Download External auditory canal closure: an alternative

Otolaryngology–Head and Neck Surgery (2007) 137, 766-771
ORIGINAL RESEARCH—OTOLOGY AND NEUROTOLOGY
External auditory canal closure: an alternative
management for the refractory chronically
draining ear
Naohiro Yoshida, MD, PhD, Calhoun D. Cunningham III, MD, and
John T. McElveen Jr, MD, Raleigh, NC; and Sendai, Japan
OBJECTIVE: To discuss the surgical technique and evaluate the
effectiveness of external auditory canal (EAC) closure in patients
with refractory chronically draining ears.
STUDY DESIGN AND SETTING: A retrospective case review of seven patients who underwent EAC closure for chronically
draining ears at a private tertiary otologic referral center between
2001 and 2004. Three patients underwent concomitant placement
of a BAHA implant, and one patient underwent cochlear implantation during a second-stage procedure.
RESULTS: All seven patients had successful closure of the external auditory canal with elimination of chronic drainage. The follow-up interval ranged from 10 to 35 months. There were no cases of
iatrogenic cholesteatoma formation or breakdown of the ear canal
closure.
CONCLUSION AND SIGNIFICANCE: In patients with refractory chronically draining ears, EAC closure, alone or in conjunction
with a bone-anchored implant, may be a treatment option. A BAHA
implant can be placed during the initial procedure or staged.
© 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved.
T
he majority of chronically draining ears can be managed
medically or surgically using conventional tympanoplasty
and mastoidectomy techniques. However, a limited number of
patients may have draining ears refractory to conventional
therapies. Moisture and exuberant granulation tissue within an
open cavity may facilitate bacterial growth from pathogens in
the patient’s surrounding environment. Closure of the external
auditory canal (EAC) eliminates the exposure to many of these
potential pathogens. By insulating the middle ear and mastoid
from the pathogens circulating in the air, one may be able to
eliminate the infection and allow the patient to resume water
exposure. The major disadvantage of this approach has been
the substantial conductive hearing loss that results from EAC
closure. Consequently, some authors, who have used similar
techniques, reserve this approach for patients with a chronically inflamed open cavity with no hearing or poor hearing.1-3
Recently, the advent of the bone-anchored hearing device
(Baha, Cochlear Corp., Englewood, CA) has made this hearing
loss less of a concern. In the cases of conductive hearing loss,
the Baha device can close the air-bone gap to within 5 dB of
the bone scores in the majority of patients.4-7 To determine the
effectiveness of this approach in controlling infection and
drainage from a chronically draining ear, we evaluated seven
patients who underwent this procedure.
PATIENTS AND METHODS
The current retrospective study was performed at a tertiary
otologic referral center. Institutional review board approval
was obtained. The patients consisted of four females and
three males ranging in age from 17 to 81 years of age (Table
1). All patients had chronically draining ears refractory to
medical therapy consisting of repeated mechanical debridement and ototopic antimicrobial preparations. These patients had been treated elsewhere and were referred to an
otologic center because of the refractive nature of their
disease. The time interval from when they were first seen at
the tertiary center to the date of their surgery ranges from 13
days to 7 years. The one patient with a relatively short
interval between the initial visit and surgery, CB, had a
markedly stenotic external canal with fungal infections and
cholesteatoma formation medial to the canal stenosis. This
patient was not interested in having a standard atresia type
of repair with a split-thickness skin graft. She had previously had this attempted with unsuccessful results.
Five patients had draining open cavities, and two patients
had intact posterior canal walls. One of the two intact canal
wall mastoidectomy patients had recurrent polyps filling the
external auditory canal and was thought to have aspirin triad
syndrome. The other patient, as noted earlier, had a markedly stenotic EAC with an extensive canal cholesteatoma
lateral to the tympanic membrane. Three of the seven had
significant sensorineural hearing losses in the operated ear.
Received August 15, 2006; revised April 6, 2007; accepted June 1,
2007.
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. All rights reserved.
doi:10.1016/j.otohns.2007.06.715
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Yoshida et al
External auditory canal closure: an alternative . . .
767
Table 1
Patients With Refractory Chronic Otitis Media
1
2
3
4
5
6
7
61
69
81
48
73
17
44
F
M
F
M
F
F
M
Diagnosis
Procedure
COM
COM
COM
COM
COM
COM
COM
CWD
Revision CWD
Revision CWD
Revision CWD
Revision (ICW)
Revision CWD
Revision CWD
Labyrinthectomy
3
1
1
7
2
1
1
Operation History
Preop.
AC (dB)
Preop.
