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Keratosis Obturans

Keratosis Obturans of External Ear (canal)

Keratosis obturans is characterized by the plugging and occlusion of the external auditory meatus with debris made up of keratin, leading to enlargement of the ear canal without bone erosion. The clinical manifestations include bilateral otalgia and conductive hearing loss. The diagnosis is based on the patient history, physical examination, and appropriate studies.


Presentation

Keratosis obturans is a disease of the external auditory meatus in which keratinaceous debris accumulate and form a plug in the ear canal, thereby causing occlusion and widening of the bony component [1] [2]. This rare disorder was previously considered as a variation of cholesteatoma of the external auditory canal (CEAC) but is now regarded as a distinct condition [1]. While the etiology is not fully understood, keratosis obturans is classified as either inflammatory, which is associated with a recent acute infection or silent, which does not have a predisposing event [3]. The estimated incidence is 4 to 5 cases per 1000 patients with ear complaints [3].

This disorder occurs predominantly in younger individuals [1] [4] who manifest with acute bilateral ear pain and conductive hearing loss [1] [5]. Furthermore, discharge is not a frequent symptom in these patients [4] [6]. Moreover, the cases are overall healthy [5]. Additionally, keratosis obturans is associated with bronchiectasis and sinusitis [1] [7].

Complications

There are a few incidences in the literature describing facial nerve palsy in patients with keratosis obturans [5] [8] [9]. This neurologic sequela may develop secondary to inflammation [5] or bone erosion [8] [9], of which the latter is not a feature of keratosis obturans [1].

Physical exam

Otoscopy typically reveals an occluding mass in the ear canal [10]. Additionally, tuning fork [5] and pure tone audiometry (PTA) [10] are performed to test and confirm conductive hearing loss.

The victim should be evaluated for neurological deficits such as facial nerve palsy. Additionally, a full head, neck, and oropharynx exam should be completed.

Crying
  • […] subscribe to these sites : and Footer ABOUT DR PAULOSE… Dr Paulose FRCS, DLO is Consultant ENT Plastic & Laser Surgeon offering private specialist care for ear nose and throat problems as well as the management Read More… GRAB THE EBOOK… Snoring is a cry[drpaulose.com]
Metallic Taste
  • A case of keratosis obturans is described in which the principal symptom was a metallic taste and the main finding was extensive erosion of the hypotympanum with exposure of the facial nerve and the annulus of the tympanic membrane.[ncbi.nlm.nih.gov]
  • Patients with Keratosis obliterans comes usually with pain and hearing loss and can also be accompanied by symptoms such as metallic taste. Patients can come without interruption ears but only with impaired only metallic taste.[dayfres.blogspot.com]
Otalgia
  • Classically, it is reported to present with severe otalgia, conductive deafness and global widening of the canal.[ncbi.nlm.nih.gov]
  • Classically, it is reported to present with severe otalgia, conductive hearing loss and global widening of the external auditory canal.[ncbi.nlm.nih.gov]
  • The clinical manifestations include bilateral otalgia and conductive hearing loss. The diagnosis is based on the patient history, physical examination, and appropriate studies.[symptoma.com]
  • Classically, it is reported to present with severe otalgia, conductive deafness and global widening of the canal. The frequency of keratosis obturans has been estimated as 4-5 in 1000 new otological cases.[austinpublishinggroup.com]
  • Risk Factors Sinusitis Bronchiectasis Diagnosis History and Symptoms Partial hearing loss Otalgia Otorrhea Associated sinusitis or bronchitis may be present.[wikidoc.org]
Normal Hearing
  • Chronic otorrhoea with normal hearing, itchiness, or pain. Older populations, usually unilateral. Pathology Keratin plug occluding canal, TM thicken& standing out in relief in a widened ear canal. Ear canal grossly widen or ballooned.[shekharkrishnadebnath.wordpress.com]
Neck Mass
  • Enhance your understanding with multiple-choice questions accompanying each case, emphasizing cranial nerves, skull base lesions, sinonasal, orbital, salivary gland, aerodigestive system mucosal lesions and deep space neck masses.[books.google.com]

Workup

The clinical presentation should raise suspicion for keratosis obturans and CEAC, in which a workup consisting of the patient history, physical exam, and appropriate tests will help determine the diagnosis.

