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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 25  |  Issue : 4  |  Page : 210-212

Postauricular abscess: An uncommon presentation of keratosis obturans


Department of ENT and Head and Neck Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission07-Nov-2018
Date of Acceptance27-Jan-2019
Date of Web Publication4-Dec-2019

Correspondence Address:
Dr. S Vijendra Shenoy
Department of ENT and Head and Neck Surgery, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_104_18

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  Abstract 


Keratosis obturans (KO) is a rare disease involving the bony external auditory canal due to hyperkeratosis of epidermis and disturbance in the epithelial migration process resulting in deafness, otalgia, and inflammation of the ear canal skin. Complications are extremely rare. Here, we present a case of KO in an elderly female presenting as a postauricular abscess, an unreported occurrence first of its kind in the literature. A 67-year-old female patient presented with complaints of dull aching pain and decreased hearing in the left ear for 1 month and swelling behind and above the left ear for 2 weeks. On examination, there was impacted wax in the left external auditory canal and the tympanic membrane was not visualized. A high-resolution computed tomography of the temporal bone reported left otitis externa with soft-tissue density with fat strands in the left postauricular region. The patient underwent examination under microscope, followed by debridement and a subsequent cortical mastoidectomy. Histopathology confirmed the diagnosis of KO. KO is an uncommon condition caused due to occlusion of external auditory canal by desquamated keratinous plug. It is important to differentiate it with other common conditions, including necrotizing otitis externa, canal cholesteatoma, osteoradionecrosis of the external auditory meatus, and tumors of the external auditory meatus. Extracranial complications are rare, including extensive bony erosion and automastoidectomy with no intracranial complications reported till date. KO is a relatively rare condition more commonly seen in the younger age group, and postauricular abscess as a complication of KO has not been reported till date. We thus highlight the importance of awareness of such rare conditions of the external auditory canal, promoting early diagnosis, prompt treatment, and successful prevention of complications.

Keywords: External auditory canal, keratosis obturans, postauricular abscess


How to cite this article:
Govindarajan S, Domah HA, Shenoy S V, Sreenivas A, Dadul RC. Postauricular abscess: An uncommon presentation of keratosis obturans. Indian J Otol 2019;25:210-2

How to cite this URL:
Govindarajan S, Domah HA, Shenoy S V, Sreenivas A, Dadul RC. Postauricular abscess: An uncommon presentation of keratosis obturans. Indian J Otol [serial online] 2019 [cited 2020 Jan 18];25:210-2. Available from: http://www.indianjotol.org/text.asp?2019/25/4/210/272221




  Introduction Top


Keratosis obturans (KO) is a rare disease involving the bony external auditory canal caused by hyperkeratosis of epidermis and disturbance of the epithelial migration process. Excessive accumulation of desquamated epidermis in the external ear canal leads to deafness, otalgia, and inflammation of the skin of the canal.[1] The accrual of desquamated keratin products also causes widening and ballooning of the canal.[2] Little is known about the natural history of the disease, and some extremely rare complications described in the literature include the cases of bone destruction and automastoidectomy,[3],[4] facial nerve palsy,[5] hypotympanic erosion,[2] and horizontal semicircular canal fistula.[4] Intracranial complications are not reported till date.

Here, we present a case of KO in an elderly female presenting as a postauricular abscess, an unreported occurrence first of its kind.


  Case Report Top


A 67-year-old female presented with complaints of pain in the left ear for 1 month which was insidious in onset and gradual in progression. The pain was dull aching in character, nonradiating, with no aggravating factors but relieved on taking medication. The patient gave no history of ear discharge or bleed but complained of decreased hearing on the same side. The patient gave no history of instrumentation of the left ear or any trauma to the site.

She also had decreased hearing from the left ear for 2 weeks which was gradually progressive in nature and continuously present. She gave no history of nasal complaints.

The patient also complained about a swelling behind and above the left ear for 2 weeks which was gradually progressive in size and was associated with dull aching and nonradiating pain. There was no history of discharge from the swelling and no trauma to the site. There was no history of fever, headache or seizures.

On examination, the patient was found to have impacted wax in the left external auditory canal, and the tympanic membrane was not visualized.

There was a diffuse swelling around 4 cm × 4 cm in size in the left postauricular region, extending from the temporal region till inferiorly 3-cm short of the mastoid tip. The skin overlying the swelling was erythematous, no discharging sinus was seen, and no visible pulsations were present [Figure 1].
Figure 1: Clinical presentation of the patient showing a swelling behind and above her left ear

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On palpation, the swelling was tender, with local rise of temperature, fluctuant, and no pulsations felt over it. The surface was smooth, margins were diffuse, and the swelling was not mobile. Right ear findings were unremarkable.

