Diagnosis Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 53–56 (DOI: 10.1159/000350605)
Otitis Media and Subcutaneous Abscess while Awaiting Surgery Hideaki Sakata
A definite diagnosis of microtia may not require the use of CT in microtia patients who present with obvious stenosis of the external auditory canal (EAC) or complete atresia of the EAC. In such cases, otorrhea may develop in the rudimentary EAC and a subcutaneous abscess can easily form at the same time. Early-stage otitis externa and otitis media are often not discovered early enough because findings are rarely obtained. Many microtia cases are complicated by otitis media with effusion and congenital cholesteatoma, and acquired cholesteatomatous otitis media should also be considered when otitis media is protracted or intractable. Malformation of mastoid air cells and lowered pneumatization found in many patients are the likely causes of otitis media. Therapy for otitis media due to transtubal infection is often delayed because of the difficulty in obtaining abnormal findings. Nevertheless, it is important to perform a CT scan as early as possible to understand the growth of mastoid air cells, severity of pneumatization, pneumatization of the mastoid antrum, pneumatization and volume of the middle ear cavity, and anatomical findings of the surrounding regions. Basically, treatment as for ordinary otitis media is instituted, but otorrhea is often protracted or intractable. With microtia patients, subcutaneous abscess is likely to occur subsequent to otitis externa and otitis media, and early pus drainage by incision is desirable. However, symptoms may often recur because sufficient lavage and dissection of the affected site are not possible due to anatomical complexity. When a case is complicated by cholesteatomatous otitis media, the cholesteatoma should be extracted by surgery as soon as possible. Curative therapy for recurrent infection is usually performed simultaneously with pinnaplasty. The characteristics of otitis media and subcutaneous abscess observed in microtia patients awaiting surgery are explained below by case reports. The pathology of otitis media and subcutaneous abscess in microtia patients is varied, and these patients should be treated carefully.
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Department of Speech, Language and Hearing Therapy, Faculty of Life Sciences, Mejiro University Clinic (Otolaryngology), Saitama, Japan
right
right
left
a
left
b
Fig. 1. Enhanced CT scan. Different slices (a, b).
Case 1 A 6-year-old girl with bilateral microtia had suspected atresia of the left EAC on CT performed after birth, but a rudimentary EAC was observed in the left ear on CT performed later. She had a heart disease complication. Antibiotics resolved a right-side earache occurring at the age of 5 years. Left-side earache developed frequently thereafter. Because details of the mild pus from the EAC were not known, the patient was treated with ear drops, ear lavage, and oral antibiotics. A mild subcutaneous abscess developed, but it was improved by incision pus drainage. The second CT was performed because recurrences persisted and remission was not achieved. Cholesteatomatous otitis media should have been considered, but no cholesteatoma was observed. Growth of the mastoid air cells was poor and there was no pneumatization. There also was no pneumatization of the tympanic cavity. Otorrhea recurred about 3 months later. Contrast CT was performed this time because the symptoms were accompanied by hemorrhage and the episode was protracted. It was not diagnosed as angioma, although net-like branching of the small vessels was observed. Branches of the external carotid artery (middle temporal artery and zygomatico-orbital artery) migrated near the outer layer of the anterior wall of the rudimentary EAC, and hemorrhage was suggested to be from these vessels or veins (fig. 1). Because the symptoms were accompanied by postauricular swelling and redness, and complicated by abscess, the patient was hospitalized for resection and treatment.
54
Sakata
Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 53–56 (DOI: 10.1159/000350605)
Downloaded by: Chinese University of Hong Kong 198.143.53.33 - 3/25/2016 2:49:17 AM
Case Reports
Infected state
right
a
Normal state
right
left
left
b
Fig. 2. CT scan. a Infected state. b Recovered state.
