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Background: Epithelial migration has been associated with the self-cleansing mechanism of the ear. The rate and pattern of epithelial migration in healthy and pathological ears are reviewed., Methods: Two authors independently screened articles over one month using the following search terms: epithelial migration, epithelial, tympanic membrane, external auditory canal and mastoidectomy cavity., Results: Ten studies were included. The fastest rate of epithelial migration was observed in the external auditory canal, with a mean of 144.75 μm per day, whereas the slowest epithelial migration was seen in post-mastoidectomy cavities, with a rate of 20 μm per day. Epithelial migration was present in both studies involving post-mastoidectomy cavities., Conclusion: Epithelial migration is faster in healthy tympanic membrane than in pathological tympanic membrane. The rate of epithelial migration in the external auditory canal was higher in the pathological group than in the healthy group. Epithelial migration is present in post-mastoidectomy cavities.

Background: The prognosis of patients with advanced squamous cell carcinoma of the external auditory canal and middle ear has been improved by advances in skull base surgery and multidrug chemoradiotherapy during the last two decades., Methods: Ninety-five patients with squamous cell carcinoma of the external auditory canal and middle ear who were treated between 1998 and 2017 were enrolled. The number of patients with tumour stages T1, T2, T3 and T4 was 15, 22, 24 and 34, respectively. Oncological outcomes and prognostic factors were retrospectively investigated., Results: Among patients with T4 disease, invasion of the brain (p = 0.024), carotid artery (p = 0.049) and/or jugular vein (p = 0.040) were significant predictors of poor prognosis. The five-year overall survival rate of patients with at least one of these factors (T4b) was significantly lower than that of patients without these factors (T4a) (25.5 vs 65.5 per cent, p = 0.049)., Conclusion: It is proposed that stage T4 be subclassified into T4a and T4b according to the prognostic factors.

Objective: This study aimed to provide a systematic review on survival outcome based on Pittsburgh T-staging for patients with primary external auditory canal squamous cell carcinoma., Method: This study was a systematic review in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines performed until January 2018; pertinent studies were screened. Quality of evidence was assessed using the grading of recommendation, assessment, development and evaluation working group system., Results: Eight articles were chosen that reported on 437 patients with external auditory carcinoma. The 5-year overall survival rate was 53.0 per cent. The pooled proportion of survivors at 5 years for T1 tumours was 88.4 per cent and for T2 tumours was 88.6 per cent. For the combined population of T1 and T2 cancer patients, it was 84.5 per cent. For T3 and T4 tumours, it was 53.3 per cent and 26.8 per cent, respectively, whereas for T3 and T4 tumours combined, it was 40.4 per cent. Individual analysis of 61 patients with presence of cervical nodes showed a poor survival rate., Conclusion: From this review, there was not any significant difference found in the survival outcome between T1 and T2 tumours. A practical classification incorporating nodal status that accurately stratifies patients was proposed.

Objective: To depict various temporal bone abnormalities on high-resolution computed tomography in congenital aural atresia patients, and correlate these findings with auditory function test results and microtia subgroup., Methods: Forty patients (56 ears) with congenital malformation of the auricle and/or external auditory canal were evaluated. Auricles were graded according to Marx's classification, divided into subgroups of minor (grades I and II) and major (III and IV) microtia. Other associated anomalies of the external auditory canal, tympanic cavity, ossicular status, oval and round windows, facial nerve, and inner ear were evaluated., Results: Minor and major microtia were observed in 53.6 and 46.4 per cent of ears respectively. Mean hearing levels were 62.47 and 62.37 dB respectively (p = 0.98). The malleus was the most commonly dysplastic ossicle (73.3 vs 80.8 per cent of ears respectively, p = 0.53). Facial nerve (mastoid segment) abnormalities were associated (p = 0.04) with microtia subgroup (80 vs 100 per cent in minor vs major subgroups)., Conclusion: Microtia grade was not significantly associated with mean hearing levels or other ear malformations, except for external auditory canal and facial nerve (mastoid segment) anomalies. High-resolution computed tomography is essential in congenital aural atresia, before management strategy is decided.

Objective: This paper reviews our experience of potassium titanyl phosphate (KTP) laser in transcanal totally endoscopic cholesteatoma surgery., Methods: A prospective cohort study was conducted in a tertiary referral centre, involving a consecutive series of children with cholesteatoma who underwent totally endoscopic cholesteatoma surgery with a KTP laser., Results: The patients' mean age was 10.5 years (range, 1.8-18 years). A KTP laser was used in 70 of the 83 cases (84 per cent). The laser was not used in 13 'clean' cases, in which disease was removed more easily. Residual disease was detected in five cases (6 per cent), of which the KTP laser had been used in four (5 per cent). No complications were associated with KTP laser use., Conclusion: The combination of KTP laser use with endoscopic visualisation is effective for minimising the risk of residual disease using a minimally invasive surgical approach. The thin, semi-flexible fibre carrier of the KTP laser is ideally suited to work alongside the endoscope within the narrow confines of the ear canal.

