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ORIGINAL ARTICLE
Year : 2014  |  Volume : 20  |  Issue : 3  |  Page : 99-101

Is Keratosis obturans a predisposing factor for external auditory canal cholesteatoma: Some interesting cases


Department of Otorhinolaryngology and Head and Neck Surgery, Deen Dyal Upadhaya Hospital, Shimla, Himachal Pradesh, India

Date of Web Publication16-Jul-2014

Correspondence Address:
Rajnish Chander Sharma
Department of Otorhinolaryngology and Head and Neck Surgery, Deen Dyal Upadhaya Hospital, Shimla -171 00, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.136837

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  Abstract 

Aim: To define that Keratosis Obturans is one of the predisposing factor for External Auditory Canal Cholestetoma. Materials and Methods: 920 patients were analysed retrospectively between July2012- March 2013 with history of dull earache, fullness and cerumen in External Auditory Canal. The External Auditory Canal examination was done only after removal of Cerumen. Result: Total 920 patients were examined and wax was removed sucssfully except in three patients where it was removed manually under cover of analgesic and antibiotic. After this examination of External Auditory Canal, tympanic membrane, middle ear, ossicles was done clinically. In case -1,only inflammation was present. In case -2,both inflammation as well as widening of bony part of EAC was present along with perforation of TM left side. In case-3, erosion in the bony part of EAC with cholesteatoma sac. On CT scan ,there was no extention of the disease process. Conclusion: KO is uncommon and occurs mainly as desquamative process of ear canal. Both KO and EACC has overlapping of sign and symptoms to some extent.KO is common in comparison to EACC and later usually occur in long standing or in neglecting cases of KO.

Keywords: Canaloplasty, Cerumen, Cholesteatoma, Ear wax, Keratosis obturans, Otalgia, Otorrhoea, Tympanitis


How to cite this article:
Sharma RC. Is Keratosis obturans a predisposing factor for external auditory canal cholesteatoma: Some interesting cases. Indian J Otol 2014;20:99-101

How to cite this URL:
Sharma RC. Is Keratosis obturans a predisposing factor for external auditory canal cholesteatoma: Some interesting cases. Indian J Otol [serial online] 2014 [cited 2020 Jan 26];20:99-101. Available from: http://www.indianjotol.org/text.asp?2014/20/3/99/136837


  Introduction Top


External auditory canal keratosis obturans (KO) is a collection of keratotic mass of desquamating squamous epithelium in the bony portion of external auditory canal (EAC) mainly in its inferior or posterior part. It results perhaps from faulty migration of squamous epithelial cells which usually arise from surface of tympanic membrane and adjacent part of canal wall and get mixed with cerumen to form dense plug. [1] The KO is usually bilateral and frequently associated with bronchiectasis and sinusitis in younger patients. [2] The KO pathologically appears as a dense plug of keratin debris with associated hyperplasia of underlying epithelium, chronic inflammation of subepithelial tissue [3] and a generalised widening of bony canal that may cause smooth erosion of medial canal rarely posing some danger to deep structures. [2] External auditory canal choleastetoma (EACC) which occur as a result of invasion of squamous tissue into a localised area of periositis in canal wall often [4] has overlapping features and requires differentiation. [5],[6],[7]] Three cases of external auditory canal keratosis obturans of varying severity ranging from simple keratosis obturan to complicated one are described in this report to share our experience.


  Materials and Methods Top


The records of 920 patients presenting between July 2012 and March 2013 in the outpatient clinic with history of dull earache, fullness in the ears, and who had cerumen in the EAC and conductive deafness on clinical examination were analyzed retrospectively. The diagnosis of ear wax/KO was mainly clinical and made at first visit itself after thorough clinical examination. In all these patients thorough clinical examination for EAC, tympanic membrane (TM), middle ear cavity, and mastoid was carried out under direct illumination after the wax removal by syringing. Keratolytic ear drops were prescribed in all patients for five days prior to syringing.


  Results and Observations Top


There were 540 males and 180 females (M: F 3:1) aged between 5 years------and-65 -----years, and 300 children (M:F) between -5 years---- and 18------- years. Ear wax/KO could be removed successfully by syringing except in three patients, one female child (Case-1, aged 12 years) and 2 males (Case-2, aged-----and Case-3, aged----years). Keratolytic eardrops along with antibiotic eardrops and oral analgesic were prescribed for another 5 days and cerumen along with desquamated epithelium was removed manually. Repeat clinical examination for EAC, TM, middle ear cavity, ossicles and mastoid. Case-1 had only EAC inflammation, Case-2 showed inflammation of the EAC and widening of its bony part, erosions of mucosa in inferior and posterior parts, perforation of the left TM, and no bone erosions. Case-3 had erosion in the inferior and posterior wall of bony part of external auditory canal, cholesteatoma sac but no extension of disease process in CT. The localized cholesteatoma sac was removed and he was managed conservatively as natural canaloplasty had taken place. His otalgia also settled after few days. The Case-1 developed otorrhoea during treatment process that subsided later after removal of the keratin plug/debris.