Examination of the nose and oral cavity was within the normal limits.

A high-resolution computed tomography (CT) of the temporal bone was done and reported as left otitis externa with soft-tissue density with fat strands in the left postauricular region. Mastoids were cellular and normal [Figure 2]. The patient underwent examination under the microscope, and KO was carefully removed, tympanic membrane was intact and normal. Subsequently, incision and drainage of postaural abscess and cortical mastoidectomy were done. A volume of 10 mL of pus was drained [Figure 3]. Defect was noted in the posterior wall of the external auditory canal due to erosion by KO [Figure 4]. Mastoid antrum and air cells were normal. Histopathology was reported as flakes of keratin with lamellated layers, consistent with KO.
Figure 2: A high-resolution computed tomography of the temporal bone showing soft-tissue density in the left external auditory canal with left postauricular swelling

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Figure 3: Procedure of incision and drainage being performed

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Figure 4: Defect was noted in the posterior wall of the left external auditory canal due to erosion by keratosis obturans

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  Discussion Top


KO is an uncommon condition caused due to occlusion of external auditory canal by the desquamated keratinous plug.[6]

It is seen in the younger age group <20 years presenting with acute conductive hearing loss associated with pain, itching, and tinnitus. Examination under microscopy usually reveals ballooning of the external auditory canal, a thickened tympanic membrane, and, rarely, otorrhea.[2] CT scan of the temporal bones is necessary to assess bony erosion or bony widening and biopsy to exclude malignancy. The etiology of KO is unknown, but it shares a strong association with seborrhoeic dermatitis, furunculosis, trauma, eczema, and sympathetic stimulation of the cerumen glands (like in bronchiectasis).[7],[8]

Two types of KO have been described: inflammatory and noninflammatory types.

Inflammatory KO usually follows a viral infection, because of temporarily alteration of epithelial migration due to inflammation. This is cured by removal. Silent type is a more serious type of disease caused by abnormal separation of the keratin. It is persistent and will need repeated clearings.[3]

Although it shares various similar clinical features with external auditory canal cholesteatoma, they are indeed two separate entities. Careful histopathological and radiological evaluation is required to differentiate the two.

Other differential diagnoses for KO include necrotizing otitis externa, canal cholesteatoma, osteoradionecrosis of the external auditory meatus, and tumors of the external auditory meatus.

KO is seen to be associated with sinusitis or bronchiectasis, particularly in children.[7],[8]

Extracranial complications are rare, including extensive bony erosion and automastoidectomy with no intracranial complications reported till date. Postauricular abscess as a complication of KO has not been described previously, probably the first-case report of its kind. In this case, there was deformity in the cartilage in the posterior part of the external auditory canal due to erosion by KO, leading to postauricular abscess. Patients are treated with debridement and subsequent canalplasty for recurrent cases.[9]


  Conclusion Top


KO is a relatively rare condition more commonly seen in the younger age group. The common presentation is otalgia and conductive deafness. Complications are uncommon and postauricular abscess has not been reported till date. The management includes microscopic examination and clearance under general anesthesia.

We thus highlight the importance of awareness of such rare conditions of the external auditory canal, promoting early diagnosis, prompt treatment, and successful prevention of complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kuczkowski J, Izycka-Swieszewska E. Keratosis obturans of the external auditory canal. Otolaryngol Pol 2007;61:675-9.  Back to cited text no. 1
    
2.
Persaud R, Chatrath P, Cheesman A. Atypical keratosis obturans. J Laryngol Otol 2003;117:725-7.  Back to cited text no. 2
    
3.
Hawke M, Shanker L. Automastoidectomy caused by keratosis obturans: A case report. J Otolaryngol 1986;15:348-50.  Back to cited text no. 3
    
4.
Saunders NC, Malhotra R, Biggs N, Fagan PA. Complications of keratosis obturans. J Laryngol Otol 2006;120:740-4.  Back to cited text no. 4
    
5.
Glynn F, Keogh IJ, Burns H. Neglected keratosis obturans causing facial nerve palsy. J Laryngol Otol 2006;120:784-5.  Back to cited text no. 5
    
6.
Morrison AW. Keratosis obturans. J Laryngol Otol 1956;70:317-21.  Back to cited text no. 6
    
7.
Black JI. Wax keratosis – A complication of chronic sinusitis? J Laryngol Otol 1964;78:785-8.  Back to cited text no. 7
    
8.
Vrabec JT, Chaljub G. External canal cholesteatoma. Am J Otol 2000;21:608-14.  Back to cited text no. 8
    
9.
Paparella MM, Goycoolea MV. Canalplasty for chronic intractable external otitis and keratosis obturans. Otolaryngol Head Neck Surg 1981;89:440-3.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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