BC (dB)
Preop.
SDS (%)
Postop.
BC (dB)
(PE tube)
(CWD)
(CWD)
(CWD)
(ICW)
(CWD)
(CWD, LSC fistula)
69
NR
95
70
66
NR
NR
29
NR
45
45
25
NR
NR
76
NR
64
68
92
NR
NR
36
NR
57
36
23
NR
NR
BAHA
CI
BAHA
BAHA
Operation history shows the total number of previous surgery experiences.
NR, no response; AC, air conduction; BC, bone conduction; COM, chronic otitis media; SDS, speech discrimination score; F, female;
M, male; CWD, canal wall down tympanomastoidectomy; ICW, intact canal wall tympanomastoidectomy; PE tube, permanent
eustachian tube insertion; LSC, lateral semicircular canal; CI, cochlear implant.
One of these had profound bilateral sensorineural hearing
loss and underwent cochlear implantation at a second-stage
procedure. The contralateral ear was not chosen for implantation because the patient continued to use a hearing aid in
that ear with some benefit. The other two patients had only
mild or moderate sensorineural hearing losses, respectively,
in the nonoperated ear, and consequently, were not cochlear
implant candidates. Three of the remaining four patients
underwent Baha implantation. One had the fixture and the
abutment placed at the time of the EAC closure, and the
other two patients underwent fixture placement only. The
abutment was placed during a separate operative procedure
approximately 5 months after their EAC closure. The one
patient with residual hearing, who has not undergone
BAHA implantation, has severe diabetes and has declined
any further surgery.
Regardless of whether the patient had a canal wall down
or an intact canal wall procedure, the surgical technique was
similar in each of the seven patients. The EAC closure
technique was similar to that described by Fisch and Mattox.8 The patients were operated on under general anesthesia. The ear canal was infiltrated with 1% xylocaine and
1:40,000 epinephrine, and the postauricular area was infiltrated with 1% xylocaine and 1:100,000 epinephrine. A
postauricular incision was made and the ear canal transected
(Fig 1). The ear canal was transected approximately a centimeter deep in the canal. The skin and cartilage were
transected, and then the cartilage was removed in a circumferential fashion, elevating the skin and soft tissue off the
cartilage and everting it. Two stay sutures were used to
retract the everted external canal skin (Fig 2). The skin was
oversewn using a running locking 2-0 permanent nonabsorbable suture. A separate, posteriorly based, postauricular
connective tissue flap was then created. It was then reflected
anteriorly and sutured in place medially to reinforce the
EAC closure (Fig 3). During the operative procedure, if
cholesteatoma was encountered, it was removed and the
bony surface drilled to ensure complete eradication of the
disease. All remaining squamous elements of the external
canal, including the tympanic membrane, incus, and malleus, were then removed, and the ear was packed with
Merogel (Medtronic, Minneapolis, MN) or Gelfoam (Pharmacia and UpJohn, Pfizer) soaked in ofloxacin otic solution
(Floxin, Ortho-McNeil, Raritan, NJ). No drains were
placed, and the eustachian tube was not occluded.
In one patient with an intact canal wall, the wall was
removed, and in the remaining patient the wall was left
intact after the squamous contents of the external canal had
been removed. The patients were treated with intravenous
antibiotics for a 23-hour period and discharged home on
oral antibiotics for a 10-day period.
Figure 1
flap.
Postauricular incision with creation of soft-tissue
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Otolaryngology–Head and Neck Surgery, Vol 137, No 5, November 2007
Figure 2
(A) Removal of cartilage, lining EAC. (B) Placement of stay sutures.
All patients underwent pre- and postoperative audiometric testing, and results were recorded by using the 4-frequency pure-tone average according to the Committee on
Hearing and Equilibrium guidelines for the evaluation of
results of treatment of conductive hearing loss (500, 1,000,
2,000, and 3000 Hz).9
Follow-up evaluation was performed 10 days postoperatively, at which time the sutures used to close the EAC
were removed, and again at 3 months. A postoperative
computed tomography (CT) scan was obtained at 12 months
to evaluate for iatrogenic cholesteatoma. Additional follow-up visits were scheduled at 6- to 8-month intervals to
monitor this study group.
RESULTS
All patients undergoing EAC closure had successful resolution of their chronic ear symptoms with follow-up
Figure 3
ranging from 10 to 35 months (mean, 18 months). In all
patients, chronic drainage subsided. There has been no
evidence of reinfection or breakdown of the EAC closure.
One-year postoperative CT scans were obtained in six
patients. One patient, JF, underwent a second-look procedure in conjunction with his cochlear implant surgery.
