|Year : 2017 | Volume
| Issue : 3 | Page : 205-207
Left mastoid abscess and right automastoidectomy: Two rare complications of cholesteatoma in a patient
Boon Chye Gan, Mohd Khairi Md Daud
Department of Otorhinolaryngology Head and Neck Surgery, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia
|Date of Web Publication||31-Aug-2017|
Mohd Khairi Md Daud
Department of Otorhinolaryngology Head and Neck Surgery, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
Source of Support: None, Conflict of Interest: None
In most cases of cholesteatoma, patients have a history of occasional scanty ear discharge, tinnitus, and gradual progression of hearing loss that may not bother their daily activities. Therefore, late presentation may occur when this group of patients attributes little importance to the otological symptoms. We report a patient with bilateral cholesteatoma who presented with mastoid abscess on the left ear and automastoidectomy on the right ear. Early detection and management of cholesteatoma is crucial in preventing its complication.
Keywords: Abscess, cholesteatoma, mastoid, otitis media
|How to cite this article:|
Gan BC, Md Daud MK. Left mastoid abscess and right automastoidectomy: Two rare complications of cholesteatoma in a patient. Indian J Otol 2017;23:205-7
| Introduction|| |
Cholesteatoma has always been described as “skin in the wrong place” due to the unusual buildup of keratinizing squamous epithelium in the ear. It is often characterized as a nonneoplastic cystic lesion in the temporal bone. This may sound benign, but if left untreated, the abnormal growth can be locally invasive and cause destruction of the temporal bone and surrounding structures. Early detection is of paramount importance in the prevention of extracranial complications such as mastoid abscess, facial nerve palsy, and labyrinthine fistula or more severe intracranial complications such as meningitis and perisinusal abscess that may lead to serious morbidity or even mortality. The diagnosis and proper management of cholesteatoma is achieved on the basis of good history taking, otoscopic features, audiometric test, imaging techniques, and intraoperative findings. However, a provisional diagnosis and early referral of cholesteatoma can be made with just good history taking and high index of suspicion coupled with accurate clinical and otological examinations. We report a patient with bilateral cholesteatoma who presented with two different rare complications in each of the ear.
| Case Report|| |
A 17-year-old female student with no previous medical illness, referred from the outpatient clinic with a complaint of worsening, throbbing pain over the left ear for 1-month duration. One week before the presentation, she noticed a gradually growing, painful swelling behind her left ear accompanied with yellowish discharge from the ear canal and low-grade fever. She has no complaint over the right ear. On further questioning, she revealed a history of recurrent left ear discharge and reduced hearing with occasional tinnitus since childhood. She tried eradicating the left ear discharge throughout the years with various antibiotic eardrops prescribed by general practitioners but with poor outcome. On examination, there was a soft, erythematous, warm, and tender swelling measured 4.0 cm × 3.5 cm over the left post auricular region [Figure 1]. The whole left external auditory canal was occupied with granulation tissue and yellowish discharge [Figure 2]. Otoscopy over the right ear revealed a widened right external auditory canal with exposed but dry mastoid cavity [Figure 3]. There was no keratin debris, and the pars tensa was intact but retracted. Culture and sensitivity of ear swab from left ear canal revealed Proteus mirabilis species that was sensitive to cefuroxime and polymyxin. A high-resolution computed tomography (HRCT) of temporal bone revealed a left mastoid abscess with soft tissue density lesion occupying the left external auditory canal and middle ear with chronic mastoiditis changes [Figure 4]. There was an incidental finding of a big cavity over the right mastoid region and the absence of normal right ear ossicles in the HRCT. She was given intravenous cefuroxime, polymyxin eardrops and underwent incision and drainage of left mastoid abscess followed by modified radical mastoidectomy. Her preoperative pure tone audiometry showed bilateral moderate conductive hearing loss. Intraoperatively, the cholesteatoma was seen occupying the middle ear, sinus tympani, and hypotympanum. The cholesteatoma eroded the posterior wall of external auditory canal, malleus, and incus. Meatoplasty was performed after complete removal of the cholesteatoma. The left ear was completely dry at the 3rd month postoperatively.
|Figure 2: Granulation tissue occupying the whole left external auditory canal|
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|Figure 3: A large external auditory canal of the right ear with intact but retracted pars tensa|
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|Figure 4: An axial view of high-resolution computed tomography temporal showing widened right external auditory canal with eroded posterior wall and left mastoid cavity fully occupied with soft tissue lesion|
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| Discussion|| |
Cholesteatoma can be divided into congenital and acquired, where the former is specific to childhood while the latter can affect both children and adult. A study done in Brazil based on 1146 patients with cholesteatoma showed that otorrhea was the most common complaint at 66.5%, followed by combined otorrhea-hypoacusis-tinnitus at 23.3%, and lastly, just hypoacusis at 7.6%. In cholesteatoma, otorrhea is usually scanty, offensive, and purulent, and there may be granulation tissue occupying the external auditory canal. Tympanic membrane perforation is mostly attical or marginal.
Automastoidectomy is a unique and poorly known entity. It is described as a destructive condition of the temporal bone in a patient with no previous surgical history, where middle ear cholesteatoma exenterates and destroys mastoid air cells and middle ear structures with the end result resembling a postmastoidectomy appearance. A Korean study involving 22 patients with automastoidectomy found that 2 of the patients had facial nerve palsy, 7 had reduced hearing, 10 complained of otorrhea, and only 3 complained of ear pain. The patient may also presented with ear polyp.
Otitis media (OM) is often characterized by presentation and duration of disease into acute or chronic OM (COM). The complications of OM can be extracranial such as mastoiditis, mastoid abscess, and facial nerve palsy or more severe intracranial complications such as meningitis, lateral sinus thrombosis, and cerebral abscess. Despite the advancement of treatment for OM, complication such as mastoid abscess is still a threat, particularly in immunocompromised patients. In the immunocompetent group, risk of developing mastoid abscess is elevated when cases of COM are associated with cholesteatoma. In cases of COM without cholesteatoma, only 6.7% developed complications in comparison to 15% in the group of patients with COM and cholesteatoma. Early detection and management of cholesteatoma is crucial in preventing its complication. It is a well-known fact that OM and cholesteatoma are diseases of the lower socioeconomic group. In most cases of cholesteatoma, most patients only complain of occasional scanty discharge, tinnitus, and gradual progression of hearing loss that may not bother their daily activities. Therefore, late presentation may occur when this group of patients attributes little importance to otological symptoms until the emergence of pain, bleeding, fever, dizziness, vomiting, and headache set in. Symptoms like these are indicative of a late-presenting cholesteatoma with extracranial or intracranial complications and in our case, mastoid abscess.
| Conclusion|| |
Late presentation may occur in those with cholesteatoma when this group of patients attributes little importance to its mild otological symptoms. Therefore, awareness among the people is vital for the proper management of cholesteatoma and prevention of its complications.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]