Primary neoplasm of the external auditory canal has historically been documented to have a low incidence rate of between one and six per million internationally, with UK incidence yet to be officially cited.

Here, we report a rise in incidence at a single UK trust with seven carcinomas (six T4 external auditory canal squamous cell and one T4 basal cell) reported within an 18-month period. All tumours underwent next generation sequencing.

The cases recorded represented a twofold rise in incidence in reference to international literature from a population-adjusted estimate of 0.5–3 cases for the catchment area to seven cases. All cases were treated with temporal bone resections (n = 7) and with post-operative radiotherapy in six cases. Tumour analysis showed all were TP53 mutant and human papilloma virus (HPV)/P16 negative.

We suggest chronic inflammation and genetic alterations as putative contributory factors in our case series and outline clinical strategies for timely detection of external auditory canal neoplasms.

The objective of this study was to evaluate graft success, hearing improvement, and complications following perichondrium–cartilage underlay myringoplasty without external auditory canal packing.

In this prospective study, we examined 37 ears of 37 patients with large perforations who underwent endoscopic perichondrium–cartilage underlay myringoplasty without external auditory canal packing. Patients were followed up for six months.

At one week after the surgery, the graft was in situ in 35 (94.6 per cent) ears. At 2–3 weeks post-surgery, among the 35 ears without infection, the graft was in situ in 29 (82.9 per cent) ears, and the graft was bulging in 6 (17.1 per cent) ears. At six months post-surgery, the graft success rate was 94.6 per cent (35 of 37 ears). No graft lateralisation or graft medialisation was encountered during the follow-up period.

The absence of external auditory canal packing did not affect the graft success or hearing improvement following underlay myringoplasty. Thus, external auditory canal packing does not appear to be necessary for underlay myringoplasty.

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.

Two authors independently screened articles over one month using the following search terms: epithelial migration, epithelial, tympanic membrane, external auditory canal and mastoidectomy cavity.

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.

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.

This study evaluated the functional results of the superior pedicled composite multi-fractured osteoperiosteal flap technique. This method is a novel technique for the reconstruction of the external auditory canal. The study also examined the effect of the superior pedicled composite multi-fractured osteoperiosteal flap technique on patients’ disease-related quality of life.

A total of 37 patients who underwent the superior pedicled composite multi-fractured osteoperiosteal flap technique were enrolled in the study. Their functional hearing results and disease-related quality of life scores were evaluated.

A significant improvement was observed in the patients’ hearing scores at the post-operative sixth month relative to the pre-operative period, and the patients’ disease-related quality of life increased significantly.

The superior pedicled composite multi-fractured osteoperiosteal flap method can be safely used, especially in patients undergoing retrograde mastoidectomy because of limited cholesteatoma. This method contributes to improving patients’ hearing levels and disease-related quality of life.

The main purpose of the present study was to evaluate whether complications related to surgery for exostoses are associated with a decrease in patients’ quality of life.

This was a retrospective study for which the following information was collected: sex, age, pre- and post-operative symptoms, pre- and post-operative audiological evaluation results, surgical approach, instruments used, complications, and Glasgow Benefit Inventory score.

The study included 67 patients (94 ears). The three main complaints reported were wax retention, otitis externa and hearing loss. Surgical complications occurred in 14.9 per cent of patients. Patients experienced a significant benefit from surgery, especially in relation to somatic state, with a global Glasgow Benefit Inventory score of + 44.3. No significant difference was found between the global Glasgow Benefit Inventory changes and surgery-related complications (p = 0.093).

After surgery for exostoses, the vast majority of patients showed improvement. Complications related to surgery in general do not seem to influence patients’ satisfaction with surgery.

Endoscopic ear surgery is a game changer in the field of otology. Training in endoscopic skills is essential for ENT residents, and is especially important during the coronavirus disease 2019 lockdown period. In such difficult times, ENT residents and surgeons can undergo hands-on training using a papaya petiole, even within their homes.

Endoscopic ear surgery training can be carried out using a papaya petiole, enabling the practice of grommet insertion, tympanomeatal flap elevation and foreign body removal from the external auditory canal. This model does not need any laboratory setup.

