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External auditory canal stenting with nonlatex glove and Gelfoam.

How we do it

At the conclusion of a surgical procedure (traumatic laceration repair, canal-wall-down mastoidectomy, or external auditory canal [EAC] atresia repair), a size 6 nonlatex glove is obtained and, depending on the size of the EAC, 2 to 3 centimeters of the tip of the fifth digit is removed and tucked into place in the EAC. The glove tip is then sutured into place in the surrounding conchal bowl with 5.0 fast-absorbing gut. The lumen of the glove is then packed with mupirocin-coated Gelfoam. This packing is then left in place for 1 week and removed during follow-up. If necessary, subsequent repacking in the office is tolerated well by patients.

Case report

We have successfully applied our stenting technique in the case of an acquired EAC stenosis in a 16-year-old girl. She underwent a left lateral graft tympanoplasty, ossicular reconstruction, and excision of acquired EAC stenosis. At the conclusion of the procedure, a nonlatex glove that was trimmed at the fingertip was placed into the EAC and filled with Gelfoam to maintain patency of the EAC. One week after the surgical procedure, the EAC stent was removed. Subsequent visits were at 1 month postoperatively, then at longer intervals, with the final evaluation at 1 year. The EAC remained patent throughout follow-up.

Discussion

The technique we have described can also be applied in multiple other situations. It has been used in patients who have undergone canal-wall-down mastoidectomies and after meatoplasties, to ensure that the canal skin is laid appropriately against the bony EAC (figure). Additionally, the same stenting technique has been used in traumatic EAC laceration repairs.

EAC stenosis, although rare, still remains an important entity, and the main treatment option is surgical resection. The most challenging concern postoperatively is prevention of recurrence, which requires aggressive and consistent monitoring.

Medical therapy plays a limited role in the management of EAC stenosis. The main goal of medical therapy is to limit infection and prevent inflammation, in order to decrease granulation tissue formation. However, once fibrosis has progressed to significant conductive hearing loss, surgical intervention is often necessary. The main goals of surgical intervention are resection of the area of stenosis, widening of the bony EAC, and reepithelialization of the EAC. The most common postoperative complication is restenosis, with published recurrence rates ranging from 6 to 27%. (1)

Paparella and Kurkjain introduced the basic surgical principle of excising the fibrous plug, enlarging the cartilaginous and bony canal, and relining the canal. (2) Additionally, reports have described leaving a rubber tube in place for at least 6 weeks for stenting the EAC open postoperatively. (3) Recent studies have investigated stents utilizing Silastic tubing, (4) silicone drains, (5) and acrylic prostheses or ear molds. (6,7)

Conclusion

In this article we have offered an alternative procedure for stenting the EAC open after surgery. This technique has been used effectively in the prevention of EAC stenosis arising from various causes. The use of a nonlatex glove has the benefit of being readily available in the operating room, inexpensive, and not requiring any additional equipment or wait time. The material is easily conformable to various contours and sizes, and the pressure applied can be adjusted depending on the amount of Gelfoam that is packed into the glove tip. Placement of the stent can be performed at the bedside in cases of repair of traumatic EAC lacerations, and it only requires a minimal amount of local anesthetic.

Overall, we have found this stenting technique to be effective in a variety of procedures that require EAC stenting.

References

(1.) Luong A, Roland PS. Acquired external auditory canal stenosis: Assessment and management. Curr Opin Otolaryngol Head Neck Surg 2005; 13 (5): 273-6.

(2.) Paparella MM, Kurkjain JM. Surgical treatment for chronic stenosing external otitis (including finding of unusual canal tumor). Laryngoscope 1966; 76 (2): 232-45.

(3.) Soliman T, Fatt-Hi A, Kadir M. A simplified technique for the management of acquired stenosis of the external auditory canal. J Laryngol Otol 1980; 94 (5): 549-52.

(4.) Vincent DA Jr., Funcik T, Adkins WY Jr. Reduced mastoidectomy complications with an open meatoplasty stent. Otolaryngol Head Neck Surg 1995; 112 (6): 689-90.

(5.) Rodnguez-Vegas JM. Inexpensive custom-made stenting of auditory meatus after stenosis release. Plast Reconstr Surg 2005; 116 (3): 926-8.

(6.) Hocwald E, Sichel JY, Sela M,et al. Prevention of post-mastoidectomy meatal stenosis by an acrylic prosthesis. Laryngoscope 2002; 112 (10): 1892-4.

(7.) Moon IJ, Cho YS, Park J,et al. Long-term stent use can prevent postoperative canal stenosis in patients with congenital aural atresia. Otolaryngol Head Neck Surg 2012; 146 (4): 614-20.

From the Department of Otolaryngology and Communication Sciences, College of Medicine, Upstate Medical University, State University of New York, Syracuse.

Corresponding author: Judy Pan, MD, Department of Otolaryngology and Communication Sciences, College of Medicine, SUNY Upstate Medical University, 241 Campus West, 750 East Adams St., Syracuse, NY 13210. Email: judy.pan81@gmail.com

February 24, 2016 by Judy C. Pan, MD; Tucker M. Harris, MD

Caption: Figure. Photo shows the EAC stent that has been inserted and sutured in place.
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Author:Pan, Judy C.; Harris, Tucker M.
Publication:Ear, Nose and Throat Journal
Date:Feb 1, 2016
Words:844
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