Case 2 A 5-year-old boy with right-sided microtia and right-sided atresia of the EAC had complications of heart disease and hydronephrosis. This case had been observed since soon after birth at the department of plastic surgery/ department of otolaryngology where the authors worked. The patient was examined at a nearby clinic because of the onset of earache, which did not improve despite antibiotic treatment, and he was referred to our institution. Postauricular redness/ swelling was remarkable at the time of initial examination. CT was performed immediately. Swelling of the soft tissues was observed around the right auricle. Pneumatization was severely disturbed in the tympanic cavity and mastoid air cells; they were filled with substances of soft tissue concentration. The bony wall of the mastoid air cells was not destroyed and inflammation of the mastoid antrum did not affect the right temporal region. The opening of the tympanic cavity was larger than that shown by CT taken when the patient was 1 year of age. The inferior wall of the EAC and tympanic cavity was distorted to face the external inferior direction. The portion that forms the bony wall of the original EAC was shown as a pipe or rather a funnel opening toward the outside. It was not clear whether this finding was an altered shape due to the child’s
Otitis Media and Subcutaneous Abscess
Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 53–56 (DOI: 10.1159/000350605)
55
Downloaded by: Chinese University of Hong Kong 198.143.53.33 - 3/25/2016 2:49:17 AM
In microtia patients, tests should be performed carefully and accurately because the symptom may not be mere otitis media or subcutaneous abscess. Dissection is scheduled as curative treatment at the time of microtia surgery.
Hideaki Sakata Department of Speech, Language and Hearing Therapy Faculty of Life Sciences, Mejiro University Clinic (Otolaryngology) 320 Ukiya, Iwatsuki, Saitama 339-8501 (Japan) E-Mail [email protected]
56
Sakata
Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 53–56 (DOI: 10.1159/000350605)
Downloaded by: Chinese University of Hong Kong 198.143.53.33 - 3/25/2016 2:49:17 AM
growth or a secondary change subsequent to inflammation. The patient was hospitalized for pus drainage by incision (fig. 2). MRI is superior for understanding the scope of inflammation, but CT should be performed initially to show the condition of the bony wall. It is desirable to repeat the CT, as the findings may differ from those of the CT performed immediately after birth.
Otitis Media and Subcutaneous Abscess while Awaiting Surgery Hideaki Sakata
A definite diagnosis of microtia may not require the use of CT in microtia patients who present with obvious stenosis of the external auditory canal (EAC) or complete atresia of the EAC. In such cases, otorrhea may develop in the rudimentary EAC and a subcutaneous abscess can easily form at the same time. Early-stage otitis externa and otitis media are often not discovered early enough because findings are rarely obtained. Many microtia cases are complicated by otitis media with effusion and congenital cholesteatoma, and acquired cholesteatomatous otitis media should also be considered when otitis media is protracted or intractable. Malformation of mastoid air cells and lowered pneumatization found in many patients are the likely causes of otitis media. Therapy for otitis media due to transtubal infection is often delayed because of the difficulty in obtaining abnormal findings. Nevertheless, it is important to perform a CT scan as early as possible to understand the growth of mastoid air cells, severity of pneumatization, pneumatization of the mastoid antrum, pneumatization and volume of the middle ear cavity, and anatomical findings of the surrounding regions. Basically, treatment as for ordinary otitis media is instituted, but otorrhea is often protracted or intractable. With microtia patients, subcutaneous abscess is likely to occur subsequent to otitis externa and otitis media, and early pus drainage by incision is desirable. However, symptoms may often recur because sufficient lavage and dissection of the affected site are not possible due to anatomical complexity. When a case is complicated by cholesteatomatous otitis media, the cholesteatoma should be extracted by surgery as soon as possible. Curative therapy for recurrent infection is usually performed simultaneously with pinnaplasty. The characteristics of otitis media and subcutaneous abscess observed in microtia patients awaiting surgery are explained below by case reports. The pathology of otitis media and subcutaneous abscess in microtia patients is varied, and these patients should be treated carefully.
Downloaded by: Chinese University of Hong Kong 198.143.53.33 - 3/25/2016 2:49:17 AM
Department of Speech, Language and Hearing Therapy, Faculty of Life Sciences, Mejiro University Clinic (Otolaryngology), Saitama, Japan
right
right
left
a
left
b
Fig. 1. Enhanced CT scan. Different slices (a, b).
