Post-traumatic Cholesteatoma With Posterior Fossa Invasion

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Acta Otorrinolaringol Esp. 2011;62(4):318---319
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CASE STUDY
Post-traumatic Cholesteatoma With Posterior Fossa Invasion夽
Irma Yolanda Castillo-López,∗ Adán G. Muñoz-Lozano, Claudia B. Bonner-Osorio
Hospital de Especialidades de la Unidad Médica de Alta Especialidad, Bajío No. 1 del Instituto Mexicano del Seguro Social,
Servicio Otorrinolaringología, Ciudad de León, Estado de Guanajuato, Mexico
Received 15 January 2010; accepted 2 March 2010
Cholesteatoma;
Posterior fossa;
Temporal bone
fracture
Abstract Post-traumatic cholesteatomas are an extremely rare variety of secondary
cholesteatomas. We present the case of a 51-year-old male with post-traumatic cholesteatoma
with posterior fossa invasion of 30-year evolution that initially manifested as acute otomastoiditis and headache. Its physiopathology and clinical manifestations are discussed.
© 2010 Elsevier España, S.L. All rights reserved.
PALABRAS CLAVE
Colesteatoma postraumático con invasión a fosa posterior
KEYWORDS
Colesteatoma;
Fosa posterior;
Fractura del hueso
temporal
Resumen Los colesteatomas postraumáticos son una variedad extremadamente rara de
colesteatomas secundarios. Presentamos el caso de un masculino de 51 años con un
colesteatoma postraumático de 30 años de evolución que invade hacia fosa posterior y se manifiesta inicialmente como una otomastoiditis aguda y cefalea. Se discute su fisiopatología y sus
manifestaciones clínicas.
© 2010 Elsevier España, S.L. Todos los derechos reservados.
Clinical Case
We report the case of a 51-year-old male patient with
a 4-month history of right otorrhea. The patient mentioned suffering a head trauma with bilateral fracture of
the temporal bone resulting in left anacusis and right tympanic perforation 30 years earlier, which was subsequently
repaired with tympanoplasty and remained asymptomatic
during this period. However, 4 months before admission,
夽 Please cite this article as: Castillo-López IY, et al. Colesteatoma
postraumático con invasión a fosa posterior. Acta Otorrinolaringol
Esp. 2011;62:318---9.
∗ Corresponding author.
E-mail address: [email protected] (I.Y. Castillo-López).
he presented acute otomastoiditis, which was treated
by retroauricular drainage and systemic antibiotics. Total
symptomatic remission was not achieved, given that the
presence of right otorrhea persisted, along with an increased
retroauricular volume and formation of a cutaneous fistula
with production of purulent material. In addition, there
was right hemicranial headache, of mild to medium intensity, and rotatory vertigo. Physical examination showed an
external auditory canal (EAC) with abundant otorrhea and
a dehiscent posterior wall in its middle third, as well as
polypoid tissue. Also present were a pars flaccida perforation with lysis and the rest of the membrane engrossed, as
well as increased, soft erythematous retroauricular volume,
with a cutaneous fistula towards the tip of the mastoid.
We performed CT and MRI scans (Fig. 1). We also initiated management with a double programme of antibiotics
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Post-traumatic Cholesteatoma With Posterior Fossa Invasion
319
Since it was a single ear, we carried out a modified radical mastoidectomy and obliterated the mastoid cavity with
synthetic fibrin and temporal fascia. The patient presented
evolved appropriately and was discharged at 7 days postoperative without complications.
Discussion
Figure 1 MRI scan, T2 sequence. There is a hyperintense mass
compressing the right lobe of the cerebellum and penetrating minimally into the middle fossa, without invading the brain
tissue.
and steroids, and opted for surgical management with
transmastoid approach. We found extensive erosion of the
cortical mastoid, with cholesteatomatous tissue; erosion of
the walls connecting with the middle and posterior fossa,
through which the dura mater appeared intact (Fig. 2),
and only inflammatory tissue in the epitympanum and aditus ad antrum. The ossicular chain was intact; there was
no evidence of cholesteatoma in the tympanic cavity and
the posterior wall of the EAC presented wide dehiscence.
Post-traumatic cholesteatomas are a well-recognised variety of secondary cholesteatomas.1 It is believed that their
formation is due to an entrapment of epithelium in the fracture line, invagination of the epithelium in a consolidated
fracture line, traumatic implantation of the tympanic membrane skin into the middle ear, or entrapment of the EAC
medial to the stenosis. The fracture lines through the posterosuperior wall of the EAC close and trap the duct skin.
This skin grows and expands to form a cholesteatoma.2 There
are few cases reported in the literature and they are even
regarded as an extremely rare condition.3
Post-traumatic cholesteatomas grow for many years
before they are detected because their presence is not suspected until they cause clinical symptoms. This absence of
symptoms promotes their extensive growth. The literature
contains intervals for their detection ranging between 6 and
29 years.4,5 In our case, the interval was 30 years and growth
of the cholesteatoma was extensive, invading the middle
and posterior fossae and compressing the cerebellum.
Headache is a commonly referred symptom in patients
with cases of giant cholesteatoma and intracranial
invasion.6,7 It sometimes appears without otological signs.8
In the case presented, the presence of otorrhea, increased
retroauricular volume and vertigo pointed to a headache of
an otogenic cause.
Post-traumatic cholesteatoma is a rare but well recognised late complication of temporal bone fractures. It must
be taken into account in patients with a history of temporal
bone fractures and associated otological symptoms.
References
Figure 2 Intraoperative view, where it is possible to observe
an autocavity that connects towards the posterior fossa, middle
fossa and the mastoid tip, and through which the dura mater can
be distinguished. The arrow points to the aditus ad antrum and
the asterisk indicates the dura mater covering the cerebellum.
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