Background: External auditory canal exostoses are known to occur in patients who engage in cold-water sports. Although the majority of patients with exostosis remain asymptomatic, larger lesions can cause wax impaction, conductive hearing loss and predispose to recurrent otitis externa., Objective: A novel technique is described of using a piezo saw to excise exostoses that are symptomatic. The piezo saw is used to perform various procedures, but its use in removing exostoses has not been described in the literature., Conclusion: Excision of exostoses of the ear canal using a piezo saw is a safe technique and patients have a speedy recovery. This paper describes a new technique for removing exostoses.

Objective: To identify epidemiological and pathophysiological factors, and treatment strategies, in external auditory canal cholesteatoma and benign necrotising otitis externa., Methods: A retrospective case study was conducted of patients suffering from external auditory canal cholesteatoma and benign necrotising otitis externa admitted to tertiary hospitals, in the Capital Region of Denmark, over a five-year period., Results: Eighty-three patients (95 ears) with external auditory canal cholesteatoma or benign necrotising otitis externa were identified. A minimum incidence rate of 0.97 per 100 000 inhabitants per year was demonstrated. Sixty-eight per cent of cases had a history of smoking. Most lesions (74 per cent) were localised in the floor of the ear canal. Treatment time was 3.2 months for patients who had surgery and 6.0 months for those who received conservative treatment., Conclusion: It is suggested that external auditory canal cholesteatoma and benign necrotising otitis externa are in fact the same disease, and therefore the diagnosis of external auditory canal cholesteatoma should be changed to benign necrotising otitis externa. Microangiopathy has a leading role in the aetiology. Surgery should be conducted in most cases.

Background: Oesophageal disorders and osteonecrosis of the jaw are recognised complications of the commonly prescribed medication bisphosphonate. Despite these diagnoses being seen comparatively frequently within the ENT clinic, osteonecrosis of the external ear is a less well reported complication., Methods: The current literature is reviewed and our experience with six cases of bisphosphonate-related ear canal osteonecrosis is presented., Results: Six cases were identified as suffering from ear canal osteonecrosis as a result of bisphosphonate treatment. One of our cases suffered bilateral ear canal osteonecrosis after only 20 months of oral alendronic acid treatment. Management ranged from bisphosphonate cessation and topical treatment, to surgical debridement in the operating theatre., Conclusion: Bisphosphonate-related ear canal osteonecrosis is undoubtedly under-diagnosed. For such a commonly prescribed medication, the risks and side effects of bisphosphonate should be better known and long-term treatment should be avoided if possible.

Objectives: The bony cochlear nerve canal is the space between the fundus of the internal auditory canal and the base of the cochlear modiolus that carries cochlear nerve fibres. This study aimed to determine the distribution of bony labyrinth anomalies and cochlear nerve anomalies in patients with bony cochlear nerve canal and internal auditory canal atresia and stenosis, and then to compare the diameter of the bony cochlear nerve canal and internal auditory canal with cochlear nerve status., Methods: The study included 38 sensorineural hearing loss patients (59 ears) in whom the bony cochlear nerve canal diameter at the mid-modiolus was 1.5 mm or less. Atretic and stenotic bony cochlear nerve canals were examined separately, and internal auditory canals with a mid-point diameter of less than 2 mm were considered stenotic. Temporal bone computed tomography and magnetic resonance imaging scans were reviewed to determine cochlear nerve status., Results: Cochlear hypoplasia was noted in 44 out of 59 ears (75 per cent) with a bony cochlear nerve canal diameter at the mid-modiolus of 1.5 mm or less. Approximately 33 per cent of ears with bony cochlear nerve canal stenosis also had a stenotic internal auditory canal and 84 per cent had a hypoplastic or aplastic cochlear nerve. All patients with bony cochlear nerve canal atresia had cochlear nerve deficiency. The cochlear nerve was hypoplastic or aplastic when the diameter of the bony cochlear nerve canal was less than 1.5 mm and the diameter of the internal auditory canal was less than 2 mm., Conclusion: The cochlear nerve may be aplastic or hypoplastic even if temporal bone computed tomography findings indicate a normal cochlea. If possible, patients scheduled to receive a cochlear implant should undergo both computed tomography and magnetic resonance imaging of the temporal bone. The bony cochlear nerve canal and internal auditory canal are complementary structures, and both should be assessed to determine cochlear nerve status.