Case 1 A 6-year-old girl with bilateral microtia had suspected atresia of the left EAC on CT performed after birth, but a rudimentary EAC was observed in the left ear on CT performed later. She had a heart disease complication. Antibiotics resolved a right-side earache occurring at the age of 5 years. Left-side earache developed frequently thereafter. Because details of the mild pus from the EAC were not known, the patient was treated with ear drops, ear lavage, and oral antibiotics. A mild subcutaneous abscess developed, but it was improved by incision pus drainage. The second CT was performed because recurrences persisted and remission was not achieved. Cholesteatomatous otitis media should have been considered, but no cholesteatoma was observed. Growth of the mastoid air cells was poor and there was no pneumatization. There also was no pneumatization of the tympanic cavity. Otorrhea recurred about 3 months later. Contrast CT was performed this time because the symptoms were accompanied by hemorrhage and the episode was protracted. It was not diagnosed as angioma, although net-like branching of the small vessels was observed. Branches of the external carotid artery (middle temporal artery and zygomatico-orbital artery) migrated near the outer layer of the anterior wall of the rudimentary EAC, and hemorrhage was suggested to be from these vessels or veins (fig. 1). Because the symptoms were accompanied by postauricular swelling and redness, and complicated by abscess, the patient was hospitalized for resection and treatment.
54
Sakata
Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 53–56 (DOI: 10.1159/000350605)
Downloaded by: Chinese University of Hong Kong 198.143.53.33 - 3/25/2016 2:49:17 AM
Case Reports
Infected state
right
a
Normal state
right
left
left
b
Fig. 2. CT scan. a Infected state. b Recovered state.
Case 2 A 5-year-old boy with right-sided microtia and right-sided atresia of the EAC had complications of heart disease and hydronephrosis. This case had been observed since soon after birth at the department of plastic surgery/ department of otolaryngology where the authors worked. The patient was examined at a nearby clinic because of the onset of earache, which did not improve despite antibiotic treatment, and he was referred to our institution. Postauricular redness/ swelling was remarkable at the time of initial examination. CT was performed immediately. Swelling of the soft tissues was observed around the right auricle. Pneumatization was severely disturbed in the tympanic cavity and mastoid air cells; they were filled with substances of soft tissue concentration. The bony wall of the mastoid air cells was not destroyed and inflammation of the mastoid antrum did not affect the right temporal region. The opening of the tympanic cavity was larger than that shown by CT taken when the patient was 1 year of age. The inferior wall of the EAC and tympanic cavity was distorted to face the external inferior direction. The portion that forms the bony wall of the original EAC was shown as a pipe or rather a funnel opening toward the outside. It was not clear whether this finding was an altered shape due to the child’s
Otitis Media and Subcutaneous Abscess
Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 53–56 (DOI: 10.1159/000350605)
55
Downloaded by: Chinese University of Hong Kong 198.143.53.33 - 3/25/2016 2:49:17 AM
In microtia patients, tests should be performed carefully and accurately because the symptom may not be mere otitis media or subcutaneous abscess. Dissection is scheduled as curative treatment at the time of microtia surgery.
Hideaki Sakata Department of Speech, Language and Hearing Therapy Faculty of Life Sciences, Mejiro University Clinic (Otolaryngology) 320 Ukiya, Iwatsuki, Saitama 339-8501 (Japan) E-Mail [email protected]
56
Sakata
Kaga K, Asato H (eds): Microtia and Atresia – Combined Approach by Plastic and Otologic Surgery. Adv Otorhinolaryngol. Basel, Karger, 2014, vol 75, pp 53–56 (DOI: 10.1159/000350605)
Downloaded by: Chinese University of Hong Kong 198.143.53.33 - 3/25/2016 2:49:17 AM
growth or a secondary change subsequent to inflammation. The patient was hospitalized for pus drainage by incision (fig. 2). MRI is superior for understanding the scope of inflammation, but CT should be performed initially to show the condition of the bony wall. It is desirable to repeat the CT, as the findings may differ from those of the CT performed immediately after birth.
