The herniation of temporomandibular tissue through the foramen of Huschke into the external auditory canal is a rare clinical anomaly. This paper describes one such case and provides an overview of the relevant literature. This paper elaborates upon the aetiology, clinical assessment, management and associated complications.

A 54-year-old woman presented with a 3-month history of right ear pain and a polypoid lesion in her right ear canal. This lesion expanded during a Valsalva manoeuvre, and imaging demonstrated a defect in the antero-superior aspect of the canal with herniation of soft tissue. The patient was managed conservatively as the symptoms resided.

Ear canal lesions that protrude or change in size with a Valsalva manoeuvre could be due to a persistent foramen of Huschke. In symptomatic cases needing surgical intervention, a variety of materials may be used to close the defect. Titanium mesh, with or without cartilage overlay, appears to be the most popular choice.

This study aimed to analyse the effectiveness of using the bony sigmoid sinus plate for repair of meato-mastoid fistulae.

A retrospective study of all cases between January 2013 and December 2019 at our secondary-tertiary centre was conducted. Inclusion criteria for study were: (1) cases with focal meato-mastoid fistulae and (2) focal meato-mastoid fistulae that were repaired by using bony sigmoid sinus plate using the bony sigmoid sinus plate technique. There were 13 cases that fulfilled these criteria.

The outcome of the repair of meato-mastoid fistulae with bony sigmoid sinus plate was very encouraging. All 13 cases did well. Two patients had delayed epithelialisation at 9 and 12 months after surgery.

The technique of repairing meato-mastoid fistulae by using bony sigmoid sinus plate is simple, repeatable and provides effective physiological reconstruction of the posterior canal wall. Bony sigmoid sinus plate is easily and locally available in all cases undergoing cortical mastoidectomy. This plate of bone has a curvature, consistency and structure that match well with that of the posterior or superior canal wall. In addition, this technique is cost-effective with good patient compliance.

This study aimed to determine the awareness, otological symptoms and prevalence of external auditory canal exostoses in Irish cold-water athletes.

An online and in person cross-sectional survey was undertaken with Irish cold-water athletes to explore athletes' awareness, known prevalence of external auditory canal exostoses and attitudes towards preventive measures.

Of the 926 participants surveyed, 67.5 per cent were aware of external auditory canal exostoses. Triathletes reported the lowest awareness (39.9 per cent) among water athletes. A total of 9.7 per cent (n = 90) had previously been diagnosed with external auditory canal exostoses and 46.7 per cent (n = 42) were non-surfers. Ear symptoms were reported in 76 per cent of athletes. Otoscopic examinations showed that 23.7 per cent had external auditory canal exostoses, 3.6 per cent of whom were aware of their diagnosis.

The majority of Irish surfing athletes are aware of external auditory canal exostoses. There is less awareness with regard to Ireland's newly emerging sports such as open water swimming and triathlons. Over 90 per cent of athletes surveyed had no idea they had external auditory canal exostoses, which highlights the need to increase public awareness.

Eczematous external otitis is a common chronic condition that can have a significant impact on the life of sufferers, causing constant discomfort and pruritus, and leading to sleep deprivation. Treatment is based on the use of topical steroids, moisturisers and occasionally antibiotics. Results, however, can be disappointing, especially over the long term.

This study compared the long-term response to pimecrolimus, administered to a group of 11 patients, against clobetasone butyrate, administered to an equivalent number of patients. Response to the treatment was assessed and statistically analysed at 3 and 12 months.

Whereas the degree of improvement following the use of pimecrolimus and clobetasone butyrate was similar for the two groups at month 3, a highly statistically significant difference was documented at month 12, with a much greater and sustained improvement in the pimecrolimus group.

This case series, conducted during the coronavirus disease 2019 pandemic, investigates the impact of leaving aural foreign bodies in situ for a prolonged period of time, including the risk of complications and success rates of subsequent removal attempts.

A retrospective study of aural foreign body referrals over a six-month period was carried out.

Thirty-four patients with 35 foreign bodies were identified (6 organic and 29 inorganic). The duration of foreign bodies left in situ ranged from 1 to 78 days. Four patients suffered from traumatic removal upon initial attempts. First attempts made by non-ENT specialists (68.8 per cent) all failed and were associated with a high risk of trauma (36.4 per cent).

Because of the coronavirus disease 2019 pandemic, this is the first case series to specifically investigate the relationship between the duration of aural foreign bodies left in situ and the risk of complications. Our data suggest that prolonged duration does not increase the incidence of complications.

This study aimed to compare the necessary scutum defect for transmeatal visualisation of middle-ear landmarks between an endoscopic and microscopic approach.