The hollow structure of the papaya petiole model is very similar to that of the external auditory canal, making training in endoscopic ear surgery easy. Use of the model helps a beginner to train in endoscopic handling and microsurgical instrumentation, and improves depth perception. In addition, it does not require high-end facilities to store equipment or undertake the training at any given point in time.

A distinct nerve innervating the external auditory canal can often be identified in close relation to the facial nerve when gradually thinning the posterior canal wall. This nerve has been attributed to coughing during cerumen removal, neuralgic pain, Hitselberger's sign and vesicular eruptions described in Ramsay Hunt's syndrome. This study aimed to demonstrate the origin and clinical impact of this nerve.

In patients with intractable otalgia or severe coughing whilst inserting a hearing aid, who responded temporarily to local anaesthesia, the symptoms could be resolved by sectioning a sensory branch to the posterior canal. In a temporal bone specimen, it was revealed that this nerve is predominantly a continuation of Arnold's nerve, also receiving fibres from the glossopharyngeal nerve and facial nerve. Histologically, the communicating branch from the facial nerve was confirmed.

Surgeons should be aware of the posterior auricular sensory branch and its clinical implications.

To examine the effects of Castellani's paint on symptomatic relief and skin flora in patients with an itchy external ear canal.

Subjective pruritus scores, and erythema and desquamation scores, were noted in 61 patients with an itchy external ear canal. External ear canal skin swabs were taken for bacterial and fungal cultures. Patients were then randomly divided into three groups: either Castellani's paint (group one) or steroid ear drops (group two) were instilled, or non-impacted cerumen was removed (group three). Patients were re-assessed at one month after the initial visit.

After treatment, subjective pruritus scores were significantly lower in all groups, erythema scores were significantly decreased in group one, and desquamation scores were significantly reduced in groups one and two, when compared with pre-treatment scores. Reproduction density of bacteria including normal flora was decreased in group one. However, the types of bacteria that constitute the normal flora of the external ear canal were unchanged.

Castellani's paint can be administered safely, effectively and easily, without affecting the type of external ear canal skin bacteria, in patients with an itchy external ear canal.

To establish the prevalence of external auditory canal exostosis (‘surfer's ear’) in Cornish surfers and investigate the potential impact on healthcare.

A total of 105 surfers were interviewed and otologically assessed on popular Cornish beaches. The degree of exostosis was graded as mild, moderate or severe.

The prevalence of external auditory canal exostosis was 63.81 per cent (33.33 per cent mild, 18.10 per cent moderate and 12.38 per cent severe). The degree of exostosis showed a significant correlation with absolute cold-water exposure time. However, there was individual variation in susceptibility to external auditory canal exostosis; 12 per cent of surfers with excessive cold-water exposure showed no exostosis. Regression analysis of surgical operations performed at the Royal Cornwall Hospital for exostosis over the last 13 years revealed an average increase of 1.23 operations per year, with an average of 13 cases per year over the last 9 years.

Exostosis of the external auditory canal is common in Cornish surfers. There appears to be individual variation in terms of susceptibility to this condition. The possible reasons for this are discussed. The increase in the technically difficult surgical operations performed for exostosis is likely to have implications for health resources in the future.

To describe the clinical features of external auditory canal cholesteatoma, and to assess the outcome following bony meatoplasty with tragal cartilage and perichondrium graft repair.

A retrospective review was carried out, comprising all patients with external auditory canal cholesteatoma who presented between January 2007 and December 2011. Patients underwent pre-operative audiometry and computed tomography imaging of the temporal bones, before undergoing bony meatoplasty via a postauricular incision. Pre- and post-operative comparisons were made of patients' otological symptoms and the otoscopic appearance of the external ear canal.

Eight patients were included in the analyses. The median age of patients was 46.5 years (range 14–68 years), with a male to female ratio of 1:1. The median length of follow up was 16 months. The most common presenting features were unilateral otalgia and purulent otorrhoea. All patients had relatively advanced disease at presentation, with erosion of the temporal bone. All patients underwent bony meatoplasty via a postauricular approach to eradicate the disease. Bony meatoplasty was successful in the definitive management of external ear canal cholesteatoma.

Myopericytoma is a relatively recently described skin and soft tissue tumour that demonstrates perivascular myoid cell or pericytic differentiation. Whilst the range of anatomical locations has expanded to include visceral locations, head and neck myopericytomas are rarely documented. There have been no previous reports of aural myopericytoma.