Background: Direct extension of an intracranial meningioma to involve the temporal bone is rare. Recognised sites of origin and routes of access to the middle ear and labyrinthine apparatus have been described. Direct spread through the temporal bone to primarily involve the external auditory canal has not been widely reported in the literature., Case Reports: This paper discusses clinical and radiological findings in three cases of temporal bone meningioma presenting as masses within the external auditory canal., Conclusion: Diagnosing temporal meningioma can be challenging because of its rarity and the often non-specific clinical and histological findings. It is important for both the surgeon and radiologist to be aware of the diagnosis and its related imaging findings in order to facilitate a timely diagnosis.

Objective: To review reports of adenoid cystic carcinomas arising in the head and neck area outside of the major salivary glands, in order to enhance the care of patients with these unusual neoplasms., Methods: An international team of head and neck surgeons, pathologists, oncologists and radiation oncologists was assembled to explore the published experience and their own working experience of the diagnosis and treatment of adenoid cystic carcinomas arising in the vicinity of the sinonasal tract, nasopharynx, lacrimal glands and external auditory canal., Results: The behaviour of adenoid cystic carcinoma arising in head and neck sites exclusive of the major salivary glands parallels that of tumours with a similar histology arising in the major salivary glands - these are relentless, progressive tumours, associated with high rates of mortality. Of 774 patients reviewed, at least 41 (5.3 per cent) developed documented regional node metastases., Conclusion: The relatively low overall incidence of nodal metastases in adenoid cystic carcinomas arising in the head and neck region outside of the major salivary glands suggests that routine elective regional lymph node dissection might not be indicated in most patients with these tumours.

Objective: This study aimed to assess the prevalence and profile of ear diseases in children from Delhi, India., Methods: A population-based cross-sectional door-to-door survey was carried out in two districts of Delhi, and involved children of all demographic sections of the region. A total of 4626 children aged between 18 days and 15 years underwent examinations including otoscopy, impedance audiometry and hearing screening., Results: In all, 14.8 per cent of the study sample was diagnosed with one or more ear morbidities, the most common being cerumen impaction (7.5 per cent) and chronic suppurative otitis media (3.6 per cent). There was clinical evidence of otitis media with effusion in 2 per cent of children, and 0.96 per cent had otitis externa (bacterial and fungal). The point prevalence of acute suppurative otitis media was 0.39 per cent. In all, 0.45 per cent of children were found to have an undiagnosed foreign body within the ear canal., Conclusion: The high prevalence of ear disease poses a significant public health problem in Delhi.

Objectives: To evaluate the primary and long-term surgical outcomes of patients with postinflammatory medial meatal fibrosis., Methods: A retrospective study was conducted of 14 ears (in 12 patients) with postinflammatory medial meatal fibrosis managed surgically. Outcome measures were primary (i.e. less than six months) and long-term (i.e. greater than five years) closure of the air-bone gap, and the incidence of otorrhoea and restenosis., Results: At primary review, the mean air-bone gap ± standard deviation had decreased from 29.9 ± 11.6 dB to 12 ± 8.4 dB (p < 0.0006). Seven (50 per cent) ears had closure of the air-bone gap to within 10 dB. However, for the 9 ears receiving long-term review, the mean air-bone gap ± standard deviation increased to 19.3 ± 15.2 dB; there was no significant difference between this result and pre-operative values (p = 0.06). Of the 9 long-term review ears, 3 (33 per cent) showed closure of the air-bone gap to within 10 dB. Recurrent otorrhoea was the most common complication, occurring in 5 of the 9 long-term review ears (56 per cent); in addition, 3 (33 per cent) of these 9 ears developed restenosis., Conclusion: Over time, the success of surgery for postinflammatory medial meatal fibrosis diminishes. This was demonstrated in the present study by progressive post-operative hearing decline and a high prevalence of otorrhoea and restenosis.

Background: Osteonecrosis is a benign condition characterised by necrotic exposed bone, and is associated with bisphosphonate use. Osteonecrosis of the external auditory canal is rare, with only a few reported cases., Method: Two case reports of temporal bone osteonecrosis are presented., Results: A 64-year-old man with a history of immunoglobulin G kappa multiple myeloma developed a right external auditory canal ulcer 6 years after commencement on clodronate. A 72-year-old woman taking alendronate for osteoporosis, initially diagnosed and treated for right-sided otitis externa, was found to have underlying exposed bone in the right external auditory canal, with a computed tomography scan confirming destruction of the temporal bone., Conclusion: With increasing use of both oral and intravenous bisphosphonates in the community for benign conditions such as osteoporosis and for malignant conditions such as breast cancer and multiple myeloma, the diagnosis of bisphosphonate-associated osteonecrosis should always be considered in patients with a temporal bone lesion, and a relevant drug history taken.

