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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 Downloaded from oto.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2016 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 Downloaded from oto.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2016 768 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. Downloaded from oto.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2016 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 Downloaded from oto.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2016 770 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- Downloaded from oto.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2016 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. REFERENCES 1. Rambo JHT. Primary closure of the radical mastoidectomy wound: a technique to eliminate postoperative care. Laryngoscope 1958;68: 1216 –27. 2. Schuknecht HF. Panel on Surgical Approach, Cavity Management and Postoperative Care in Ear Surgery. Arch Otol 1963;78:350 – 8. 3. Sanna M, Sunose H, Mancini F, et al. Middle ear and mastoid microsurgery. New York: Thieme; 2003. p. 417–9. 4. Tjellstrom A, Lindstrom J, Hallen O, et al. Osseointegrated titanium implants in the temporal bone. A clinical study on bone-anchored hearing aids. Am J Otol 1981;2:304 –10. 5. Branemark PI, Albrektsson T. Titanium implants permanently penetrating human skin. Scand J Plast Reconstr Surg 1982;16:17–21. 6. Hakansson B, Lien G, Tjellstorm A, et al. Ten years experience with the Swedish bone anchored hearing system. Ann Otol Rhinol Laryngol 1990;99:1–16. 7. Lustig LR, Arts HA, Brackmann DE, et al. Hearing rehabilitation using the BAHA bone-anchored hearing aid: results in 40 patients. Otol Neurotol 2001;22:328 –34. 8. Fisch U, Mattox D. Microsurgery of the skull base. New York: Thieme; 1988. p. 22– 4. 9. Committee on Hearing and Equilibrium. Guidelines for the evaluation of results and treatment of conductive hearing loss. Otolaryngol Head Neck Surg 2001;175:628 –30. 10. Axon PR, Mawman DJ, Upile T, et al. Cochlear implantation in the presence of chronic suppurative otitis media. J Laryngol Otol 1997; 111:228 –32. 11. Gray RF, Irving RM. Cochlear implants in chronic suppurative otitis media. Am J Otol 1995;16:682– 6. 12. El-Kashlan HK, Arts HA, Telian SA. Cochlear implantation in chronic suppurative otitis media. Otol Neurotol 2002;23:53–5. 13. El-Kashlan HK, Arts HA, Telian SA. External auditory canal closure in cochlear implant surgery. Otol Neurotol 2003; 24:404 – 8. 14. Meyerhoff W, Stringer S, Roland P. Rambo procedure: modification and application. Laryngoscope 1998;98:795– 6. Downloaded from oto.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2016