This paper reports the clinicopathological features of a biopsy-proven, slow-growing, 20 × 20 mm, polypoid myopericytoma that involved the external auditory canal and tragus in an 18-year-old woman. Excision was curative.

Heightened clinicopathological awareness of the expanding anatomical distribution of myopericytoma is critical to its diagnosis when it presents in unusual and novel locations. Myopericytoma should be added to the range of external auditory canal neoplasms, especially those characterised by an admixture of spindle cells and a prominence of blood vessels, including those with a haemangiopericytomatous pattern.

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.

This paper describes a 10-year personal case series of external auditory canal lesions with chart, imaging and histopathology review.

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.

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.

To describe a relatively unknown clinical entity – inflammatory cast of the tympanic membrane after acute otitis media – and its simple out-patient treatment.

Retrospective review of case series.

Subspecialty practice at a tertiary hospital.

Seven patients diagnosed previously with acute otitis media with perforation or otitis externa, and with persistent ear discomfort.

Retrospective chart review.

The patients presented with weeks to months of persistent hearing loss after acute otitis media with perforation or acute otitis externa. Visits to their primary care physicians had been uninformative. After comparison of the affected and unaffected tympanic membranes, a thin, hard cast was identified and removed from the affected tympanic membrane. Improvement in hearing was documented in the three patients who underwent audiometric testing; the remainder had subjective improvement without audiometric evaluation.

Otolaryngologists should be aware of the possibility of an inflammatory cast of the tympanic membrane following acute otitis media with perforation or otitis externa, and should carefully compare the unaffected and affected ears in such cases. Treatment – removal of the rigid cast – is both simple and effective.

Ceruminous mucoepidermoid carcinoma of the external auditory canal is extremely rare. This paper highlights the impact of concurrent chemoradiotherapy on the outcomes of this disease.

A 47-year-old female presented with a 2-month history of otalgia and a mass in her right ear. Biopsy revealed high grade ceruminous mucoepidermoid carcinoma. She underwent surgical excision of the right external auditory canal and right upper neck dissection. Pathological analysis of tumour–node–metastasis staging revealed a T2 N0 (stage II) tumour. One year later, computed tomography scanning of the temporal bone showed tumour recurrence. Biopsy revealed recurrent ceruminous mucoepidermoid carcinoma. The patient underwent salvage resection. Pathology revealed that the tumour was diffusely invading nearby structures, with perineural invasion, lymphatic spread and extracapsular extension. Pathological analysis of tumour–node–metastasis staging revealed a T3 N1 M0 (recurrent stage IV) tumour.

The patient subsequently received concurrent chemoradiotherapy. There was no evidence of disease at 37 months' follow up.

The trimodality approach, using surgery plus concurrent chemoradiotherapy, provided reasonable loco-regional control with tolerable toxicity. Further detailed case reports are warranted to optimise the management of this rare malignancy.

Temporomandibular joint fistula into the external auditory canal is a very rare condition. We report a case of spontaneous fistula which presented with repeated episodes of clear fluid otorrhoea and ear infection.

A 53-year-old woman complained of occasional episodes of clear fluid otorrhoea from the right ear followed by infection. Otoscopic examination showed a normal tympanic membrane and normal skin in the external auditory meatus. Otomicroscopy showed a small punctum on the anteroinferior part of the meatus. Computed tomography identified a foramen of Huschke. Surgery revealed a fistula between the meatus and the temporomandibular joint, which was successfully resolved.

This report presents a rare case of a fistula between the temporomandibular joint and the external auditory meatus, associated with Huschke's foramen. Such a defect can be quite difficult to detect. It should be suspected in cases of chronic otorrhoea when neither middle nor external ear disease is apparent. Surgery is usually successful, and is advised in cases with repeated complications.

Syringing of the ear is one of the most common procedures performed for cleaning cerumen from the external auditory canal. Common complications following syringing are pain, external auditory canal trauma and otitis externa. Hearing and vestibular loss have also been reported as complications. However, we are unaware of any report of facial nerve palsy as a complication of ear syringing. Such a case is reported.

We describe a case of facial nerve palsy as a complication of syringing, which demonstrates the dramatic presentation of this condition and emphasises the need for great care while syringing the ears.

