extensive external auditory canal cholesteatoma in the infratemporal

8/9/2019 Extensive External Auditory Canal Cholesteatoma in the Infratemporal

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Extensive external auditory canal cholesteatoma in the infratemporal area wit...Jun Ho Lee; Sang Ho Jung; Chan Hum Park; Seok Min HongEar, Nose & Throat Journal; Sep 2010; 89, 9; ProQuest Media! Li"rar#pg$ %&8

ORIGINAL ARTICLE

Extensive external auditory canalcholesteatoma in the infratemporalarea without mastoid involvement:Use of a new surgical technique

'un Ho Lee, M(; Sang Ho !ung, M(; Chan Hum Park, M(; Seok Min Hong, M(

Abstrct

The external auditory canal (EAC) is nn unusual location

fora cholesteatoma. )e present the casesof patients !ith

EAC cholesteatoma !ho experienced extensi"e dama#e that

extended from the inferior EAC !all to the infratemporal

area; there !as no mastoid in"ol"ement. $n %oth cases, the

cholesteatomas !ere remo"ed under local anesthesia and

the inferior canal !all !as reconstructed !ith a techni'ue

that in"ol"ed the placement oa pedicled musculoperiosteal

flap, a cartila#e #raft, and a fullthic*ness s*in #raft.

This simple procedure preser"es n normal fAC contour,

middle ear space, and mastoid ca"ity.

Introduction

*+terna! auditor# ana! *-C. ho!esteatoma is an

unommon /orm o/ the disease, )hen it does our, it

usua!!# a//ets o!der patients, ho t#pia!!# present ith

hroni otorrhea and du!! ota!gia$ arious treatmen ts /or

*-C ho!esteatoma hae "een preious!# reported$343 '/

the "on# de/et in the *-C is sma!!, the erosie "one an

"e saueri5ed ith a diamond "ur, and the area o/ the

de/et an "e /i!!ed ith a so/t6tissue gra/t, arti!age, and

tempora!is /asia$ J '/ the ad7aent anatomi strutures

i$e$, the mastoid, sku!! "ase, temporomandi"u!ar 7oint,

andor /aia! nere. are damaged, a ana!6a!!6don

mastoidetom# and o"!iteration are pre/erred$3

rom the (epartment o/ :torhino/ar#ngo!og#6Head and ek Surger#,Hn!!#m <niersit# Co!!ege o/ Mediine, Chunheon, Sou!h =orea

(r$ Lee, (r$ Park, and (r$ Hong., and the (epartment o/ :torhi6

no!ar#ngo!og#6Head and ek Surger#, >onsei <niersit# )on7u

Co!!ege o/ Mediine, won!u" South =orea (r$ !ung.$

Corresponding author4 7un 1610 Lee, M(, (epartment o/ :rorhino!ar6

#ngo!og#6Head and ek Surger#, Ha!!#m <niersit# Co!!ege o/

Mediine, 1?& =#o6(ong,Chun"eon, =angon, @epu"!i o/=orea$

*6mai!4 5oono+rsnnte$orn

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)e report the ases o/ 2 patients ith *-C ho6

!esteatoma ho ere treated ith an in/erior ana! aJJ

reonstrution tehniAue that ino!ed the p!aement

o/ a pedi!ed musu!operiostea! /!ap, a arti!age gra/t,

and a /u!!6thikness skin gra/t$

Cse reports

+atient 1$ - B6#ear6o!d oman isited our hospita!

/or ea!uation o/ intermittent right6sided otorrhea

that had dee!oped oer the preeding month$ She

a!so omp!ained o/ mi!d hearing impairment on the

a//eted side, She as reeiing media! treatment /or

h#pertension$

:n ph#sia! e+amination, a !arge de/et in the in/erior

a!! o/ the *-C as o"sered; the t#mpani mem6

"rane as norma! /igure !, -.$ Methii!!in6resistant

taphylococcus at-reus as u!tured /rom the draining

otorrhea$ Computed tomograph# CD. o/ the tempora!

"one shoed destrution o/ the in/erior a!! o/ the

right *-C "# a !esion ith a so/t6tissue densit#, "ut

the aeration o/ the mastoid air e!! and the midd!e ear

spae as norma!$

Dhe patient as taken /or surger# under !oa! anesthe6

sia$ o!!oing e+posure o/ the *-C ia a retroauriu!ar

approah, the in/erior a!! o/ the *-C as /ound to "e

destro#ed "# the ho!esteatoma$ -/ter remoa! o/ the

ho!esteatoma sa, a huge dead spae as seen on the

in/erior *-C /igure !, E.$ Dhe musu!ar /asias o/ the

in/ratempora! area ere pa!pated th rough this dead spae$

- mastoidetom# as not neessar# "eause the mastoid

ait# as apparent!# norma! and "eause the remoa!