No evidence of any residual cholesteatoma was noted
during the second-look procedure. In the patients undergoing CT scans, there was no evidence of iatrogenic
cholesteatoma, and all but one patient had aeration in the
middle ear as shown in Figure 4 (case 3). As seen in
Figure 4 (case 7), radiologic evaluation may show evidence of what appears to be residual or persistent disease
and therefore should be correlated with clinical findings,
and, as seen in this case, follow-up imaging should be
taken 6 months after the initial CT scan or sooner should
clinical signs of infection warrant it.
Depending on the eustachian tube function, you may or
may not get complete aeration of the middle ear mastoid
(A) Eversion and closure of everted EAC skin. (B) Soft-tissue flap reinforcement of EAC closure.
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Yoshida et al
External auditory canal closure: an alternative . . .
769
atively after EAC closure and Baha insertion were unchanged when compared with the preoperative scores. In
these three patients, the Baha compensated for the conductive hearing loss created by the EAC closure.
One patient with profound bilateral sensorineural hearing
loss underwent placement of a cochlear implant 16 months
after EAC closure. At the time of implant placement, exploration of the mastoid and middle ear revealed only fibrinous material and no squamous elements. This patient
has shown no evidence of complications related to cochlear
Figure 4
Postoperative CT scans.
cavity, and this could also result in some opacification of
this space as seen on the CT scan. Again, these patients are
followed from a clinical standpoint for worsening signs or
symptoms. Patients with normal contralateral ears have
been able to resume water activities. From a cosmetic standpoint, the ear canal closure has recessed into the ear canal
such that it is not obvious (Fig 5).
Three patients underwent successful Baha placement
(Fig 5). The compact Baha device was used in patient BA
who had a postoperative bone conduction pure tone average (PTA) of 23 dB. The remaining two patients with
greater bone-conduction scores were implanted with the
standard Baha device. The bone hearing levels postoper-
Figure 5
opening.
Postoperative view of the BAHA device and metal
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Otolaryngology–Head and Neck Surgery, Vol 137, No 5, November 2007
implant placement and continues to perform well with his
device.
Complications occurred in one patient who developed a
postoperative hematoma. This was treated with local wound
care and oral antibiotics, and the hematoma resolved without further problems.
DISCUSSION
The concept of EAC closure is not new.1,2 Closure of the
EAC has been used in conjunction with the infratemporal
fossa approach in the treatment of glomus jugulare tumors,
with cochlear implantation in canal wall down (CWD) patients, and in some cases of cerebrospinal fluid leaks after
translabyrinthine surgery.3 However, the approach is rarely
used for the treatment of chronic otitis media, particularly if
residual hearing is present. The seven patients in this series
represent about 0.9% of the chronic ear cases performed
from 2001 to 2004 at our institution.
As seen in this series, the chronically draining ear is
usually associated with a CWD mastoidectomy. Most of
these cases respond to conservative therapy consisting of
water precautions, topical medical therapy, and frequent
cleaning of the cavity. In refractive cases, the cavity can be
revised by lowering the facial ridge, enlarging the meatus,
and/or in some cases obliterating the mastoid cavity. In the
five CWD patients in our series, one patient required cochlear implantation that necessitated EAC closure. Of the
remaining four patients, two had dead ears and one patient
who was 81 years had a persistent fungal infection and
wanted to undergo the procedure that was most likely to
result in a dry ear. The remaining CWD patient had undergone seven prior surgical procedures before being seen at
our institution and was not interested in further revision
procedures that could result in persistent drainage.
It is unusual to have to perform EAC closure in patients
with intact canal walls. In the two patients with intact
posterior canal walls, one had an immune disorder resulting
in eosinophilic polyposis in the middle ear and EAC. It is
anticipated that this patient had a complete resolution of her
symptoms because of the isolation of the middle ear from
the contaminants entering through the open EAC. The remaining patient was 73 years old and would have required
enlargement and relining of the ear canal with a splitthickness skin graft, as is performed for congenital atresia.
She declined this more involved procedure.
Four of the seven patients had hearing preoperatively.
All of these patients maintained bone scores consistent with
their preoperative levels. As one might expect in cases of
chronic ear inflammation and infection, all of these patients
had some degree of sensorineural hearing loss preoperatively. By eliminating the inflammation and infection, we
may have prevented further sensorineural loss. In addition,
there was no further need for ototopic medications, some of
which can be associated with potential vestibulotoxic and
ototoxic effects.