Objective: This study aimed to investigate the computed tomography and magnetic resonance imaging findings of primary middle-ear carcinoma., Methods: In this retrospective study of 13 patients with primary middle-ear carcinoma, we collected pre- and post-contrast magnetic resonance images for all 13 cases, high-resolution computed tomography scans for 11 cases, and conventional computed tomography scans with contrast for 2 cases., Results: Soft-tissue masses were mainly located in the tympanum, tympanic sinus and deep within the external auditory canal, and involved the jugular fossa (9 of 13 patients), middle cranial fossa (5/13), parotid gland (2/13) and temporomandibular joint fossa (1/13). An irregular, 'moth-eaten' bone destruction pattern was seen on high-resolution computed tomography images, most commonly in the eustachian tube (9/13), jugular foramen (9/13) and facial nerve canal (7/13). On non-contrast magnetic resonances images, masses were isointense or slightly hypointense on T1-weighted images, and isointense or slightly hyperintense on T2-weighted images. On post-contrast images, lesions were moderately and homogeneously enhanced in seven cases and inhomogeneously enhanced in six., Conclusion: High-resolution computed tomography precisely detects regions of bone destruction, whereas MRI can better assess soft-tissue tumour margins, intracranial extension and vessel patency. Eustachian tube erosion is an important characteristic of primary middle-ear carcinoma.

Background: Lesions arising in the external auditory canal that require surgical excision are uncommon. They are associated with a range of pathologies, including bony abnormalities, infections, benign and malignant neoplasms, and epithelial disorders., Methods: This paper describes a 10-year personal case series of external auditory canal lesions with chart, imaging and histopathology review., Results: In total, 48 lesions required surgical management, consisting of: 13 bony lesions; 14 infective lesions; 14 neoplasms with 11 histological types (including ceruminous adenoma and the extremely rare cavernous haemangioma); 3 epithelial abnormalities; and 4 other benign lesions. The surgical management is described., Conclusion: This study emphasises the diagnostic differences between exostoses and osteomas, and between external auditory canal cholesteatoma and keratosis obturans. It also discusses the management of aural polyps, and highlights the need to excise external auditory canal masses for histology in order to guide subsequent treatment.

Objectives: We describe a rare case of spontaneous temporomandibular joint herniation into the external auditory canal, and we also review the presentation, aetiology and management of such cases., Case Report: An 87-year-old woman presented with a four-month history of left-sided otorrhoea and otalgia. Examination revealed a soft, polypoid mass in the left ear canal. When the patient opened her mouth the lesion disappeared. Subsequent computed tomographic imaging of the patient's temporal bones confirmed an 8.6 mm defect in the antero-inferior portion of the left ear canal, with herniation of retrodiscal soft tissues., Conclusion: The external auditory canal is intimately related to the temporomandibular joint, separated only by its bony anterior wall. Neoplasm, trauma or inflammation in this area can result in displacement of the temporomandibular joint into the ear canal; however, spontaneous herniation is rare. Persistence of the primitive foramen of Huschke can result in dehiscence of the anterior canal wall, allowing articular tissue to prolapse into the ear canal. Surgical closure of these defects is known to be effective in ameliorating symptomatic cases.

Objective: To raise awareness of nasal malignant melanoma, a rare tumour, and to highlight the difficulty associated with its optimum management., Method: Case report and literature review., Case Report: A 71-year-old, Caucasian man was diagnosed with malignant melanoma in the right nasal cavity, after presenting with right-sided epistaxis. He underwent endoscopic medial maxillectomy; histological analysis confirmed that the resection margins were clear. However, within six months he re-presented with a metastatic deposit of malignant melanoma in his right external auditory canal, for which he underwent right temporal bone resection. There was no evidence of distant metastasis on radiological studies. Unfortunately, within a month the tumour recurred in the right nasopharynx. A multidisciplinary team decision was made to offer the patient palliative chemoradiotherapy., Conclusion: Mucosal malignant melanoma of the nose is very rare, and aural metastasis from this primary site has not previously been reported. Optimum management must involve a multidisciplinary team.

