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Thread: Cysts of External Auditory Meatus pictures - Ear Atlas

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    Default Cysts of External Auditory Meatus pictures - Ear Atlas

    INTRODUCTION
    Dermoid cysts are often present at birth. They are asymptomatic affecting mainly males. They grow in a slowly way, are unilocular, and the cyst masses can cause only few symptoms, that originate from the dimensions by its growth. They are often found in the ovary and testicles, and 7% can affect the head and neck area. Although the origin of those cysts is uncertain, it is believed that is associated to the remaining pluripotent embryo tissues during the first and second bronchial arches fusion in the third and fourth weeks of intrauterus life. Disorganized and difference growth of those "kidnapped" cells start from dermoid cyst.

    Dermoid cysts can be classified into three histological types: epidermoid cyst (with no dermal annexes in its covering epithelium); dermoid (presence of skin annexes such as sweat gland cells and hair follicle) and teratoid ones (covering containing structures from the three generative layers).

    When occurring in the head and neck, dermoid cysts are more common to be found in the fronto-orbital area, in the external superior forth of the orbit. Other sites can be the midline of the nose or neck and sublingual area.

    The differential diagnosis of a retroauricular cyst should be done with the following: Epidermal inclusion cyst, Trichilemmal cyst, lipoma and hamangioma.

    This study reports a case of epidermoid cyst in the retroauricular area. It is evaluated the secondary symptoms (conductive hearing loss) regarding its extension towards the interior of the external auditory meatus. Surgical removal was suggested aiming the recovery of patient's hearing ability as there was no other alteration that justified hearing loss.
    Cysts External Auditory Meatus pictures attachment.php?s=b9d363d33199291d3f213272b427c2ae&attachmentid=1876&d=1441393795

    CASE REPORT
    A 41-year-old-femaleL Caucasian patient searched for assistance complaining of hearing loss to the left side, with no otorrhea or ear pain. Symptoms arouse around 5 years ago with small retroauricular node, but no phlogistic signs, which receded gradually in two months and so did the signs and symptoms. In the following months, she noticed a progressive hypoacusis recurrence and after searching for ENT assistance was diagnosed of Cerumen impaction, which blocked the external ear meatus. She was also submitted to two warm water irrigations with no improvement of symptoms, and developed intense itching and pain. Then, she was examined (by the authors) through clinical ENT exam with an otoscope, and presented left EAC stenosis (external ear canal), which prevented the observation of the ipsilateral tympanic membrane. Tonal audiometry presented hearing threshold within normal limits to the right and mild conductive hearing loss to the let (Picture 1); immitanciometria showed curve A and bilateral stapedial reflexes. CT scan of mastoid bone with no contrast presented oval structure (Picture 2A), presence of fat, its larger axis measuring about 1.5 x 1.2cm (Picture 2B), between the soft tissues which cover the superior wall of the EAC inside, presenting a lipoma aspect. According to the diagnosis, surgical resection with complete removal of the lesion through retroauricular access and then anatomopathological exam of the surgical specimen were recommended. During surgery, it was found a 2cm diameter mass with citrine liquid (Picture 2C). This mass had uneven surface; it was soft and redish, and was placed in the posterior EAC area, extending into the mastoid bone (Picture 2D). Histopathological result was a suppurated epidermal cyst with giant-cell reaction.

    DISCUSSION
    A nodule in the ear is quite notable and should be seen by an ENT or skin doctor. It is a close, prominent, touchable, profound lesion sited on the dermis or cartilage, what can perforate by secondary cutaneous ulcer. Clinical context, precise localization, dermal and histological aspects help on diagnosing it.

    Dermoid cysts on the outer ear are rare. There are three cases of retroauricular dermoid cystsdescribed in the literature and five ones in the Japanese literature. All of them occurring in the superior part of the ear.

    Trichilemmal or sebaceous cysts are similar to the epidermoid one. The histopathological exam assures the diagnosis by a capsule formed by all epidermis layers and its content is composed by horny material (keratin). Lipomas are benign tumor composed by fatty tissue and can present the same aspect of the dermoid cysts. Hemangiomas are often present at birth; they are benign tumors of the vascular endothelial which can develop in spontaneous manner.

    In the current report, anamnesis and physical exam showed progressive hearing loss complaint in the past 5 years and a nodule on the posterior wall of the EAC. Therefore, among all possibilities of diagnosing, excisional biopsy was chosen in order to be confirmed by the histopathological exam of the specimen. Tonal audiometry to measure hearing loss degree and CT scan to better evaluate the anatomy of the lesion and possible involvement of adjacent structures were chosen as preoperative exams. Surgical removal is the therapy for epidermoid cysts, and its localization determines surgical approach and also it should be a healing type.