Imaging

Key imaging modalities include high-resolution computed tomography (HRCT) scan of the temporal bone, which will display the soft-tissue accumulation residing in the external ear canal(s) [5] [11] and dilation of the walls of the canal [2] [11]. These findings are typically bilateral in people with keratosis obturans but unilateral in CEAC [12]. Moreover, imaging of the external auditory canal with axial CT reveals no necrosis or bone erosion [1]. Very importantly, keratosis obturans does not involve osseous erosion of the canal as seen with CEAC [2] [12].

Pathology

Keratosis obturans is associated with an enlarged ear canal, epithelial hyperplasia, and subepithelial inflammation [13]. Moreover, histopathological analysis of the debris reveals lamellar keratinous elements [1].

Other

In addition to performing a complete physical exam including a focus on the head and neck region, testing with the tuning fork and PTA are important to evaluate hearing loss [5] [10].

Treatment

  • The clinical symptoms, pathologic processes, and treatment are outlined and compared. Case reports are presented to illustrate the features of these two diseases.[ncbi.nlm.nih.gov]
  • Treatment: The treatment of keratosis obturans includes the mechanical removal of the epidermal plug and periodic cleansing of the canal. Granulation tissue may be managed by removal, cauterization, or the use of topical steroid drops.[medigoo.com]
  • While this remains the treatment of choice for keratosis obturans, surgery may be required to eradicate EACC.[ncbi.nlm.nih.gov]
  • The essential component of treatment in all cases of EACC was microscopic debridement of the ear canal. We conclude that EACC may produce significant erosion of bone with exposure of vital structures, including the facial nerve.[ncbi.nlm.nih.gov]
  • A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions.[leehealth.org]

Prognosis

  • Outlook (Prognosis) Regular follow-ups and cleaning by the provider are important to avoid infections. In some people, lifetime cleaning may be needed.[account.allinahealth.org]
  • […] usually show air foci e xternal auditory canal cholesteatoma : EAC soft tissue density with bony erosion external auditory canal carcinoma: irregular mass with or without bony erosion otitis externa : surrounding inflammatory fat stranding Treatment and prognosis[radiopaedia.org]

Etiology

  • Etiology: Keratosis obturans is postulated to occur due to abnormal epithelial migration of ear canal skin. The movement of the surface epithelium appears to be reversed in these patients.[sites.google.com]
  • While the etiology is not fully understood, keratosis obturans is classified as either inflammatory, which is associated with a recent acute infection or silent, which does not have a predisposing event.[symptoma.com]
  • Seite 53 - A longitudinal study of respiratory viruses and bacteria in the etiology of acute otitis media with effusion - Henderson FW, Collier AM, Sanyal MA et al. ‎[books.google.de]
  • الصفحة 53 - A longitudinal study of respiratory viruses and bacteria in the etiology of acute otitis media with effusion - Henderson FW, Collier AM, Sanyal MA et al. ‏[books.google.com]
  • Etiology keratosis obturans until now unknown. However, it may be because of eczema, seborrheic and furonkulosis.[dayfres.blogspot.com]