Objective: To report an unusual case of fungal mastoiditis caused by entomophthorales in an immunocompetent patient, and its management., Method: Case report with a review of the literature., Case Report: A 13-year-old girl presented to us with a mastoid abscess. Entomophthoromycotic infection of the mastoid was diagnosed on histopathological examination, and subsequently treated with surgical debridement and amphotericin B injection., Conclusion: This is the first reported case of mastoid abscess secondary to entomophthoromycosis. Early detection and treatment contributed to this patient's good outcome.

Objective: This study aimed to demonstrate the histological and immunohistological features of skin biopsy specimens from patients complaining of isolated itching of the external auditory canal., Materials and Methods: A prospective, case-control study was performed of 24 patients undergoing evaluation for contact dermatitis of the external auditory canal, and 24 controls. Skin biopsies were examined histologically by a single, blinded dermatopathologist, using light microscopy, to determine histopathological characteristics. The immunohistological presence of the antimicrobial peptides human β-defensin-3 and LL-37 cathelicidin was also assessed. Findings for patients and controls were compared., Results: There was a statistically significant difference in the degree of inflammation, comparing patients and controls (p < 0.05). There was no significant difference in the presence of spongiotic changes, comparing patients and controls (p > 0.05). Furthermore, the patients' skin biopsies did not show pronounced expression of human β-defensin-3 or LL-37 cathelicidin., Conclusion: Histological and immunohistological examination of skin biopsies from cases of isolated itching of the external auditory canal did not support a diagnosis of dermatitis.

Background: Of the acquired ear canal atresias, idiopathic, inflammatory, medial meatal, fibrotising otitis has been suggested as a distinct disease entity, for reasons of aetiology., Objective: To report three more cases of idiopathic, inflammatory, medial meatal, fibrotising otitis and to further consider the possible relationship between this condition and lichen planus., Patients: Three adult patients with idiopathic, inflammatory, medial meatal, fibrotising otitis, two with bilateral aural symptoms, treated and followed up at the department of otorhinolaryngology of Helsinki University Hospital., Results: We found idiopathic, inflammatory, medial meatal, fibrotising otitis, affecting solely the glabrous skin of the osseous part of the external ear canals, in three patients who also suffered from severe oral lichen planus., Conclusions: The aetiopathology or pathophysiology of idiopathic, inflammatory, medial meatal, fibrotising otitis may be linked with lichen planus. Early, active treatment of idiopathic, inflammatory, medial meatal, fibrotising otitis with local corticosteroids may prevent total medial meatal atresia.

Three patients with extensive keratosis obturans were treated during a 12-month period. One presented with an idiopathic sensorineural hearing loss and was found to have keratosis obturans in the contralateral, asymptomatic ear. The disease process had resulted in a horizontal semicircular canal fistula in what was now, effectively, the only hearing ear. The second patient had an extensive dehiscence of the tegmen tympani. The third presented with a facial palsy. An automastoidectomy cavity was present, with circumferential skeletonization of the descending facial nerve over a length of 1.5 cm and dehiscence of the temporomandibular joint and jugular bulb. All three patients were successfully treated by surgical formalization of their automastoidectomy cavities. They appeared to represent cases of keratosis obturans rather than external auditory canal cholesteatoma, on the basis of previously published reports.These complications and patterns of bone erosion have not previously been described in keratosis obturans. The third patient is believed to have the most extensive case of keratosis obturans yet described.

Keratosis obturans is characterized by the accumulation of desquamated keratinous material in the bony portion of the external auditory canal. Classically, it is reported to present with severe otalgia, conductive hearing loss and global widening of the external auditory canal. Extensive erosion of the bony meatus, with exposure of the facial nerve, has been previously reported, but no case of facial nerve palsy has as yet been published. We report the first published case, to our knowledge, of a unilateral facial nerve palsy secondary to neglected keratosis obturans.

We report two cases of carcinoma in situ in the external auditory canal (EAC), presenting with symptoms such as pain, long-term itching of the ear, easy contact bleeding, canal otorrhea and hearing loss. Otoscopic examination revealed granulation tissue and a greyish-black tumour with irregular surface. The first patient had previously been diagnosed with otitis externa with persistent ear itching for the past three years. The second patient had received tympanoplasty for treatment of chronic otitis media on the right ear ten years ago. The first case was treated with wide excision, whereas the second patient received resection of the skin of the EAC together with its adjacent soft tissue, followed by skin grafting. No tumour recurrence was noted in the fourth and third post-operative year for the first and second patient respectively. We suggest that EAC carcinoma can be detected early and treated.

