|Year : 2015 | Volume
| Issue : 1 | Page : 64-66
Foreign body of middle ear masquerading cholesteatoma
Santosh S Garag, Raghunath D Shanbag, S Rashmi, JS Arunkumar
Department of ENT, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
|Date of Web Publication||10-Mar-2015|
Dr. Santosh S Garag
Department of ENT, Sri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Sattur, Dharwad - 580 009, Karnataka
Source of Support: None, Conflict of Interest: None
Numerous theories have been proposed in the past for the etiology of cholesteatoma. Foreign body (FB) of middle ear has been rarely reported in the literature which if neglected for long duration of time can lead to cholesteatoma. An adolescent male presented with chronically discharging ear. Patient was taken up for exploration. During which multiple FB was seen in the middle ear overlying extensive cholesteatoma. Patient underwent canal wall down mastoidectomy with tympanoplasty. Foreign body of external auditory canal should be managed meticulously by skilled otologist. Patient with chronic ear discharge not responding to antibiotics should raise a suspicion of FB. Neglected middle ear FB can cause cholesteatoma. Early intervention in these cases will prevent complications
Keywords: Cholesteatoma, Foreign body, Middle ear, Tympanoplasty
|How to cite this article:|
Garag SS, Shanbag RD, Rashmi S, Arunkumar J S. Foreign body of middle ear masquerading cholesteatoma. Indian J Otol 2015;21:64-6
| Introduction|| |
Cholesteatoma is a nightmare for the otologist, whose excision needs a high level of surgical expertise and skill. Its pathogenesis has been debated in depth in the past. This includes theories such as metaplasia, invagination, migration, hyperplasia, etc. ,
Foreign body (FB) of external auditory canal (EAC) is a well-known entity in pediatric age group. However, there are very few instances of middle ear FB. PubMed search engine yielded no results for cholesteatoma developing following an FB in the middle ear. Here we are reporting a case of multiple FB in an 18-year-old male who presented to us with foul smelling ear discharge and earache. On examination granulation, polyp was seen occluding the EAC. He did not respond to any oral antibiotics. He was taken up for middle ear and mastoid exploration surgery. During which multiple FB was seen within the middle ear. Extraction of FB revealed the cholesteatoma sac in the middle ear and mastoid. Patient was treated by canal wall down mastoidectomy with tympanoplasty. Here, we are emphasizing the role of FB of middle ear in the development of extensive cholesteatoma in this patient.
| Case report|| |
An 18-year-old male presented to us with the chief complaint of throbbing type of right earache since 5 days. It was associated with a high degree of fever. On examination, thick mucopus was seen in right EAC, on clearing of which reddish polypoidal mass with posterosuperior canal bulge was seen. Tympanic membrane could not be visualized. Further examination showed signs of acute mastoiditis like the mastoid tenderness. Patient was admitted and treated with injectable broad spectrum antibiotics. Patient underwent all routine hemotological investigations, which showed features of acute infection. Ear swab was sent for culture sensitivity, which showed Proteus mirabilis species, which was sensitive to prescribed antibiotics. High-resolution computed tomography temporal bone was done which revealed soft tissue mass occupying right EAC, mastoid, middle ear with erosion of anterior and floor of EAC. Patient symptoms reduced after 5 days course of antibiotics, after which he was taken up for mastoid and middle ear exploration. The fleshy polypoidal mass in the EAC was excised by sharp dissection. After which cotton fibers was seen occluding the view of tympanic membrane [Figure 1]. These cotton fibers were removed piecemeal, revealing a large central perforation of the tympanic membrane. Through the perforation a FB surrounded by extensive granulation tissue was noticed. Postaurally the tympanomeatal flap was elevated. Granulation tissue was seen filling the middle ear and FB seen at the junction of anterior epitympanum and mesotympanum [Figure 2]. FB was removed enmass, which was a plastic cap of 1 cm in length having a lumen [Figure 3]. Mastoid was opened, which showed the cholesteatoma sac in antrum extending up to the sinodural angle posteriorly and towards the mastoid tip inferiorly [Figure 4]. In the middle ear the cholesteatoma sac was seen in epitympanum, mesotympanum, supratubal recess, extending into the Eustachian tube More Details. All ossicles except the footplate of stapes were eroded, Fallopian canal More Details and semicircular canals were intact. Canal wall down mastoidectomy with tympanoplasty and wide meatoplasty done. Tissue was sent for histopathological examination, which was consistent with cholesteatoma. Patient was followed-up for 6 months without any signs of recurrence till now.
|Figure 2: Foreign body (plastic cannula) seen after removal of cotton fibers, through a central perforation of tympanic membrane|
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| Discussion|| |
The pathogenesis of acquired cholesteatoma can be explained by invagination, metaplasia, hyperplasia etc., which have stood the test of time. Formation of cholesteatoma is triggered by perforation or retraction of the tympanic membrane.  Though there are multiple theories for the pathogenesis of cholesteatoma, chronic inflammation appears to be the core of all this mechanisms. 