  Discussion Top


Keratosis obturans is uncommon and occurs mainly as a chronic desquamative process of ear canal but what initiates the process is poorly known. Although it is often seen as a complication of long standing ear wax/cerumen in EAC, combination of cerumen with squamous epithelial cells, arising usually from surface of tympanic membrane and adjacent part of canal wall, has been implicated frequently in its pathogenesis. [1] External auditory canal (EAC)-KO is closely related to EACC and both have overlapping of sign and symptoms often to an extent that it seems to be the same disease process. [8] External auditory canal-KO is more common than EACC and seen more often as complication of neglected or long standing keratosis obturans. It usually occurs in younger patients and is mostly bilateral. While it is frequently seen associated with bronchiectasis or sinusitis, cholesteatoma formation may occur as complication in long standing cases. [1] The common initial clinical presentation is similar to that of cerumen in the EAC, symptoms of fullness, uneasiness and sometimes conductive hearing loss especially in children. Hence, the diagnosis of EAC-KO cannot be presumed on the first visit itself. However, pain and discomfort is relatively more in EAC-KO. All our three patients diagnosed having EAC-KO had similar symptoms and signs of EAC fullness and uneasiness, inflammation of EAC and thickened TM. Our Case-1 [Table 1] had only mild disease manifesting as EAC inflammation while pain and discomfort was little more in Case-2 [Table 1] perhaps from inflammation of the EAC as he showed no bone erosion. The left TM perforation in him might have been either due to pressure or chronic infection of the keratotic mass which is not a uncommon event*. Although our Case-3 had history of removal of impacted wax 3-4 years back, he remained undiagnosed in the early stages for lack of follow up and now had erosions of bony part of EAC and cholesteatoma formation [Table 1]. The erosions and widening of the bony canal in him were perhaps due to the pressure exerted by the keratin plug, and faulty epithelial migration, low migrating rate in the inferior wall and changes in EAC cell proliferation apparently lead to EACC. Fortunately, there was no extension of the disease and he responded to conservative treatment.
Table 1: Characteristic features of keratosis obturans ranging from simple to complicated one

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In all the three cases the diagnosis of KO and EACC on first visit was not even suspected and their symptoms were attributed to more common condition of ear wax/cerumen with mild otitis externa. The diagnosis of EAC-KO became apparent on complete removal of cerumen/KO and during the course of treatment suggesting that clinical suspicion is the key for early diagnosis. Presence of erosions of the bone of external auditory canal particularly in the inferior or posterior wall along with keratin plug must always raise the suspicion of cholesteatoma and is an indication for diagnostic CT. An early diagnosis by close surveillance in early stages is perhaps more important than canaloplasty, [4] as tendency seems significantly high towards recurrence and invasion of middle ear and other vital structures. Regular follow up is necessary to prevent recurrences or EACC development in long standing or neglected cases.

 
  References Top

1.Edward D. McCoul, Mathew B Hanson. External auditory canal cholesteatoma and keratosis obturans: The role of imaging in preventing facial nerve injury. ENT journal. December 15,2011; 1/8-7/8.  Back to cited text no. 1
    
2.Marta E. Heilbrun, Karen L. Salzman, Christine M. Glastonbury, H. Ric Harnsberger, Richard J. Kennedy, and Clough Shelton: External Auditory Canal Cholesteatoma: Clinical and Imaging Spectrum. AJNR Am J Neuroradiol 24: 751-756, April 2003.  Back to cited text no. 2
    
3.Neilberg J, Berger G, Hawke M. The pathologic features of keratosis obturans andcholesteatoma of external auditory canal. Arch Otolaryngol 1984 Oct; 110:690-3.  Back to cited text no. 3
    
4.Seung-Ho Shin, Jae Han Shim, Ho- Ki Lee, (CEO) Clinical and Experimental Otorhinolaryngology vol. 3, No. 1:24-26, March 2010.  Back to cited text no. 4
    
5.Naresh K Panda, Roshan Kumar Verma, Ajay Jain: Autotympanomastoidectomy in a case of Cholesteatoma with Foreign Body. Indian J Otolaryngol Head Neck Surg. 9 July 2011) 63 (Suppl 1):S68-S70; DOI 10.1007/s 12070-011-0201-2.  Back to cited text no. 5
    
6.Shire JR, Donegan JO: Cholesteatoma of the external auditory canal and keratosis obturans: Am J Otol 1986 Sep; 7:361-4.  Back to cited text no. 6
    
7.Piepergerdes MC, Kramer BM, Behnke EE: Keratosis obturans and external auditory canal cholesteatoma; Laryngoscope 1980 Mar; 90:383-91.  Back to cited text no. 7
    
8.Persaud RA, Hajioff D, Thevasagayam MS, Wareing MJ, Wright A; Keratosis obturans and external ear canal cholesteatoma: how and why we should distinguish between these conditions; Clin Otolaryngol Allied Sci 2004 Dec; 29:577-81.  Back to cited text no. 8
    



 
 
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