Objective: We report our technique and results for endoscopy-aided CO2 laser therapy for the treatment of intractable granular myringitis, as an out-patient office procedure., Materials and Methods: A total of 21 patients (14 women and seven men; mean age 32.6 years) were retrospectively reviewed, all of whom suffered from intractable granular myringitis and had undergone endoscopy-aided laser treatment. Granulation tissue was vaporized for one to two seconds with a CO2 laser (spot size 0.5-1 mm with a power setting of 5-10 W in continuous mode). The mean follow-up period was 11 months., Results: Eighteen of the 21 patients (85 per cent) were cured after a single treatment. Three patients with the diffuse form of the disease required repeat laser treatments coupled with self-irrigation with a diluted vinegar solution. We noted no perforations of patients' tympanic membranes after laser vaporization. We also observed no recurrences over follow-up periods ranging from three months to 2.6 years. Our laser procedure produced no adverse effect on hearing thresholds, nor were any other complications observed., Conclusion: Our results suggest that endoscopy-aided CO2 laser ablation is a reliable and minimally invasive method associated with low rates of recurrence and a low incidence of complications. It can be conducted as an office procedure.

The aim of this study was to investigate the aetiology of acquired atresia and stenosis of the external auditory meatus and to present our results for surgical management. Over an 18-year period (from 1986 to 2004), data were collected prospectively from patient cohorts in Dundee and Edinburgh. Stenosis of the auditory meatus was due to chronic otitis externa in 64 per cent of cases, compared with 37 per cent of cases with acquired atresia; the latter had instead a history of chronic suppurative otitis media in 43 per cent. Surgical treatment of canal stenosis with meatoplasty alone achieved a widely patent ear canal in 80 per cent of cases, with 78 per cent of ears remaining free of discharge. Cases of acquired atresia treated with simple surgical excision of the soft tissue plug experienced a 100 per cent failure rate. The additional use of a split skin graft achieved a patent meatus in 70 per cent of cases, with hearing improvement in 79 per cent. However, the ear canal remained unstable and late recurrence was observed.

Tubular apocrine adenoma (TAA) is a very rare sweat gland tumour. Comprehensive review of the literature reveals that TAA in the external auditory canal (EAC) has not yet been reported. We report a case of TAA in the EAC, together with characteristic histopathological findings.

Bilateral myringotomy with insertion of ventilation tube (grommet) is the most common surgical procedure done on children under general anaesthetic. A prospective study was conducted on children undergoing grommet insertion to ascertain any relationship between exposures of passive smoking to the outcome of grommet insertion. Six hundred and six children (with 1174 ears) who underwent grommet insertion for recurrent secretory otitis media were followed up till the grommets were extruded. Thirty-three children (65 per cent), whose mothers smoked when they were pregnant, had bilateral narrow external ear canals. The median survival rate of grommet was 59 weeks in children who were exposed to passive smoking as compared to 86 weeks for non-exposed children and the extrusion rate of grommet was 36 per cent higher at the end of one year if both parents smoked compared to the non-smoking group. Post-extrusion myringosclerosis was 64 per cent if both parents smoked and less than 20 per cent if neither parents smoked. It is concluded that post-operative infection rate, attic retraction, post-extrusion myringosclerosis and permanent perforations of tympanic membrane were more common in children exposed to passive smoking. The study provides further support to professional and governmental advice that passive smoking is harmful.

Narghile (water-pipe) smoking requires the generation of significant negative intrapharyngeal pressure, which may be transmitted to the middle ear through the Eustachian tube. A total of 80 ears from regular narghile smokers were examined otoscopically and by tympanometry. Seventy ears from heavy cigarette smokers were similarly examined and served as a control group. There was a highly significant increase in the prevalence of attic retractions (P < 0.01) in the narghile smokers. The tympanometric changes were not significantly different between the two groups (P > 0.05).

Until now, little was known about the mode of parotid involvement in external auditory canal (EAC) carcinoma. The incidence of parotid node metastasis and direct parotid invasion was examined in patients with EAC carcinoma. The study comprised 11 patients with squamous cell carcinomas (SCC) and 10 patients with adenoid cystic carcinomas (ACC). A retrospective review of the surgical specimens was undertaken with specific reference to parotid node metastasis and parotid invasion. Parotid node metastasis was noted only in two cases of advanced staged SCC, whereas none of the ACC patients showed parotid node metastasis. Direct parotid invasion occurred only in advanced staged SCC, however, it did occur in early stage ACC. Our data indicated that elective parotidectomy for control of occult parotid node metastasis is necessary only in advanced SCC carcinoma, whereas parotid management to secure adequate safety margins is mandatory for advanced SCC and all cases of ACC.

