Middle Ear Obliteration With Blind Sac Closure of the External Auditory Canal in Ballistic Injury
Fiona C. E. Hill FRACS, Michael Tykocinsky, FRACS First Published January 30, 2019 Other
https://doi.org/10.1177/0145561318824891
Article information
Free Access
A 17-year-old male refugee presented with hearing loss and a chronically discharging left ear 7 years following ballistic trauma from the detonation of an improvised explosive device. Clinical examination revealed purulent discharge from his left ear, with a spherical metal foreign body lodged in the external auditory canal (EAC) and extending into his mesotympanum (Figure 1). An audiogram demonstrated that the left ear was anacoustic. The hearing in the contralateral right ear was normal.
Figure 1. Otoscopic view of the external auditory canal with the spherical metal foreign body lodged in the medial external auditory canal.
Computerized tomography demonstrated significant bony trauma with subsequent neo-osteogenesis lateral to the foreign body (Figures 2–3). There was no obvious deformity to the cochlea, which was fluid filled. Opacification medial to the foreign body was suspected to either represent granulation tissue or an entrapment cholesteatoma.
Figure 2. Coronal CT temporal bone of the left ear at the level of the oval window, demonstrating the spherical foreign body at its maximal dimensions. Significant neo-ossification surrounding the object can be seen. Opacification medial to the object was found to be an entrapment cholesteatoma. Right side demonstrates normal anatomy for comparison. CT indicates computed tomography.
Figure 3. Axial CT temporal bone of the left ear at the level of the oval window demonstrating the spherical foreign body at its maximal dimensions. Right side demonstrates normal anatomy for comparison. CT indicates computed tomography.
An examination under anaesthetic was performed, at which time it was decided that the foreign body could not be removed without significant loss of the posterior EAC wall.
The case was reviewed by the hospital’s multidisciplinary team. Two options were offered to the patient: radical mastoidectomy with the option of an osseointegrated hearing aid or Contralateral Routing of Signals aid at a later time; or a blind sac closure with mastoid obliteration with the option of future cochlear implantation.
The patient opted for the second option and underwent a successful mastoid obliteration, with removal of the foreign body and blind sac closure (Figure 4). At the time of surgery, the middle ear opacification was found to represent a cholesteatoma. He is planned to have second look surgery at 6 to 12 months postop, with cochlear implantation at the same time if the ear remains healthy.
Figure 4. The spherical metal foreign body after surgical removal during the mastoid obliteration.
Mastoid obliteration with blind sac closure was a procedure traditionally used for patients with cerebrospinal fluid otorrhoea, osseoradionecrosis, skull base surgery, and chronic suppuratives otitis media refractory to treatment. Cochlear implantation requires a safe, stable ear without any contact between the tympanic membrane or skin of the EAC and the prosthesis. In patients with a canal wall down mastoidectomy, this normally requires a blind sac closure to facilitate safe implantation.
This case represents a unique treatment challenge and is the first case of its kind described in the literature. The use of a mastoid obliteration with blind sac closure simultaneously allows treatment of the foreign body and cholesteatoma, while creating an environment that will facilitate a cochlear implant at a second-stage operation.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
View Abstract
Fiona C. E. Hill FRACS, Michael Tykocinsky, FRACS First Published January 30, 2019 Other
https://doi.org/10.1177/0145561318824891
Article information
Free Access
A 17-year-old male refugee presented with hearing loss and a chronically discharging left ear 7 years following ballistic trauma from the detonation of an improvised explosive device. Clinical examination revealed purulent discharge from his left ear, with a spherical metal foreign body lodged in the external auditory canal (EAC) and extending into his mesotympanum (Figure 1). An audiogram demonstrated that the left ear was anacoustic. The hearing in the contralateral right ear was normal.
Figure 1. Otoscopic view of the external auditory canal with the spherical metal foreign body lodged in the medial external auditory canal.
Computerized tomography demonstrated significant bony trauma with subsequent neo-osteogenesis lateral to the foreign body (Figures 2–3). There was no obvious deformity to the cochlea, which was fluid filled. Opacification medial to the foreign body was suspected to either represent granulation tissue or an entrapment cholesteatoma.
Figure 2. Coronal CT temporal bone of the left ear at the level of the oval window, demonstrating the spherical foreign body at its maximal dimensions. Significant neo-ossification surrounding the object can be seen. Opacification medial to the object was found to be an entrapment cholesteatoma. Right side demonstrates normal anatomy for comparison. CT indicates computed tomography.
Figure 3. Axial CT temporal bone of the left ear at the level of the oval window demonstrating the spherical foreign body at its maximal dimensions. Right side demonstrates normal anatomy for comparison. CT indicates computed tomography.
An examination under anaesthetic was performed, at which time it was decided that the foreign body could not be removed without significant loss of the posterior EAC wall.
The case was reviewed by the hospital’s multidisciplinary team. Two options were offered to the patient: radical mastoidectomy with the option of an osseointegrated hearing aid or Contralateral Routing of Signals aid at a later time; or a blind sac closure with mastoid obliteration with the option of future cochlear implantation.
The patient opted for the second option and underwent a successful mastoid obliteration, with removal of the foreign body and blind sac closure (Figure 4). At the time of surgery, the middle ear opacification was found to represent a cholesteatoma. He is planned to have second look surgery at 6 to 12 months postop, with cochlear implantation at the same time if the ear remains healthy.
Figure 4. The spherical metal foreign body after surgical removal during the mastoid obliteration.
Mastoid obliteration with blind sac closure was a procedure traditionally used for patients with cerebrospinal fluid otorrhoea, osseoradionecrosis, skull base surgery, and chronic suppuratives otitis media refractory to treatment. Cochlear implantation requires a safe, stable ear without any contact between the tympanic membrane or skin of the EAC and the prosthesis. In patients with a canal wall down mastoidectomy, this normally requires a blind sac closure to facilitate safe implantation.
This case represents a unique treatment challenge and is the first case of its kind described in the literature. The use of a mastoid obliteration with blind sac closure simultaneously allows treatment of the foreign body and cholesteatoma, while creating an environment that will facilitate a cochlear implant at a second-stage operation.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
View Abstract
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