o/ the *-Cho!esteatoma as re!atie!# eas# and did not

reAuire ana! idening to reah the mastoid area$

<sing an in/erior pedi!ed rnusu!operiosrea! nap

/igure ', C., e oered the dead spae /igure !, (.$

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Eeause the harested /!ap as

rotated in an anterornedia! in6

/erior diretion, the remaining

!ateroin/erior portion o/ the "on#*-C as saueri5ed to reate a /!ap

patha#$ Do maintain the sta"i!it#

o/ the in/erior *-C, the rotated

nap as oered "# the arti!ages

/igure 1, *.$ Eeause the de/et

in the in/erior EAC as seere, e

used seera! piees o/ traga! and

onha! arti!age$ Dhesearti!ages

ere s!ied a!ong the hori5onta!

p!ane to ma+imi5e the area o/

arti!age used$ - /u!!6thikness

skin gra/t /rom the postauriu!ar

area as oered ith gra/ted

arti!age$

-t the &6eek postoperatie

/o!!o6up, the !atera! portion o/

the skin gra/t as /ound to "e

de/etie$ )e "e!ieethattheause

o/ this de/et as an insu//iient

mount o/ /u!!6thikness skin

gra/t to oer the *-C de/et$ )e

o"tained another skin gra/t /rom

the rerroauriu!ar area and per6

i#ure 1$ +atient -. A/ The extensi"e destruction of the illferior EAC is seen 34 presentation.

The tympanic mem%rane is relati"ely -0-1-022022T2h2e. exposed &il- ferior -J3$$4all-ll$lus

shado! ((-rrol5l) is seen. 6/ $rl-(#e snos she denr- space (nrro!hear-) resultin# from the

remo"e7 of the cholesteatoma so$ C4 All inferior pedicled niuscntoperioueai 8np is

lmr"ested. (4 Tile $9l0"ested8np;s rotnted;2$ nil antennnediai il-ferior direction 1.0 co"er the

dead spnce. E/ The rotated flap is co"ered by the tra#al and concha7 cortiia#e, and a :utl

shic*ness s*ill #raft :mm t0he postauricuior aren is co"ered %y cnrtila#e. / i"e !ee*s

foflolill# the re"ision #mtt- the 6AC is neavly 110I"IIlCd and the ly/ll/)(1l1ic druin F1F01G1.remains nommi.

/ormed a reision proedure ia a transana! approah$

ie eeks !ater. the *-C as near!# norma! and the

t#mpani drum remained norma! /igure 1, .$

+atient 2$ - %B6#ear6o!d man presented ith a mi!d

!e/t6sided "earing impairment o/ 1 #ear3s duration$'rn6

pated eara+ as o"sered on ph#sia! e+amination$

o!!oing remoa! o/ a !arge amount o/ keratinous

materia!, a huge de/et as noted in the in/erior *-C$

)e did not per/orm a "ateria! u!ture "eause the ho6

!esteatoma sa as apparent!# not

in/eted$ Dhe mastoid ait# as

not ino!ed in the ho!esteatoma

sa, and the eardrum had a norma

t#mpani shado. so e did not

o"tain tempora! "one CD$

Do eeks a/ter remoa! o/

the impated a+, surger# as

per/ormed ith !oa! anesthesia$

'ntraoperatie!#, the narure o/ the

an anterior!# e+posed mastoid segment o/ the /aia!

nere -gure 2, -.$ )e oered the dead spae and the

e+posed /aia! nere ith an in/erior pedi!ed rnus6

u!operiostea! /!ap, arti!age, and a /u!!6thikness skin

gra/t /igure 2, E.$

Postoperatie!#, the ontour o/ the in/erior *-C as

near!# norma! and the r#mpani drurn remained norma!

/igure2,C.$-t the B6111011th /o!!o6up, the reonstru6

tion as e!! maintained /igure 2, 56.

*-C destrution as /ound to

"e a!most the same as that seen

in patient 1; the on!# signi/iant

di//erene as that patient 2 had

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i#ure 2$ +atient 2$ A/ The (ll/feriorly mastoid se#lllcllt :acia7 nerve ((II"I"OIV) is

seen follo!in# remo"al of the choiesteatsnna. 6/ The dead space and the exposed :acini

ner"e ore co"ered litll '!11 ineriorpeaided $$$l2scll-operiostenl8np. C4 11 the immediote

postopemsi"e period, the il-ferior fAe appears (a %e !ell reconstructed. 57 At tue <=ll-olllh

fo-lol=l$p, lite reconstructed il-ferior EAC is maintnined.

