Automastoidectomy — a case report

Abstract

Background

Automastoidectomy denotes extensive destruction of the middle ear cavity and the mastoid air cells, mimicking the appearance of a reminiscent image of the post-mastoidectomy cavity. This condition, although rare, might occur as a unique complication of chronic otitis media with cholesteatoma with subsequent destruction of the posterior wall of the external auditory canal and spontaneous partial or complete evacuation of the cholesteatoma through the canal.

Case presentation

Seventy-year-old gentleman, a retired soldier, presented to us in the ENT OPD with right ear pain for more than a year, right ear discharge for 9 months, and a decrease in the hearing of the right ear for 6 months. The condition started 18 months ago with intermittent right otalgia; Dull aching in nature. Ten months later, the patient started to experience right-sided otorrhoea which was profuse, offensive, mucopurulent, and yellowish in color. Later on, he noticed a gradually deteriorating hearing.

On examination of the right ear, there is a fleshy mass obstructing the EAC, no auricular deformity tenderness, no preauricular swelling, sinus, or deformity, and there is thinning of the skin in the right postauricular region with mild tenderness but no swelling or sinus and preserved sulcus. Otoscopic examination shows a mass obstructing the EAC found to be an everted skin tag from the posteroinferior wall of the canal. There was a widening of the canal with the destruction of the walls and the absence of the TM, the annulus tympanicum, and the ossicles with polypoidal mucosa all over the middle ear cavity.

Investigation

HRCT scan of the temporal bone shows destruction of the air cells of the right mastoid cavity with the absence of the ossicles and destruction of the posterior EAC walls.

Conclusion

Although uncommon it is considered to be a known complication of Cholesteatomatous otitis media and sometime keratosis obturates with the main feature of osteogenic destruction of the posterior wall of the EAC.

Background

Automastoidectomy denotes extensive destruction of the middle ear cavity and the mastoid air cells, mimicking the appearance of a reminiscent image of the cavity appearing after radical mastoidectomy [1]. This condition, although uncommon, might occur as a unique complication of chronic otitis media with cholesteatoma with subsequent destruction of the posterior wall of the external auditory canal and spontaneous partial or complete evacuation of the cholesteatoma through the canal [2]. In such circumstances, it is often referred to as mural cholesteatoma or unusual cholesteatoma shell, as there is no residual soft tissue mass [3]. It had been also reported to occur with keratosis obturans [4].

Case presentation

Seventy-year-old gentleman, a retired soldier, presented to us in the ENT OPD with right ear pain for more than a year, right ear discharge for 9 months, and a decrease in the hearing of the right ear for 6 months. The condition started 18 months ago with intermittent right otalgia; Dull aching in nature. Ten months later, the patient started to experience right-sided otorrhoea which was profuse, offensive, mucopurulent, and yellowish in color. Later on, he noticed a gradually deteriorating hearing, with no tinnitus or vertigo. He also reported a history of left-sided hearing loss 5 years ago with no history of ear discharge or pain on the left side. No history of headache, fever, neck stiffness, or projectile vomiting. He is Not known to be diabetic or hypertensive and has no chronic illness. No history of trauma, hospitalization, or surgeries.

On examination of the right ear, obviously, there is a fleshy mass obstructing the EAC, no auricular deformity tenderness, no preauricular swelling, sinus or deformity, there is thinning of the skin in the right postauricular region with mild tenderness but no swelling or sinus and preserved sulcus. Otoscopic examination shows a mass obstructing the EAC found to be an everted skin tag from the posteroinferior wall of the canal (Fig. 1). There was a widening of the canal with the destruction of the walls absence of the TM, the annulus tympanicum, and the ossicles with polypoidal mucosa all over the middle ear cavity.

Fig. 1

A mass obstructing the EAC which was found to be an everted skin tag from the postero-inferior wall of the canal

The other ear’s examination was unremarkable. There was no facial nerve palsy, − ve fistula. Rinne test: − ve in both ears, Weber test: centralized, no palpable neck masses.

Investigation

The pure tone audiogram showed mild conductive loss on the left side, while the right ear had severe conductive hearing loss with an air–bone gap of 40–50 dB (Fig. 2).

Fig. 2

Pure tone audiogram shows mild conductive loss on the left side (30 dB), while the right ear had severe conductive hearing loss with an air–bone gap of 40–50 dB

Swab for microbiology culture and sensitivity cultivated heavy growth of E. coli.

HRCT scan of the temporal bone shows destruction of the air cells of the right mastoid cavity with the absence of the ossicles and destruction of the posterior EAC walls. The presence of air in the mastoid cavity may be used as evidence that the cholesteatoma, either in its part or entirety, has gone out (Fig. 3).

Fig. 3

HRCT–temporal bone–axial and coronal cuts show the automastoidectomy cavity with the destruction of all the air cells boundaries on the right side and erosion of the posterior wall of the right EAC. Courtesy of Dr. Fatima Ayed Akoud – ENT Registrar Sudan Medical Specializations Board

Plan of treatment

The patient is admitted to the hospital and started a ceftazidime injection with regular toilet suction of the ear with regular instillation of antibiotic + steroid ear drops. The patient was planned for mastoid exploration but he did not show up for a follow-up visit and contact was lost with him.

Discussion

In a patient with a chronic middle ear infection within compliance to medication or reluctance to follow up, with a chronic medical illness or simply negligence; automastoidectomy may occur as a consequence of cholesteatomata’s mass digging it way out through the posterior canal wall with subsequent partial or complete shedding or evacuation of the culprit destructive mass. In such cases, a meticulous study of an HRCT–temporal bone is always crucial and the need to go for exploratory mastoidectomy is usually thought of as cholesteatoma debris may still nest silently in the mastoid cavity.

Conclusion

Although uncommon, it is considered to be a unique complication of cholesteatomatous otitis media which hypothetically resolved spontaneously with the main feature of osteogenic destruction of the posterior wall of the EAC through which the cholesteatomatous debris may shed off.