It is important to be aware of this unusual complication with its distinctive presentation. Surgical intervention should be undertaken at the earliest opportunity, for favourable results. A risk-minimising strategy for ear syringing is recommended.

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.

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.

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.

Histological and immunohistological examination of skin biopsies from cases of isolated itching of the external auditory canal did not support a diagnosis of dermatitis.

(1) To identify newly diagnosed cases of methicillin-resistant Staphylococcus aureus ear infection in our local population; (2) to determine the risk factors involved in these patients' clinical courses, and (3) to type the bacterial strains isolated and thus identify whether they were hospital- or community-acquired.

Retrospective review of case notes, together with laboratory-based molecular studies in the departments of otolaryngology and medical microbiology in a university teaching hospital in Scotland, UK.

Over a two-year period, 35 patients were identified with ear swabs positive for methicillin-resistant Staphylococcus aureus infection. These cases came from both hospital and community settings.

(1) Identification of primary methicillin-resistant Staphylococcus aureus otorrhoea in patients with no previously documented colonisation; and (2) molecular typing of the strains isolated, using spa technology, to identify whether they were hospital- or community-acquired.

Of the 35 positive patients, 27 were previously known carriers of methicillin-resistant Staphylococcus aureus. The eight patients with newly diagnosed methicillin-resistant Staphylococcus aureus otorrhoea presented initially in the community. All of these patients had had contact with hospital staff (as in-patients or out-patients) in the weeks preceding development of their ear infection. Using the spa technique for molecular typing, we identified hospital-acquired (‘epidemic’) methicillin-resistant Staphylococcus aureus type 15 in all eight patients' isolates. All were sensitive to topical gentamicin.

In our cohort, hospital-acquired methicillin-resistant Staphylococcus aureus type 15 was the commonest cause of methicillin-resistant Staphylococcus aureus otorrhoea, despite the fact that these patients all first presented in the community. We believe that contact with hospital staff or health care workers is a risk factor for acquiring methicillin-resistant Staphylococcus aureus otorrhoea in the community.

The intact posterior meatal skin, canal wall down technique for difficult cochlear implantation provides expanded access to the middle ear for cochleostomy in cases of obscured middle-ear landmarks, limited facial recess access and limited mastoid cavity dimensions. Careful preservation of the posterior canal wall skin in this procedure obviates the need for obliteration of the middle-ear mucosa and closure of the external auditory canal.

To present a canal wall down technique for cochlear implantation, which preserves the intact posterior external auditory canal wall skin. This approach is employed when a standard facial recess cochleostomy is not possible.

Three cases of intact posterior meatal skin, canal wall down cochlear implantation are presented together with long-term follow-up results. In all three cases, implantation via a facial recess approach was not possible. One patient suffered from severe cochlear otosclerosis with obliteration of the round window niche. The second patient had severe middle-ear fibrosis with encasement of all middle-ear structures and obliteration of routine landmarks. The third patient had an anterior sigmoid sinus obscuring access to the facial recess. Cochlear implantation via the canal wall down, intact posterior canal wall skin technique was successfully performed in each of these patients.

All three patients were successfully implanted, with full electrode insertion achieved. All patients subsequently became active implant users. One patient did suffer from a minor wound complication post-operatively, unrelated to the approach. Patient follow up ranged from four to six years.

We present an extremely rare case of a 44-year-old woman with right gustatory otorrhoea and otalgia.

The patient had been initially treated for otitis externa after Pseudomonas aeruginosa was grown from a microbiological swab. The otorrhoea fluid was collected and tested positive for amylase. Sialography and computed tomography imaging of the temporal bone confirmed a sialo-aural fistula from the right parotid gland to the bony external acoustic meatus. The defect was consistent with a patent foramen of Huschke. The fistula was identified surgically via a superficial parotidectomy approach, after contrast injection of Bonney's blue dye into the parotid duct, and then ligated and divided. The patient had immediate and sustained resolution of her otorrhoea.

Sialo-aural fistulae are extremely rare, and usually arise as a complication of surgery or as an acquired disease process. To date, only four cases have been reported. This case demonstrates the use of sensitive investigation involving sialography and computed tomography, as well as successful surgical management, with complete resolution of symptoms.