Treatment of Ear Exostosis
Surgical Removal is the Definitive Treatment
Surgical removal of external auditory canal exostoses is indicated when patients develop symptomatic canal stenosis causing recurrent external otitis, cerumen impaction, or conductive hearing loss that is recalcitrant to medical management. 1, 2, 3
Clinical Context and Indications
External auditory canal exostoses are benign bony growths that typically occur bilaterally in patients with frequent cold-water exposure. 2, 3 These lesions are usually multiple and located in the medial ear canal near the tympanic membrane. 1
When to Observe vs. Operate
Asymptomatic exostoses require no treatment, as most cases remain asymptomatic throughout life. 2, 3
Symptomatic exostoses with canal obstruction >80% that cause recurrent external otitis, cerumen impaction preventing tympanic membrane visualization, or conductive hearing loss warrant surgical consideration. 1, 2, 3
Medical management first: Initial episodes of external otitis should be treated with aspiration and antibiotic drops before considering surgery. 2, 3
Surgery is reserved for patients with severe canal stenosis who fail medical treatment or have recurrent infections despite appropriate medical therapy. 2, 4, 3
Surgical Approach and Technique
Preferred Surgical Methods
The transcanal approach using an osteotome and mallet under local anesthesia is the preferred technique, as it minimizes morbidity compared to post-auricular or endaural approaches with drilling. 5, 3
Endoscopic transcanal removal provides superior visualization with wide-angled views without blind spots, reducing the theoretical risk of inadvertent injury to the facial nerve or inner ear. 5
Piezo surgery is a novel alternative technique that offers safe excision with speedy patient recovery. 6
Outpatient surgery is typically feasible, with maximum hospitalization of 3 days when needed. 4
Healing period averages 6 weeks (range 3-10 weeks). 4
Surgical Outcomes and Complications
Expected Results
No recurrence of exostoses has been reported in long-term follow-up (mean 43 months). 4
Severe complications are rare, but minor complications are relatively common and may have troublesome sequelae. 4
Potential Complications
Intraoperative complications include:
- Tympanic membrane perforation 4
- Exposure of the temporomandibular joint capsule (which may lead to chronic pain) 4
Postoperative complications include:
- Early or late soft tissue stenosis of the external auditory canal 4
- Recurrent stenosis requiring revision surgery 4
- Rare but serious complications such as bilateral petrositis (reported in one case) 4
No severe complications such as facial nerve paresis, ossicular chain injury, or inner ear damage have been reported in the literature reviewed. 4
Critical Decision-Making Algorithm
Assess severity: Determine degree of canal obstruction and presence of symptoms (recurrent otitis externa, cerumen impaction, hearing loss). 1, 2, 3
Trial of medical management: Treat acute infections with aspiration and topical antibiotics. 2, 3
Consider surgery if:
Surgical approach: Transcanal endoscopic removal with osteotome is preferred for optimal visualization and minimal morbidity. 5, 3
Important Caveats
Indication must be made cautiously because even minor complications can have troublesome consequences, and the potential for severe complications should not be underestimated. 4
Conventional cerumen management is often ineffective in patients with stenotic canals from exostoses, and safe irrigation is not possible in these patients. 1
Bilateral surgery carries additional risks and should be approached with particular caution given rare but serious complications like bilateral petrositis. 4