What Is In That Ear?

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Patient Presentation
A 3-year-old female came to clinic for their health maintenance visit. She had not been seen since her 18 month appointment and the mother had no concerns. The past medical history showed that the child had pressure equalizing tubes placed at 13 months of age for recurrent otitis media but again no followup at the institution had occurred and the mother said the child had been well.

The pertinent physical exam revealed a happy child with normal development who was growing just above the 50th percentiles. She had poor dentitia. Her left tympanic membrane showed no tube and some minor tympanic sclerosis. The right tympanic membrane had no tube in place. The external canal had a pinkish/blue mass just lateral to the tympanic membrane that appeared to be arising from the floor and ventral wall (about 6-8 o’clock.) It appeared glistening and somewhat translucent with the tissue appearing healthy overall. The rest of her examination was normal.

The diagnosis of a healthy female with poor dentitia and an external auditory canal lesion was made. The pediatrician thought that this may be a retained pressure-equalizing tube with overgrowth of the surrounding tissue. This was confirmed by the otolaryngologist who removed the tissue and tube surgically. The external canal healed normally and she did not have any problems with it over the next 1 year.

Discussion
The external auditory canal mainly derives from the ectoderm however it abuts other structures which arise from mesodermal or endodermal tissues. The lateral 1/3 is primarily cartilaginous with the inner 2/3rd being bony with the tympanic, temporal and mastoid bone forming various parts. The canal is lined with squamous epithelium and has various structures such as sebaceous glands, hair follicles and of course ceruminous glands.

It is not surprising that this structure is subject to obstruction given its small size. Cerumen, hair and other cellular debris may become impacted if they are not regularly expelled from the canal through movement of the contents and also through water/soap during washing of the head. Because of mild irritation and/or pressure or decreased hearing, people may also insert foreign bodies to move the cerumen and may cause impaction and/or retention of the object. Children often will explore their bodies and insert small foreign objects into various body parts including the external auditory canal. Complications of cerumen can be reviewed here.

Therefore it is not uncommon that health care providers encounter middle ear obstructions especially cerumen plugs or foreign bodies. Otitis externa is often caused by retention of cerumen and debris and water that is blocked by the debris setting up a usually minor infection but which can be quite painful and may need debridement. A review of otitis externa can be viewed here.

Much less commonly do other lesions occur in the external canal, but because of the location and the multiple types of tissues in the area the lesions have broad origins. Fortunately, most causes are benign and usually do not require extensive treatment.

Reasons that lesions may come to attention include pain, feeling of fullness/pressure, pruritis, hearing loss, tinnitus, otorrhea, bleeding, or visualization of the mass itself.

Learning Point
The differential diagnosis of external ear canal lesions includes:

  • **Cerumen impaction
  • **Foreign bodies
  • Bony tumors
    • Exostosis
    • Osteoma
  • Dermatological problems
    • Cholesteatoma
    • Epidermoid cyst
    • Keratosis obliterans
  • Infectious
    • Papilloma
    • Malignant otitis externa or basilar skull osteomyelitis
  • Neoplastic
    • Benign – most are benign
      • Adenoma
      • Angiofibroma
      • Capillary hemangioma
      • Hamartoma
      • Granuloma
      • Lipoma
      • Neuroma
    • Malignant
      • Langerhans cell histiocystosis
      • Yolk sac tumor
      • Malignant spread

** – most common problems

Questions for Further Discussion
1. What lesions are found on the tympanic membrane or in the middle ear?
2. What causes hearing loss? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Spielmann PM, McKean S, White RD, Hussain SSM. Surgical management of external auditory canal lesions. J Laryngol Otol. 2013;127(3):246-251. doi:10.1017/S0022215112003155

Shi H, Tang Q, Zhen T, Li H, Zhang F, Han A. Yolk sac tumor of the external auditory canal: a case report and literature review. Int J Clin Exp Pathol. 2015;8(11):15001-15006.

Luo W, Wu J, Peng KA, et al. Clinical Characteristics of Patients With Papilloma in the External Auditory Canal. The Laryngoscope. 2021;131(5):1132-1137. doi:10.1002/lary.29113

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published