In developing countries where there is a large scale ignorance about the medical illness, neglected FB can lead to a variety of complications. FB of otorhinolaryngology is commonly seen in children.  In the ear, FB of the EAC is more common. In PubMed database, there are very few articles regarding middle ear FB. Majority of cases of middle ear FB are due to failed attempt to remove EAC FB by inexperienced and unskilled doctors.  FB middle ear can occur due to violent, accidental perforation of the tympanic membrane by FB like welding beads.  There are instances of FB like impression material used for ear mold in hearing aid entering the middle ear via the perforated tympanic membrane.  In patients with earache and ear discharge not responding to any antibiotics, FB in the middle ear should be kept in mind in the differential diagnosis. , A forgotten middle ear FB will have perforated drum with granulation tissue, as it was in our case. 
There are studies conducted on experimental animals, which have proven the theory of epithelial migration.  This had substantiated the claim of FB in the middle ear triggering the inflammatory reaction leading to cholesteatoma formation. This if not diagnosed early can cause serious intratemporal and intracranial complications. In our case, patient presented to us with features of acute mastoiditis. Thus, FB in the middle ear can lead to life-threatening complications.
Patients with FB in EAC should be managed meticulously by skilled otologist. Where repeated attempts should be avoided, as patients hearing is at risk. Proper instrumentation with immobilization of the patient should be tried in an uncomplicated FB. 
Patient should be taken for microscopic removal under general anesthesia in failed and uncooperative cases.  Postural approach gives wide exposure of the medial part of external auditory meatus and middle ear, so it is the preferred route of removal of impacted FB.  In cases where FB has led to the formation of extensive granulation or cholesteatoma, it is wise to do modified radical mastoidectomy.
| Conclusion|| |
Neglected FB in the middle ear in children's can lead to cholesteatoma and its dreaded complications. Cholesteatoma secondary to FB in the middle ear has not been reported so far, after extensive literature search. Pediatric patients with chronic ear discharge not responding to antibiotics should raise a suspicion of FB in the middle ear. FB of EAC should be removed by skilled otologist with proper instrumentation and minimal attempts. Patient should be taken under general anesthesia in complicated FB.
| Summary|| |
- In patients with chronic ear discharge not responding to antibiotics, FB of middle ear should be suspected
- Neglected FB of middle ear can trigger cholesteatoma formation
- FB of EAC should be managed by skilled otologist with proper instrumentation.
| References|| |
Louw L. Acquired cholesteatoma pathogenesis: Stepwise explanations. J Laryngol Otol 2010;124:587-93.
Persaud R, Hajioff D, Trinidade A, Khemani S, Bhattacharyya MN, Papadimitriou N, et al.
Evidence-based review of aetiopathogenic theories of congenital and acquired cholesteatoma. J Laryngol Otol 2007;121:1013-9.
Adhikary B, Bora H, Bandyopadhyay SN, Sen I, Basu SK. Foreign body in ENT - General practitioner's duty. J Indian Med Assoc 2008;106:307-9.
Katarkar A, Katarkar S, Jain A, Modh SD, Shah RP. Difficult case of middle ear foreign body: An unusual case report with review of literature. Southeast Asian J Case Rep Rev 2013;2:178-85.
Eleftheriadou A, Chalastras T, Kyrmizakis D, Sfetsos S, Dagalakis K, Kandiloros D. Metallic foreign body in middle ear: An unusual cause of hearing loss. Head Face Med 2007;3:23.
Shashinder S, Tang IP, Velayutham P, Rahmat O, Loganathan A. Foreign body in the middle ear, a hearing aid complication. Med J Malaysia 2008;63:267-8.1
Supiyaphun P, Sukumanpaiboon P. Acute otalgia: A case report of mature termite in the middle ear. Auris Nasus Larynx 2000;27:77-8.
Dutta M, Ghatak S, Biswas G. Chronic discharging ear in a child: Are we missing something? Med J Malaysia 2013;68:368-71.
Massuda ET, Oliveira JA. A new experimental model of acquired cholesteatoma. Laryngoscope 2005;115:481-5.
Ansley JF, Cunningham MJ. Treatment of aural foreign bodies in children. Pediatrics 1998;101:638-41.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]