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5

i#ure J$ This simple techni'ue preser"es (- l$onnal EAC COlltOI.lI~middle eM space, and mastoid

ca"ity. -4 Tile dotted lines indicate tile %orders of the i->lJeTior EAC defect. Te defect should %e

sauceri?ed at the tateroirferict portion of tire %ony EAC in order to mn*e a path!ay for

the inerior pedicled muscuioperiosteai flap (arro!). 6/ The har"ested flap is rotated ill an

(222 teromedial il-ferior direction (arro!s) to co"er the dead space. C4 Tra#al and cOI!leal

cartila#e is used to co"er the ro"ned flap (arro!head). 57 The fullthic*ness s*in #mft is

co"ered !ith cnrtiln#e :arro!@.

portion to oer the dead spae

and the pedi!ed portion to oer

the arti!aginous part o/ the *-C

and the !ateroin/erior portion o/

the "on# part o/ the *-C$ Dhe

"on# part o/ the !ateroin/erior

*-Cshou!d "e saueri5ed to make

a patha# /or this pedi!e$

Jahnke and Lie"erum sug6

gested that the deision to p!ae

a so/t6tissue gra/t must "e "ased

primari!# on the surgeon3s sat6

is/ation that no epithe!ia! /rag6

rnents remain hidden i'' the

"on# de/et$3 ortunate!#, in our

2 ases, the operating /ie!d as

not "!oked "# norma! strutures$

Dhus, omp!ete remoa! o/ the

ho!esteatoma sa and gra/ting

oer the dead spae ere easi!#

per/ormed$

Makino and -rnatsu rote

that norma! epithe!ia! migration

5iscussion

'n this report, e present a ne tehniAue /or managing

in /erior!#e+rensi2e *-Cho!esteatomas itha! t mastoid

ino!ement /igu re &.$ Seera! other surgia! tehniAues

/or *-C ho!esteatoma hae "een reported$ airn er a!

"ased their hoie o/ proedure on the seerit#o/thease;

the# reommended a rransana! or endaura! approah

/or a minima!!# inasie ondition and a postauriu!ar

approah and ana!6a!!6don tehniAue in ases o/

mastoid ino!ement$3 :thers hae reommended the

o"!iteration o/ !arge de/ets ith seera! materia!s$343

'n "oth o/ our ases, the ho!esteatoma aused ex)

treme damage that e+tended /rom the in/erior *-C a!!

to the in/ratempora! region$ ortunate!#, the mastoid

area as not ino!ed$ 'n most patients, i/ the in/erior "on# ana! is a!most destro#ed, the mastoid ait# is

inaded "# the ho!esteatoma$ <nder suh onditions,

the ana!6a!!6don mastoidetom# and meatop!ast#

are essentia! proedures, "ut sine the mastoid ait#

as not inaded in our patients, the ana!6a!!6don

mastoidetom# as onsidered oertreatment$ 'f e

had used simp!e e+ision and saueri5ation in our pa6

tients ithout a mastoidetom#, then meatop!ast# and

ana!op!ast#ou!d ha"e "een impossi"!e "eause o/ the

presene o/ the ma7or "on# de/et and a !arge dead spae$

'nstead, e used an in/erior pedi!ed musu!operiostea!/!ap$ 'n p!aing this /!ap, e used the ternpora!is mus!e

/rom the t#mpani mem"rane and *-C is an important

se!/6!eansing /untion o/ the outer ear$F O/f tehniAue

!eaes the ontour o/ the *-C in a near!# norma! state,

un!ike the ase ith ana!6a!!6don mastoidetom#$

-s a resu!t, our tehniAue on/ers the adantage o/

presering norma! epithe!ia! migration,

Linthium demonstrated the ourse o/ o"!iterated

mastoid tissues oer time, as the tota! o!ume o/ the

/ree mus!e gra/t or pedi!ed mus!e gra/t gradua!!#

diminishes oer seera! #ears$F Do preent this, e used

seera! arti!ages to oer the pedi!ed mus!e /!ap$ -d6

diriona!!#, e "e!iee that the risk o/ /!ap /ai!ure is !oer

"eause e used a pedi!ed /!ap$ not a free so/t6tissue

/!ap, /or oering the !arge dead spae resu!ting /rom

the remoa! o/ the ho!esteatoma$

References1$ Nirn @, Linthium Jr $I Shen D, t a!$ C!assi/iation o/ the e+terna!

auditor# ana! ho!esteatoma$ Lar#ngosope 200?; 11?&.4%??6B0$

2$ 3!os M$ Manua! o/ Midd!e *ar Surger#, e >ork4 eorg Dhieme

er!ag; 199$

&$ ai"erg . Eerger , Hake M$ Dhe patho!ogi /eatures o/ keratosis

o"rurans and ho!esteatoma o/ the e+terna! auditor# ana!$ -$rh

:t!ar#ngo! 198%; '' :, 10.4B906&$

%$ Jahnke =, Lie"erurn E$ Surger# o/ ho!esteatoma o/ the ear ana!

Kin erman$ Lar#ngorhinooto!ogie 199?;%1.4%B69$

?$ Makino =,-mats!i M$ *pithe!ia! migration on the t#mpani mem6

"rane and e+terna! ana!$ -rh :torhino!arngo! 198B;2%& 1.4&96

%2$

B$ Linthium H Jr$ Dhe /ate o/ mastoid o"!iteration tissue4 - histo6

patho!ogia! stud# Lar#ngosope 20024 112 10.4 1681

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extensive external auditory canal cholesteatoma in the infratemporal

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