External auditory canal cholesteatoma

Last revised by Yahya Baba on 11 Jul 2023

External auditory canal cholesteatomas are a rare site for acquired cholesteatoma.

The external acoustic canal is a rare location for a cholesteatoma with an estimated incidence of around 1.2 per 1,000 new otological patients. The overall incidence rate in one large study was 0.30 per year per 100,000 inhabitants 1. For comparison, the annual incidence of middle ear cholesteatoma is around 9.2 per 100,000.

Patients often present with chronic dull otalgia and otorrhea. A less common presentation is conductive hearing loss due to canal occlusion 2

A distinction from keratosis obturans has been introduced only in the last few decades. Both mainly consist of epithelial debris in the external acoustic canal. The most useful findings confirming an external auditory canal cholesteatoma are focal osteonecrosis with or without sequestration and lack of epithelial covering of the bony surface 2. The distinction between keratosis obturans and cholesteatomas is not merely one of pedantry, but impacts on treatment strategy 3.

External auditory canal cholesteatoma can be divided into:

  • primary (idiopathic/spontaneous)
    • rare
    • no antecedent cause identified
  • secondary
    • more common
    • postoperative, postinflammatory, posttraumatic, radiation-induced

A special type of secondary cholesteatoma of the external auditory canal are those associated with congenital atresia of the external auditory canal.

The Schüller, Stenvers, and Mayer views of the petrous bone have been largely replaced by CT.

High-resolution bone window temporal bone CT is the method of choice to localize the cholesteatoma and to demonstrate bony erosions. They appear as soft tissue attenuating lesions. 

MRI cannot show the early involvement of compact bone. Its role in EACC is not defined.

Small lesions can be treated endoscopically under local anesthesia, whereas larger lesions need surgery to remove the cholesteatoma and affected bone areas. Grafting of defects may be necessary. Prognosis depends on the extent at the time of diagnosis.

External auditory canal cholesteatomas were first reported by Toynbee in 1850.

General imaging differential considerations include

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Cases and figures

  • Case 1
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  • Case 2
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  • Case 3: with facial nerve invasion
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  • Case 4
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  • Case 5: with middle ear extension
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  • Case 6
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