Previous authors advocate closing the eustachian tube
and obliterating the mastoid cavity with fat to avoid longterm complications of air containing space in communication with the nasopharynx.10-14 In these seven patients who
we have followed from 10 to 35 months, we have not found
this necessary. In only one patient did we encounter a
problem postoperatively with a hematoma. Whether this
would have occurred even with a fat graft is uncertain. The
hematoma was drained postoperatively, and the problem
resolved. By not obliterating the mastoid cavity with fat, we
are better able to assess the ear radiographically to rule out
the possibility of any residual cholesteatoma. We do fill the
mastoid cavity and middle ear space with Merogel soaked in
Ofloxacin (Floxin, Daiichi-Sankyo, Parsippany, NJ). This
allows us to administer antibiotics to the mastoid and middle ear space temporarily and also minimizes the dead space
that would exist in the early postoperative healing phase.
This is a technique that is commonly used in standard intact
canal wall mastoid surgery. In the patient undergoing cochlear implantation 16 months after EAC closure, only
fibrinous material was found in the mastoid, which facilitated finding the round window and implantation. In addition, the lack of a fat graft may lessen the likelihood of
concealing residual squamous elements on postoperative
CT scans. Using magnetic resonance imaging (MRI) and fat
suppression techniques, the squamous elements may be
differentiated but not without cost.
None of the seven patients have shown iatrogenic cholesteatomas postoperatively. However, this is always a potential risk. It is essential that the surgeon closely inspect the
anterior aspect of the annulus. In this region, the skin may
be more difficult to free from its bony attachments. In cases
with an intact tympanic membrane, the ossicles are disarticulated, and the annulus and tympanic membrane are removed in continuity with the canal skin. If there is any
concern, the area should be drilled to insure complete removal of any squamous elements.
All of the patients have been satisfied with their outcomes. The cochlear implant patient is now able to hear
from the affected ear, and the three patients who had Baha
implants are hearing exceptionally well. There are no longer
concerns for water precautions, and the social stigma associated with a foul-smelling, draining ear have been eliminated. From a cosmetic standpoint, the blind sac is retracted
slightly within the ear canal, producing the effect of a
normal ear canal as seen in Figure 5. To produce this effect,
it is important that the surgeon adequately everts but not
“overeverts” the skin from the ear canal.
Lastly, the long-term health care savings is substantial in
this group of patients. Before their EAC closure, these patients
required medical visits every 4 to 6 weeks. In addition, the cost
of topical and/or systemic antibiotics was not insignificant.
Their surgical procedures were performed in less than 2 hours,
and the patients required only two follow-up visits within a
3-month period. Although not essential, it is recommended that
these patients have a follow-up CT scan or MRI 1 year post-
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Yoshida et al
External auditory canal closure: an alternative . . .
operatively. Although CT evaluation is less accurate than direct microscopic evaluation in detecting cholesteatoma, in
these patients it is not possible because of the EAC closure. In
addition to the radiographic evaluation, these patients are also
followed clinically for evidence of infection or breakdown of
the EAC closure, which can occur with recurrent cholesteatoma formation. If the CT scan or MRI is negative, they can be
seen on an “as needed basis”. Even with the additional cost of
the scan, and in some cases an implant, the health care savings
should be substantial, particularly in younger patients such as
case 6 who was only 17 years old when she underwent EAC
closure.
CONCLUSION
Closure of the EAC for chronic otitis media should be
reserved for a limited number of patients refractory to other
medical and surgical treatment modalities. Although EAC
closure in the chronically draining ear may seem drastic, as
shown in these patients, it is very effective in resolving the
drainage while affording the patient the ability to resume
water activities. In addition, when performed in conjunction
with the Baha device, the hearing deficit previously associated with EAC closure is circumvented.
ACKNOWLEDGEMENT
We would like to acknowledge Margaret Fleischhauer, RN, for her assistance in caring for these patients; Stan Coffman for medical illustrations;
and Tammy Hughes for manuscript transcription.
AUTHOR INFORMATION
Carolina Ear Research Institute, Raleigh, NC (Drs Cunningham, and
McElveen) ; and Department of Otolaryngology, Tohoku University,
School of Medicine, Sendai, Japan (Dr Yoshida).
Corresponding author: John T. McElveen Jr, MD, Carolina Ear & Hearing
Clinic, PC, 3100 Duraleigh Road, Suite 300, Raleigh NC 27612.
E-mail address: [email protected]
771
AUTHOR CONTRIBUTIONS
John T. McElveen, Jr., Naohiro Yoshida, and Calhoun D. Cunningham, III, assist in data collection and writing article.
FINANCIAL DISCLOSURE
None.
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