Pleomorphic adenoma arising from the external auditory canal is a very rare neoplasm, and there has been no report on magnetic resonance (MR) imaging of pleomorphic adenoma of the external auditory canal. We report here a case of 65-year-old male with this tumour, measuring 12 mm in a diameter. Histopathology was confirmed from the specimen obtained at the surgical excision. MR revealed that the tumour had a well-defined margin showing hypointensity on T1-weighted images and hyperintensity on T2-weighted images relative to the parotid gland. The tumour was well enhanced by contrast material. No invasion to the surrounding tissue was observed. These MR findings were compatible with pleomorphic adenoma of the salivary gland origin. In treating pleomorphic adenoma of the external auditory canal, complete surgical excision is essential for the prevention of recurrence. It can be concluded that MR imaging is helpful for making a differential diagnosis of external auditory canal tumours and selection of adequate treatment.

Keratosis obturans is a rare condition characterized by the accumulation of desquamated keratin material in the bony portion of the external auditory canal. Classically, it is reported to present with severe otalgia, conductive deafness and global widening of the canal. 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. This presenting symptom and resorption pattern are atypical of keratosis obturans and have not been documented previously.

Maldevelopment of the first branchial cleft can produce a broad spectrum of anomalies in its derivative structure, the external auditory canal (EAC). Failure of the cleft to develop normally can result in either the absence of a normally patent EAC (atresia, or stenosis) or a duplication anomaly (cyst, sinus, or fistula). Despite their common origins, the coexistence of these anatomical abnormalities is quite unusual. We present four patients with both aural atresia and duplication anomalies of the EAC. Three patients had non-syndromic unilateral aural atresia and presented with periauricular lesions originating from the first branchial cleft. The other patient had a variant of Treacher Collins syndrome and presented with draining infra-auricular fistulae. The classification and management of first branchial cleft anomalies is reviewed in light of these cases. An understanding of the embryogenesis of the external ear is necessary to successfully recognize and treat this spectrum of deformities. A classification system is presented that encompasses the full spectrum of first cleft anomalies.

The diagnosis and management of a patient with a sloughing otitis externa thought to be necrotizing fasciitis is described. The clinical characteristics of this condition, diagnostic difficulties faced and a brief literature review are presented.

A minimum dataset for recording of findings during myringotomy and ventilation tube insertion for cases of otitis media with effusion is presented. With increasing pressures on surgeons to audit existing practices and hence improve standards of health care, it is appropriate to produce such a set of guidelines for a surgery that is frequently performed world-wide. We believe that the data presented is not too exhaustive and can be readily incorporated into the operative notes.

A case is presented of an entirely intracanalicular meningioma in a 48-year-old woman that was excised via a conventional translabyrinthine approach to the internal auditory canal (IAC). Pre-operative magnetic resonance imaging (MRI) suggested that the tumour was a vestibular schwannoma (VS). Histological examination confirmed the intra-operative impression that the tumour was a meningioma. Although VS is by far the commonest intracanalicular tumour, the differential diagnosis includes meningioma. MRI is unable to distinguish between these two entities when the tumour is located entirely in the internal auditory canal.

A case of bilateral progressive stenosis of both external auditory canals with resultant conductive hearing loss is presented. The stenosis revealed multifocal erosive and synechiant lichen planus. To our knowledge, this is the first reported case of lichen planus involvement of the external ear.

Acquired medial canal fibrosis is a discrete clinicopathological entity characterized by formation of fibrous tissue in the bony external auditory meatus. Over a seven-year period, a total of 14 operative procedures were performed on 12 ears involving 10 patients. Four cases had followed otitis externa, two were complications of suppurative otitis media, and three cases were iatrogenic. The cause could not be identified in three ears involving two patients. Treatment entails excision of all the fibrous tissue and involved skin, a wide canaloplasty, a meatoplasty, and then reconstruction by split skin graft. Two cases of canal cholesteatoma were encountered. Average follow-up of two years showed hearing improvement in all patients. The only complication was a recurrence of the stenosis in two ears. The paper discusses terminology, aetiology, pathophysiology, diagnosis, and principles of treatment of this condition.

