Ceruminous Gland Adenoma of External Auditory Canal

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Copyright: © 2016 Almuhanna K, et al.
Case Report
Journal of Otolaryngology and Reconstructive Surgery
Open Access
Ceruminous Gland Adenoma of External Auditory Canal- A Case Report
1
Khabti Almuhanna1* and Renad Alkadi2
Otorhinlayrgiology Department, Prince Sultan Military Medical City Riyadh, Saudi Arabia
2
King Abdul-Aziz Medical City, National Guard health affair, Riyadh-Saudi Arabia
Received Date: April 21, 2016, Accepted Date: July 28, 2016, Published Date: August 08, 2016.
*Corresponding author: Khabti Almuhanna, Otorhinlayrgiology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; E-mail:
[email protected]
Case Report
Abstract
Ceruminous Adenoma (CA) is a benign neoplasm of ceruminous
glands. Developing exclusively in the external auditory canal (EAC) with
benign clinical behavior and was first reported by Hang in 1894. It is rare in
humans and poses a diagnostic problem for the clinician, due to the variety
of clinical presentations. This tumor is mainly composed of the ceruminous
gland cells (modified apocrine sweat glands). These glands are localized
deep in the skin mostly in the cartilaginous part of the external auditory
meatus. We are presenting a 45 year old female patient who was referred to
our otology department with a two year history of right ear blockage with
progressive hearing loss, her other medical history was unremarkable. The
surgical finding under microscope showed soft tissue mass under the skin
that fulfilled half of the posterior inferior portion of the external auditory
canal (EAC) that was completely excised under general anesthesia utilizing
a postaurical approach. The excised tumor specimen after proper staining
confirmed the diagnosis of ceruminous adenoma. In conclusion the CA is
benign rear tumor raised from ceruminous gland in EAC slowly growing
when getting bigger can block the EAC leading to heating loss; it can be
presented with variety of symptom such as mild otolgia, ear blockage
sensation and hearing loss treatment of choice is complete excision along
with over line skin to prevent recurrence.
Keywords: Auditory Canal Adenoma; Ceruminous Gland
The present case report is about a 45 year old female patient
who was referred to our otology department with a two year history
of right ear blockage associated with mild hearing loss and on and
off otolgia. Her other medical history was unremarkable. History
was negative for ear discharges, tinnitus, trauma and previous
ear surgery. The physical examination and otoscopy showed soft
mass of skin that fulfilled half of the posterior inferior portion of
the EAC (Figure 1) and Weber’s test was done to check the hearing
loss of right ear. A Computed tomography (CT) scan of the temporal
bone revealed a soft lesion occupying the EAC with no signs of
bone destruction (figure 2). Tympanic cavity and mastoid cleft
were normal (Figure 3). There was no intracranial involvement.
Intraoperative findings showed diffused cystic swelling and
whitish cheesy fluid discharge. A specimen from the discharges
was submitted for microbiological study, it was negative for microorganism. The lesion was excised completely along with over lining
skin under general anesthesia utilizing a postauricular approach
(Figure 4). The exposed bone covered with temporalis fascia graft.
Abbreviations: CA: Ceruminous Adenoma; EAC: External Auditory Canal; CK7= Cytokeratin 7; CT: Computed Tomography; IHC:
Immunohistochemistry.
Introduction
Ceruminous Adenoma (CA) is a benign neoplasm of ceruminous
glands. Developing exclusively in the external auditory canal (EAC)
with benign clinical behavior and was first reported by Hang in
1894 [1]. The CA is located primarily in the cartilaginous portion
of the EAC. Ceruminous tumors have been reported in patients
as young as 12 years and as old as 92 years [2,3]. The mean age
for patients with the most common benign tumor, CA is the sixth
decade [4]. Ceruminous pleomorphic adenomas are less common
than CA; the mean age for affected individuals is also in the sixth
decade [5-8].
CA and pleomorphic adenomas have been reported in both
sexes. The sex distribution for CA is nearly 50-50 [4]. A few more
cases of ceruminous pleomorphic adenoma have been reported in
men than in women, but the overall number of cases is too small to
suggest a statistically significant difference [4-8].
They demonstrate a dual cell population of basal myoepithelialtype cells and luminal ceruminous cells [9]. The most often
symptom of the CA of the EAC is the conductive hearing loss. It is
treated by complete surgical excision with excellent prognosis
[10]. It is rare in humans and poses a diagnostic problem for the
clinician, due to the variety of clinical presentations [1]. We present
herein a new case of CA to delineate the salient clinic-pathological
features of this rare tumor.