Human cadaveric heads were used. In group 1, middle-ear landmarks were visualised by endoscope (group 1 endoscopic approach) and subsequently by microscope (group 1 microscopic approach following endoscopy). In group 2, landmarks were visualised solely microscopically (group 2 microscopic approach). The amount of resected bone was evaluated via computed tomography scans.

In the group 1 endoscopic approach, a median of 6.84 mm3 bone was resected. No statistically significant difference (Mann–Whitney U test, p = 0.163, U = 49.000) was found between the group 1 microscopic approach following endoscopy (median 17.84 mm3) and the group 2 microscopic approach (median 20.08 mm3), so these were combined. The difference between the group 1 endoscopic approach and the group 1 microscopic approach following endoscopy plus group 2 microscopic approach (median 18.16 mm3) was statistically significant (Mann–Whitney U test, p < 0.001, U = 18.000).

This study showed that endoscopic transmeatal visualisation of middle-ear landmarks preserves more of the bony scutum than a microscopic transmeatal approach.

A method is described for topical local anaesthesia of the tympanic membrane and ear canal using lidocaine and phenylephrine (Co-phenylcaine) spray and soaked micropatties.

The advantages of this method are discussed in comparison to existing methods.

To analyse the clinical outcomes of biodegradable synthetic polyurethane foam versus ribbon gauze and ear wick in the treatment of severe acute otitis externa.

Ninety-two adults with severe acute otitis externa were randomly assigned to groups receiving ear wick (n = 28), ribbon gauze (n = 34) or biodegradable synthetic polyurethane foam (n = 30). Clinical efficacy, in terms of otalgia, oedema, erythema and tenderness of the external auditory canal, was assessed before packing was applied and at follow up on the 3rd and 7th days of presentation.

All packing materials were associated with improved otalgia and oedema on the 3rd day; however, there were significant differences between biodegradable synthetic polyurethane foam and the other packing materials, and there was no significant reduction in tenderness in the biodegradable synthetic polyurethane foam group on the 3rd day. In the ribbon gauze and ear wick groups, improvements in all clinical efficacy scores were statistically significant for all pairwise comparisons.

The three packing materials were all quite effective in treating severe acute otitis externa, but ear wick and ribbon gauze were superior to biodegradable synthetic polyurethane foam for relieving signs and symptoms, especially on the 3rd day.

To identify epidemiological and pathophysiological factors, and treatment strategies, in external auditory canal cholesteatoma and benign necrotising otitis externa.

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.

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.

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.

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.

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.

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.

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.

To determine the proportion of UK surfers aware of external auditory canal exostosis, to identify surfer characteristics associated with knowledge of the condition and to explore attitudes to earplug use.

An online, cross-sectional survey of UK-based surfers.

Of 375 surfers, 86.1 per cent (n = 323; 95 per cent confidence interval = 82.3–89.3) reported awareness of external auditory canal exostosis. Further investigation revealed that, despite their awareness of the condition, 23.4 per cent of these surfers (88 out of 323; 95 per cent confidence interval = 19.5–28.0) had little or no knowledge about external auditory canal exostosis. Predictors of knowledge included: distance from nearest surfing beach (p = 0.001), surfing standard (ability) (p = 0.008), earplug use (p = 0.024) and positive external auditory canal exostosis diagnosis (p = 0.009).

The findings suggest that a significant minority of UK surfers have no knowledge about this condition. Knowledge of external auditory canal exostosis was significantly associated with earplug use when surfing. Efforts to improve surfers’ knowledge are required to enable surfers to better protect themselves, which could reduce the incidence of external auditory canal exostosis.

To evaluate the primary and long-term surgical outcomes of patients with postinflammatory medial meatal fibrosis.

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.

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.

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.

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.

Two case reports of temporal bone osteonecrosis are presented.

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.

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.

Skull base osteomyelitis typically presents in an immunocompromised patient with severe otalgia and otorrhoea. Pseudomonas aeruginosa is the commonest pathogenic micro-organism, and reports of resistance to fluoroquinolones are now emerging, complicating management. We reviewed our experience of this condition, and of the local pathogenic organisms.

A retrospective review from 2004 to 2011 was performed. Patients were identified by their admission diagnostic code, and computerised records examined.

Twenty patients were identified. A facial palsy was present in 12 patients (60 per cent). Blood cultures were uniformly negative, and culture of ear canal granulations was non-diagnostic in 71 per cent of cases. Pseudomonas aeruginosa was isolated in only 10 (50 per cent) cases; one strain was resistant to ciprofloxacin but all were sensitive to ceftazidime. Two cases of fungal skull base osteomyelitis were identified. The mortality rate was 15 per cent. The patients’ treatment algorithm is presented.