Epidemiology

  • Definitions, differential diagnosis, and epidemiology. Am J Surg Pathol 1996; 20(1):103-111. ‎ Seite 91 - Everett LA, Glaser B, Beck JC, Idol JR. Buchs A, Heyman M, Adawi F, Hazani E, Nassir E.[books.google.de]
  • Definitions, differential diagnosis, and epidemiology. Am J Surg Pathol 1996; 20(1):103-111. ‏ الصفحة 91 - Everett LA, Glaser B, Beck JC, Idol JR. Buchs A, Heyman M, Adawi F, Hazani E, Nassir E.[books.google.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Keratosis obturans is thought to occur due to abnormal epithelial migration of ear canal skin. The movement of the surface epithelium appears to be reversed in these patients.[wikidoc.org]
  • The disease is sometimes associated with bronchiectasis and chronic sinusitis Pathophysiology There are two different forms of the pathophysiology of keratosis obliturans or obliterans.[dayfres.blogspot.com]

Prevention

  • Increased awareness of these uncommon conditions is warranted to prompt appropriate investigation and prevent iatrogenic complications such as facial nerve injury.[ncbi.nlm.nih.gov]
  • "External auditory canal cholesteatoma and keratosis obturans: the role of imaging in preventing facial nerve injury". Ear Nose Throat J. 90 (12): E1–7. PMID 22180115.[wikidoc.org]
  • In addition, surgery can be performed with general anesthesia for surgical debridement, canal plasty and timpanomastoidektomi can be done to Prevent the continued erosion of bone.[dayfres.blogspot.com]
  • Wax is secreted for protection, and keeps the canal acidic, helping to prevent infection. It also acts as a collection point for debris, dust and dirt. Generally it migrates out on its own.[earcare.co.nz]

References

Article

  1. Dalton SR, Ferringer T, Mowad CM. Obstruction of the external auditory canal by a keratin cast: Keratosis obturans or cholesteatoma? J Am Acad Dermatol. 2011;65(3):e88-89.
  2. Persaud RA, Hajioff D, Thevasagayam MS, Wareing MJ, Wright A. Keratosis obturans and external auditory canal cholesteatoma: how and why we should distinguish between these conditions Clin Otolaryngol Allied Sci. 2004;29(6):577-581.
  3. Tristram HJ. Keratosis obturans and primary auditory canal cholesteatoma. Scott-Brown's Otorhinolaryngology: Head and Neck Surgery. 7th ed. London, England: Hodder Arnold; 2008: 3342-3344.
  4. Tran LP, Grundfast KM, Selesnick SH. Benign lesions of the external auditory canal, Otolaryngol Clin North Am. 1996;29(5):807-825.
  5. Saniasiaya J, Nik Othman NA, Mohamad Pakarul Razy NH. Keratosis obturans complicated with facial nerve palsy: a diagnostic dilemma. Braz J Otorhinolaryngol. 2016; pii: S1808-8694(16)30092-1.
  6. Holt JJ. Ear canal cholesteatoma. Laryngoscope 1992;102(6):608–613.
  7. Piepergedes JC, Behnke EE. Keratosis obturans and external auditory canal cholesteatoma. Laryngoscope. 1980;90(3):383-391.
  8. Glynn F, Keogh IJ, Burns H. Neglected keratosis obturans causing facial nerve palsy. J Laryngol Otol. 2006;120(9):784-785.
  9. Al-Juboori AN. Keratosis obturans: a rare cause of facial nerve palsy. Austin J Otolaryngol. 2015; 2:1039.
  10. Corbridge RJ, Michaels L, Wright T. Epithelial migration in keratosis obturans. Am J Otolaryngol. 1996;17(6):411-414.
  11. Brea B, Roldán Fidalgo A. Imaging Diagnosis of Benign Lesions of the External Auditory Canal. Acta Otorrinolaringol Esp. 2013;64(1):6-11.
  12. Dubach P, Mantokoudis G, Caversaccio M. Ear canal cholesteatoma: meta-analysis of clinical characteristics with update on classification, staging and treatment. Curr Opin Otolaryngol Head Neck Surg. 2010;18(5):369-376.
  13. Naiberg J, Berger G, Hawke M. The pathologic features of keratosis obturans and cholesteatoma of the external auditory canal. Arch Otolaryngol. 1984;110(10):690–693.

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Last updated: 2019-07-11 21:29