J Oto Rec Surg
Figure 1: Preoperative Exam of the Right External auditory canal
showing the cystic mass.
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Figure 2: Computed tomographyscan of temporal bone.
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Immunohistochemistry (IHC) has greatly assisted surgical
pathologists in the diagnosis of neoplastic diseases. Currently, IHC
has a wide variety of uses, including, but not limited to, confirmation
of diagnosis, determination of the primary site of origin for metastatic
tumors, classification of neoplasms, and use as a prognostic and
predictive biomarker. We used immunohistochemistry in our case
by ultraview universal DAB detection kit method.
Figure 3: Computed tomographyscan of temporal bone showing the
soft tissue mass in the outer 1/3 of the right External auditory canal.
Immunohistochemical studies also confirmed the presence
of two distinct cell types. CA demonstrate labeling of the luminal
cells expressed cytokeratin 7 (CK7) (Figure 7) while peripheral
(basal) cells expressed keratin 5/6, S100 protein and p63
(Figure 8). Cerumin is positive for PAS (Figure 9). Based on these
histopathological and immunohistochemical findings the diagnosis
of ceruminous gland adenoma was established.
The postoperative course was uneventful and the excision site
was well healed with no evidence of recurrence until seven months
follow up.
Discussion
Ceruminous glands are modified sweat glands, confined to the
skin of the cartilaginous part of the EAC. Tumors arising from these
glands are extremely rare and resemble those arising from sweat
glands elsewhere in the body [4,11-13]. Wetli, et al, indicated that
malignant tumors out-number benign (2.5:1) with equal male to
Figure 4: Intra-operative photo showing the Right External auditory
canal cystic mass (blue arrow) with normal tympanic membrane
(green arrow).
Figure 6: Microscopic Examination (H & E stain) of Inner cuboidal
cells contain eosinophilic cytoplasm and apical snouts (arrow).
Figure 5: The Excised Mass measuring 1.5 cm.
Macroscopically the excised tumor specimen was a fusi
form skin specimen measuring 1.5 cm in dimension (Figure 5).
Microscopic examination showed that lesions consisted of two
types of cells including inner cuboidal or columnar cells with
eosinophilic cytoplasm and epical snouts and outer spindled
myoepithelial cells with hyper chromatic nuclei (Figure 6). Mitotic
figures, pleomorphism, necrosis, and invasiveness were not seen.
Figure 7: Immuno-histochemical staining of the inner luminal cells
are strongly positive for CK7 (arrow).
Citation: Almuhanna K, Alkadi R (2016) Ceruminous Gland Adenoma of External Auditory Canal- A Case Report. J Oto Rec
Surg 2(1): 115.
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Vol. 2. Issue. 1. 31000115
difficulty of surgery at this location leading to recurrence [4,19,20].
However, there is no evidence of recurrence for these tumors in the
literature, with a mean follow-up time of 15 years [11,12,14]. Our
patient underwent total surgical excision of the mass along with the
over lining skin and showed good healing process without signs of
recurrence up to seven months later.
Conclusion
Figure 8: The outer myoepithelial cells are strongly positive for p63
(arrow).
Ceruminomas are rare tumors arising from the ceruminous
gland, which is a modified apocrine gland in the skin of the
external canal. In our case, the lesion was excised completely using
post auricle approach. After surgery the follow up of patient was
uneventful. Ceruminous gland adenoma at hat are pedunculated
rarely recur because of the ease of adequate surgical excision.
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Figure 9: Inset shows PAS positive granules in the inner cell layer
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Citation: Almuhanna K, Alkadi R (2016) Ceruminous Gland Adenoma of External Auditory Canal- A Case Report. J Oto Rec
Surg 2(1): 115.
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*Corresponding author: Khabti Almuhanna, Otorhinlayrgiology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; E-mail:
[email protected]
Received Date: April 21, 2016, Accepted Date: July 28, 2016, Published Date: August 08, 2016.
Copyright: © 2016 Almuhanna K, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Almuhanna K, Alkadi R (2016) Ceruminous Gland Adenoma of External Auditory Canal- A Case Report. J Oto Rec Surg 2(1): 115.
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Citation: Almuhanna K, Alkadi R (2016) Ceruminous Gland Adenoma of External Auditory Canal- A Case Report. J Oto Rec
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