The hybrid bone-substitute ionomeric cement is suitable for restoring the original anatomy of the posterior canal wall. During a four-year period the posterior meatal wall was rebuilt with ionomeric cement in 74 patients. The canal wall was totally rebuilt in 38 patients, two-thirds rebuilt in 22 cases, and one-third rebuilt in 14 cases. On the meatal side, the canal wall was covered by a musculo-periosteal (Palva) flap. In the majority of cases, the drum was closed with (cartilage)-perichondrium. Revisions were performed in 27 patients (due partially to cholesteatoma, and/or poor visualization of radical mastoidectomy cavities). The ears were non-infected at the time of operation. Permanent epithelialization of the bone replacement material was achieved in 57 cases, with secondary closure of a cutaneous defect of the meatal wall being required in six cases. The auditory canal wall had to be removed in 17 patients owing to deficient soft-tissue coverage, persistent inflammation, and/or partial adhesive processes with development of cholesteatoma. In terms of surgical technique, utilization of the material over a follow-up period of maximally seven years proved it to be a sophisticated procedure for reconstructing the meatal wall. Despite the finesse of the surgical technique employed, the overall failure rate of 31 per cent was inadmissibly high. Implantation of the material should therefore be restricted to middle ears with permanent ventilation and no trace of infection.

Collapse of the external auditory meatus during audiometry can lead to spuriously increased hearing thresholds being obtained, particularly at high frequencies, and may simulate conditions such as noise-induced hearing loss, presbyacusis and retrocochlear pathology. Consequently, inappropriate investigations and management may be undertaken. Two patients with elevated thresholds secondary to ear canal collapse are described. The implications of initially failing to identify the true nature of their 'hearing losses' are highlighted and strategies to avoid such pitfalls are discussed.

Epithelial-myoepithelial carcinoma (EMC) accounts for approximately one per cent of salivary gland tumours. This tumour is gaining wider recognition following inclusion into the WHO histological classification of salivary gland tumours in 1990. Salivary gland tumours characteristically present with an enlarging mass. We describe an unusual presentation of a salivary gland tumour with stenosis of the external ear canal in the absence of a palpable mass. EMC usually arises from the salivary glands but isolated cases have been described arising primarily from the paranasal sinuses, trachea and lacrimal gland. The management of this tumour is still evolving with surgical excision being the main-stay of treatment. The efficacy of radiotherapy has not yet been established but high local recurrence rates despite apparently adequate excision and the possibility of a multicentric origin of the tumour may herald an increasing role for radiotherapy in the future. We stress the importance of awareness of adjacent structures when considering the cause of cartilaginous canal stenosis.

Medial meatal fibrosis is a rare entity which is linked to inflammatory and traumatic factors. This pathology significantly benefits from surgical management. Criteria for achieving successful results are strict and concern the complete removal of the fibrous tissue and covering of the bony canal with skin graft. The aim of this paper is to present our experience with this rare pathology and to discuss current approaches.

Pleomorphic adenoma arising in the external auditory canal is rare. We report the case of a 38-year-old man. To better grasp the clinical features and natural history of this uncommon tumour, we also reviewed the worldwide literature and found 24 similar cases, which we analysed together with our own.

The clinical and pathological features of glandular tumours of the external auditory meatus are presented. Their heterogenous clinical and pathological features make the collective term 'ceruminoma' ambiguous and misleading. The spectrum of pathological behaviour and histological features demonstrated by these interesting tumours necessitate a broader classification system. In our hospital 32 patients presented with tumours of the external auditory meatus over a 30-year period, of which seven were glandular in origin. A review of the histology of these glandular tumours enabled us to reclassify them as adenoma, cylindroma, adenoid cystic carcinoma or ceruminous adenocarcinoma. Together with the less common mucoepidermoid carcinoma and pleomorphic adenoma this subdivision forms a basis for a more meaningful classification system with prognostic and therapeutic implications specific to each tumour type. The term 'ceruminoma' should no longer be used unqualified.

Eccrine cylindroma is a benign tumour arising from sweat glands in the skin. It favours the face, forehead and scalp involving the turban area and hence is called a turban tumour. Amongst a variety of tumours originating from adnexal skin structures, which may appear in the ear canal, eccrine cylindroma forms a very rare entity. We present such a case and discuss its pathological and clinical features.

A case of primary amyloidosis of the external auditory canal is described. To the best of our knowledge this is the first case described in the literature.

To the best of our knowledge, this is the first report of external ear canal schwannoma in the English literature. Several detailed clinical and pathological features were demonstrated. We suggest that if a tender, encapsulated mass is found in the external ear canal, the diagnosis of schwannoma should be taken into consideration.

A rare case of paraganglioma of the external auditory canal is presented. It was treated by excision and no recurrence has been noted after 18 months of follow up.

Otitis externa is a relatively common complication of ear syringing. Temporomandibular joint complications of otitis externa are rare. A case of otitis externa with communication between the external auditory canal and the temporomandibular joint is described.