Our treatment algorithm reflects the need for multidisciplinary input, early microbial culture of specimens, appropriate imaging, and prolonged and systemic antimicrobial treatment. Resolution of infection must be confirmed by close follow up and imaging.

We present the first published description of a painful paraganglioma of the external auditory canal. Atypical histopathology made the diagnosis difficult. We discuss the potential pitfalls of clinical diagnosis and treatment of such a case.

A 49-year-old woman presented with left-sided otalgia, hearing loss and tinnitus. Physical examination revealed a firm swelling arising from the superior portion of the left external auditory canal. A clinical diagnosis of otitis externa was made.

There was minimal response to medical treatment. The swelling was aspirated, leading to brisk bleeding. A tumour was suspected from the computed tomography scan, and confirmed by a biopsy. The patient underwent excision of the paraganglioma. The histopathology was atypical, making diagnosis difficult.

Such unusual masses of the external ear should always be borne in mind, especially when dealing with atypical presentations of commonly encountered diseases. Clinicians should have a low threshold for early intervention with imaging and biopsy.

Chronic obliterative otitis externa is a rare cause of conductive hearing loss, characterised by stenosis of the deep ear canal secondary to chronic inflammation. A multitude of canalplasty techniques have been described, with variable success.

Fourteen patients undergoing canalplasty performed by the senior author for refractory obliterative otitis externa, over an 8-year period, were included in the study. All underwent split-skin grafting of the denuded canal and meticulous post-operative aural care. Outcome measures included the Glasgow Benefit Inventory and pure tone audiology.

At 3 months post-operatively, the four-tone average threshold had improved by a mean of 13.9 dB (95 per cent confidence interval –9.9 to 37.8 dB; t < 0.001) in the operated ear. The mean Glasgow Benefit Inventory score was 20 (95 per cent confidence interval −2.3 to 42.1).

Significant improvements in both hearing and quality of life are achievable in patients with end-stage obliterative otitis externa treated surgically. Highly trained and competent aural care practitioners are a prerequisite for the success of the procedure, and a substantial number of patients must be prepared to submit to long-term follow-up care.

Osteoradionecrosis of the temporal bone is an uncommon but well documented finding after radiotherapy in the head and neck region, and results in exposed, necrotic bone with a soft tissue defect in the external auditory canal. The defect can be treated either conservatively or surgically. This paper aims to describe the results of reconstruction of the external auditory canal by transpositioning of the superficial layer of either the anterior or posterior part of the temporalis muscle to cover the defect.

Three patients with large, symptomatic defects in the external auditory canal were treated with transposition of the superficial layer of the temporalis muscle.

The duration of follow up was 4 to 16 months. No complications occurred. In all patients, re-epithelialisation was complete within 3 months.

During reconstruction of the external auditory canal, transposition of the superficial layer of the temporalis muscle provides a reliable flap with a satisfactory outcome.

To determine the expansile and absorptive properties of the expandable ear wick when tested with commonly prescribed ear drop preparations.

This in vitro study assessed wick expansion and absorption of drops when different ear drop preparations were applied. Nine commonly used ear drop preparations were tested (Gentisone HC, Sofradex, Otomize, Betnesol, Exocin, Canesten, Locorten-Vioform, EarCalm and ichthammol glycerin) with a standard expandable ear wick.

Weight, length and width of otowick following exposure to ear drops.

There was a marked difference in the absorption and expansion of the otowick when different drops were used. This corresponded to the aqueous or oil base of each preparation. All aqueous ear drop preparations (i.e. Gentisone HC, Sofradex, Otomize, Betnesol, Exocin and EarCalm) produced similar rates of absorption into, and expansion of, the otowick. The oil-based ear drop preparations (i.e. Canesten, Locorten-Vioform and ichthammol glycerin) failed to expand the wick and showed poor rates of absorption into the wick.

Expandable ear wicks should only be used in conjunction with aqueous ear drops. When using expandable otowicks as an adjunct to treating fungal otitis externa, acetic acid ear drops should be prescribed, as all other anti-fungal drops are oil-based.

To present a rare case of rectal adenocarcinoma metastasising to the external auditory canal, in a patient in whom computed tomography staging of the abdomen, chest and pelvis was clear for metastatic disease.

Case report and review of the literature.

Metastatic tumours to the external auditory canal are rare, with rectal adenocarcinoma being one of the rarest. However, it is important that the external auditory canal is regarded as a potential site for metastasis, even when computed tomography staging is clear. Metastatic tumour should be included in the differential diagnosis of a patient presenting with an ear mass.