What is the management of bony growths (exostoses) in the ear canal?

Management of Bony Growths (Exostoses) in the External Ear Canal

The management of ear canal exostoses should prioritize mechanical removal of cerumen impaction when symptomatic, with surgical intervention reserved only for cases with severe canal stenosis that are resistant to medical treatment.1

Diagnosis and Assessment

• Exostoses are broad-based hyperostotic lesions that are typically multiple, bilateral, located in the medial ear canal near the eardrum, and associated with prior history of cold-water swimming 1
• These bony growths may severely limit the patency of the ear canal and trap cerumen and keratin debris, preventing adequate visualization of the tympanic membrane 1
• Osteomas, which are less common, are usually lateral in the bony ear canal, solitary, unilateral, and pedunculated 1
• A thorough assessment should identify modifying factors that affect management, including ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy 1

Conservative Management

For Asymptomatic Exostoses:

• Observation is appropriate for non-impacted cerumen that is asymptomatic and does not prevent adequate assessment of the patient 1
• Regular follow-up examinations are recommended to monitor for progression 1

For Symptomatic Cases with Cerumen Impaction:

1. Manual removal with instrumentation:

   • Preferred method for exostoses cases as it allows direct visualization without exposing the ear to moisture 1
   • Requires adequate illumination (binocular microscope offers stereoscopic magnification advantage) 1
   • Instruments used include metal or plastic curette loop/spoon, alligator or cup forceps 1

2. Aural toilet when needed:

   • Clear inflammatory debris, obstructing cerumen, or foreign objects 1
   • Can be performed by gentle lavage using body-temperature water, saline solution, or hydrogen peroxide 1
   • Alternative methods include removing debris with suction or dry mop (cotton-tipped applicator) 1
   • Adequate visualization may require an otoscope with an open head or binocular otologic microscope 1

3. Irrigation considerations:

   • Should be avoided in patients with:
     • Nonintact tympanic membrane 1
     • Anatomic abnormalities of the canal (including exostoses) that might trap water 1
     • Diabetes or immunocompromised state (higher risk of malignant otitis externa) 1
   • If irrigation is performed in diabetic patients, instruct them to report otorrhea/otalgia promptly 1
   • Consider reacidifying the ear canal after irrigation with vinegar or acetic acid drops 1

Surgical Management

Surgical intervention is indicated only when:

• Canal stenosis is severe (>80% obstruction) 2
• Patient experiences recurrent episodes of external otitis resistant to medical treatment 3, 2
• Conductive hearing loss is present due to canal obstruction 3, 2

Surgical Approaches:

1. Transcanal approach:

   • Can be performed under local anesthesia 2
   • Uses specialized mallet and thin chisel 2
   • Associated with decreased morbidity compared to open, drilled approaches 4

2. Endoscopic transcanal removal:

   • Provides superior visualization of the external auditory canal and tympanic membrane 4
   • Offers improved wide-angled views without blind spots 4
   • May reduce risk of complications 4

3. Other approaches:

   • Post-auricular or endaural approaches may be necessary for extensive cases 4

Potential Surgical Complications:

• Tympanic membrane perforation 5
• Postoperative hearing loss (temporary or permanent) 5
• Canal stenosis (more common in cases with preoperative severe persistent external otitis) 5
• Facial nerve injuries (rare) 5
• Accidental opening of the mastoid 5

Special Considerations

• Meatal skin preservation without circular meatal flap incision is recommended to avoid postoperative canal stenosis 5
• Surgery should be reserved for uninfected ear canals 5
• Patients with preexisting sensorineural hearing loss require special attention to reduce intraoperative noise exposure 5
• Postoperative care should include keeping the ear dry during healing 1
• Regular follow-up is essential to monitor for recurrence or complications 1

Prevention

• For patients with a history of exostoses, recommend avoiding cold water exposure, particularly in ocean swimming 6
• Consider the use of earplugs or neoprene headbands for those who continue aquatic activities 1
• Never use materials like Playdoh or silly putty as earplugs as they can become trapped in the ear canal 1