considered overtreatment.
If we
had used simple excision and saucerization in our patients without a mastoidectomy, then meatoplasty and
canaloplastywould
have been impossible because of the
presence of the major bony defect and a large dead space.
Instead, we used an inferior pedicled musculoperiosteal
flap. In placing this flap, we used the ternporalis muscle
442 www.entjournal.com

leaves the contour of the EAC in a nearly normal state,

unlike the case with canal-wall-down mastoidectomy.
As a result, our technique confers the advantage of
preserving normal epithelial migration,
Linthicum demonstrated
the course of obliterated
mastoid tissues over time, as the total volume of the
free muscle graft or pedicled muscle graft gradually
diminishes over several years." To prevent this, we used
several cartilages to cover the pedicled muscle flap. Addirionally, we believe that the risk of flap failure is lower
because we used a pedicled flap. not a free soft-tissue
flap, for covering the large dead space resulting from
the removal of the cholesteatoma.
References
1.

Nairn R,
auditory

Linthicum
F Jr . Shen T, ct al. Classification
of the external
canal cholesteatoma.
Laryngoscope
2005; 115(3):455-60.

2. 'los M.
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Manual of Middle Ear Surgery, New York: Georg Thieme

Verlag; 1997.
Naiberg 1. Berger G, Hawke M. The pathologic
features of keratosis
obrurans
and cholesteatoma
of the external auditory
canal. A.rch
Otclaryngol
1984; II O( 10):690-3.
Jahnke K, Lieberurn B. Surgery of cholesteatoma
of the ear canal
[in German]. Laryngorhinootologie 1995;74(1):46-9.
Makino K,Amatsli
M. Epithelial migration
on the tympanic
membrane and external canal. Arch Otorhinolarvngol
1986;243( 1):3942.
Linthicum
pathological

FH Jr. The fate of mastoid obliteration

tissue:
study Laryngoscope
2002: 112( 10): 1777-81

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