    For being a lesion sited on the posterior wall of the EAC by the mastoid and in order to completely ease symptoms, the current authors chose the retroauricular access for being a better accessible surgery and for providing easy identification and resection of the pathological process. It was necessary EAC packing by using Gelfoamâ and antibiotic cream in order to re-establish the skin canal, which was previously displaced by the cyst.

    WHAT IS GOING ON IN MY BODY? The most common type of benign ear cyst is a cholesteatoma (also known as keratoma). A cholesteatoma is a cyst that forms usually in the middle ear (the space behind the eardrum). There are several ways that a cholesteatoma can form. They can result from remnants of skin in the middle ear left over from the embryologic process of middle ear development and are, therefore, termed congenital cholesteatomas. They typically arise in the upper, most forward portion of the middle ear space. Another way that cholesteatoma forms is from a retraction pocket arising from the tympanic membrane (eardrum). A retraction pocket forms when the eustachian tube that normally drains the ear into the back part of the nasal cavity does not function well, and a vacuum develops behind the drum. This vacuum then starts to pull the eardrum inward, and if this process continues long enough, pockets or pouches can form from it. The outer layer of the tympanic membrane is a very thin layer of skin. As this pocket or pouch continues to enlarge, the skin lining of the pocket has more difficulty getting rid of the dead skin, and therefore, it starts to accumulate. As it accumulates within the pouch, it can get infected or can start to erode some of the bony structures in the middle ear, such as the ossicles or the bony structure (cochlea) that houses the inner ear or the bony covering of the facial nerve. Another way in which a cholesteatoma can form is if there is a hole in the eardrum (perforation). This is particularly likely if the edge of the hole is in contact with the outer ear canal. The skin that lines the ear canal or the eardrum can then grow through the perforation into the middle ear and then the enlarging mass of skin can accumulate, creating the same problem mentioned above for a retraction pocket cholesteatoma. Lastly, it is also thought that chronic inflammation in the middle ear can lead to cholesteatoma. With chronic inflammation of any mucous membrane surface it can start to change into a lining more similar to skin. If this transformation becomes complete, then skin can replace areas of the normal mucous membrane behind the eardrum. Since the shedding skin is then trapped behind the eardrum, the skin continues to accumulate and can result in infection or destruction of middle ear structures. One of the main causes of cholesteatoma formation is a eustachian tube that does not function well. Eustachian tube problems tend to run in families or certain ethnic groups, such as Eskimos or individuals of American Indian descent. Other disorders, such as cleft palate, Down’s syndrome, or other craniofacial abnormalities that impair eustachian tube function may also have a higher frequency of cholesteatoma formation.
    Cysts External Auditory Meatus pictures attachment.php?s=b9d363d33199291d3f213272b427c2ae&attachmentid=1876&d=1441393795

    WHAT ARE THE SIGNS AND SYMPTOMS? For cholesteatomas often there is a history of difficulty with eustachian tube function, so that there may have been frequent ear infections in the past. The most common symptom of a hematoma is gradual decline in hearing. These individuals often have an ear that drains infected material out of the ear canal on an intermittent basis. This would be mostly true for those patients who have retraction pocket or perforation-related cholesteatomas. The individual with congenital hearing cholesteatoma will mostly demonstrate progressively declining hearing. Symptoms of great concern in an individual with hearing loss and ear drainage would be facial paralysis or vertigo. These symptoms would be an indication of erosion through the bony canal housing the facial nerve or the bony boundary of the inner ear, respectively. Prior to the employment of antibiotics and improved access to health care, cholesteatomas were complicated by meningitis, brain abscess, or epidural abscess with a subsequent high morbidity and mortality rate.

    WHAT ARE THE CAUSES AND RISKS? As mentioned previously, the main cause of cholesteatoma would be congenital, retraction pockets consequent to eustachian tube dysfunction, or tympanic membrane perforation, often a result of eustachian tube dysfunction, previous ventilation tube placement, or trauma. Lastly, chronic middle ear disease may also increase the risk of cholesteatoma formation. As discussed previously, other factors that would cause a poorly functioning eustachian tube and place a patient at risk are cleft palate, Down’s syndrome, craniofacial abnormality, or Eskimo/American Indian descent. One other group deserves special mention. Welders who get slag burns of the eardrum have a fairly high risk of cholesteatoma formation.

    References:
    Benign Ear Cyst or Tumor | Advanced Otolaryngology











    Last edited by Medical Photos; 09-04-2015 at 07:11 PM.

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